NCLEX Review: CH 21 and CH 25

The nurse assesses a patient who is diagnosed with decompensated cirrhosis. Which of the following are clinical indicators consistent with that diagnosis? Select all that apply. a) A firm, enlarged liver b) Clubbing of the fingers c) Splenomegaly d) Ascites e) Jaundice f) Vascular spiders

b, d, e

A patient is admitted to the hospital with possible cholelithiasis. Which diagnostic test of choice will the nurse prepare the patient for? 1) Cholecystography 2) Ultrasonography 3) CT Scan 4) Abdominal X-Ray

2) Ultrasonography has replaced cholecystography (discussed later) as the diagnostic procedure of choice because it is rapid and accurate and can be used in patients with liver dysfunction and jaundice. It does not expose patients to ionizing radiation.

Which of the following is considered the "gold standard" for the diagnosis of liver disease? 1) Cholecystography 2) Paracentesis 3) Ultrasonography 4) Biopsy

4) Biopsy

Which of the following is commonly associated with acute episodes of pancreatitis? a) Bacterial infection b) Viral infection c) Fungal infection d) Long-term use of alcohol

d)

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider? a) Measure abdominal girth according to a set routine. b) Ask the client about food intake. c) Provide the client with nonprescription laxatives. d) Report the condition to the physician immediately.

a) If the abdomen appears enlarged, the nurse measures it according to a set routine. The nurse reports any change in mental status or signs of gastrointestinal bleeding immediately. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis.

Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit? a) Appendicitis b) Pancreatitis c) Peptic ulcer d) Cholecystitis

b) Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity. The other conditions are less likely to exhibit fluid volume deficit.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client? a) Maintaining adequate nutritional status b) Teaching about the disease and its treatment c) Preventing fluid volume overload d) Relieving abdominal pain

d) The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can't help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? a) Serum potassium level of 3.5 mEq/L b) Loss of 2.2 lb (1 kg) in 24 hours c) Blood pH of 7.25 d) Serum sodium level of 135 mEq/L

b) Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: a) black, tarry stools. b) yellow sclerae. c) circumoral pallor. d) light amber urine.

b) Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively

Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following may occur as a result of vitamin C deficiency? a) Beriberi b) Hypoprothrombinemia c) Scurvy d) Night blindness

c) Scurvy may result from a vitamin C deficiency. Night blindness, hypoprothrombinemia, and beriberi do not result from a vitamin C deficiency.

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? a) Hepatitis B is transmitted primarily by the oral-fecal route. b) Hepatitis C increases a person's risk for liver cancer. c) Hepatitis A is frequently spread by sexual contact. d) Infection with hepatitis G is similar to hepatitis A.

b) Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? a) Instruct the client to avoid coughing. b) Monitor pulse oximetry every hour. c) Withhold oral feedings for the client. d) Reposition the client every 2 hours.

d) Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure? a) Positioning the client on the side with the knees flexed b) Encouraging frequent visits from family and friends c) Administering frequent oral feedings d) Administering an analgesic once per shift, as ordered, to prevent drug addiction

a) The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching? a) "I'll wash my hands often." b) "How did this happen? I've been faithful my entire marriage." c) "I'll take all my medications as ordered." d) "I'll be very careful when preparing food for my family."

b) The client requires further teaching if he suggests that he acquired the virus through sexual contact. Hepatitis A is transmitted by the oral-fecal route or through ingested food or liquid that's contaminated with the virus. Hepatitis A is rarely transmitted through sexual contact. Clients with hepatitis A need to take every effort to avoid spreading the virus to other members of their family with precautions such as preparing food carefully, washing hands often, and taking medications as ordered

The patient admitted with acute pancreatitis has passed the acute stage and is now able to tolerate solid foods. What type of diet will increase caloric intake without stimulating pancreatic enzymes beyond the ability of the pancreas to respond? a) High-carbohydrate, high-protein, low-fat diet b) High-carbohydrate, low-protein, low-fat diet c) Low-sodium, high-potassium, low-fat diet d) Low-carbohydrate, high-potassium diet

b) The nurse should provide a high-carbohydrate, low-protein, low-fat diet when tolerated. These foods increase caloric intake without stimulating pancreatic secretions beyond the ability of the pancreas to respond.

A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate? a) Providing generous servings at mealtime b) Providing the client with plenty of P.O. fluids c) Reserving an antecubital site for a peripherally inserted central catheter (PICC) d) Limiting I.V. fluid intake according to the physician's order

c) Pancreatitis treatment typically involves resting the GI tract by maintaining nothing-by-mouth status. The nurse should reserve the antecubital site for a PICC, which enables the client to receive long-term total parenteral nutrition. Clients in the acute stages of pancreatitis also require large volumes of I.V. fluids to compensate for fluid loss

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client? a) Thiamine b) Riboflavin c) Vitamin A d) Vitamin K

c) Problems common to clients with severe chronic liver dysfunction result from inadequate intake of sufficient vitamins. Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency can lead to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Vitamin K deficiency can cause hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation? a) The client didn't take his morning dose of lactulose (Cephulac). b) The client is relaxed and not in pain. c) The client is avoiding the nurse. d) The client's hepatic function is decreasing.

d) The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client? a) Providing mouth care b) Placing the client in a semi-Fowler's position c) Maintaining nothing-by-mouth (NPO) status d) Administering morphine I.V. as ordered

d) The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: a) eructation and constipation. b) abdominal ascites. c) severe abdominal pain radiating to the shoulder. d) anorexia, nausea, and vomiting.

d) Early hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Abdominal pain may occur but doesn't radiate to the shoulder. Eructation and constipation are common in gallbladder disease, not hepatitis A. Abdominal ascites is a sign of advanced hepatic disease, not an early sign of hepatitis A

An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is: a) Acetaminophen b) Ibuprofen c) Benadryl d) Dextromethorphan

a)

A patient is diagnosed with mild acute pancreatitis. What does the nurse understand is characteristic of this disorder? a) Edema and inflammation b) Pleural effusion c) Disseminated intravascular coagulopathy d) Sepsis

a) Mild acute pancreatitis is characterized by edema and inflammation confined to the pancreas. Minimal organ dysfunction is present, and return to normal function usually occurs within 6 months.

A focused GI assessment begins with a complete history and physical examination. Identify the quadrant of the abdomen to be palpated or percussed for a patient with pancreatitis. a) Right upper b) Left upper c) Left lower d) Right lower

b)

Which of the following is the most effective strategy to prevent hepatitis B infection? a) Barrier protection during intercourse b) Covering open sores c) Vaccine d) Avoid sharing toothbrushes

c)

The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason? a) To decrease metabolism b) To depress the central nervous system and increase the pain threshold c) To relieve nausea and vomiting d) To reduce gastric and pancreatic secretions

d)

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as? a) Constructional apraxia b) Ataxia c) Fetor hepaticus d) Asterixis

d)