12.C Liver Disease
The nurse is performing an assessment for a client diagnosed with cirrhosis. Which finding should lead the nurse to determine that treatment is effective? (Select all that apply.) A. Absence of bruising or bleeding B. Stable liver function tests C. Increasing abdominal girth measurements D. Increasing serum albumin levels E. Decreasing blood urea nitrogen levels
A, B, D Rationale: For treatment to be effective, liver function tests should remain stable during treatment. The client should exhibit the absence of bruising or bleeding. Serum albumin levels should increase. Abdominal girth measurements should decrease. Blood urea nitrogen levels are used to diagnose kidney failure, not liver failure.
Which information is most important for the nurse to include in the discharge teaching for a client diagnosed with cirrhosis of the liver? A. Physical therapy consult B. How to institute bleeding precautions C. Ways to increase fluid consumption D. Importance of high-impact aerobic exercise
B. How to institute bleeding precautions Rationale: The client diagnosed with cirrhosis is at risk for bleeding because the liver's ability to manufacture clotting factors is impaired. The client should be taught how to institute bleeding precautions. A referral for home health services, dietary consultation, social services, and counseling may be needed; a physical therapy consult is not. Ways to manage fatigue and conserve energy should be taught; the client should not engage in high-impact aerobic exercise. Cirrhosis affects water and salt regulation because of portal hypertension, hypoalbuminemia, and hyperaldosteronism, which causes fluid volume overload. Therefore, the client will most likely be on fluid restriction.
The nurse is caring for a client suspected of having hepatorenal syndrome. Which assessment finding leads the nurse to determine this is correct? A. Asterixis B. Esophageal varices C. Sodium retention D. Fever
C. Sodium retention Rationale: Hepatorenal syndrome causes sodium retention, oliguria, and hypotension. Asterixis develops with portal systemic encephalopathy, and fever occurs with bacterial peritonitis. Esophageal varices are a complication of cirrhosis.
The nurse is caring for a client experiencing severe ascites. Which collaborative intervention should the nurse expect? A. Gastric lavage B. Transjugular intrahepatic portosystemic shunt (TIPS) C. Insertion of Sengstaken-Blakemore tube D. Paracentesis
D. Paracentesis Rationale: For severe ascites, the treatment of choice is paracentesis, which is removal of fluid from the peritoneal cavity. The goal of this treatment is to reduce respiratory distress. A Sengstaken-Blakemore tube is used to treat bleeding esophageal varices. Gastric lavage, irrigation of the stomach with large quantities of normal saline, is performed to improve visualization of the stomach. The TIPS procedure is performed to relieve portal hypertension.
The nurse is discussing risk factors for cirrhosis with a group of community members. Which risk factor should the nurse include in the discussion? (Select all that apply.) A. Injection drug use B. Obesity C. Excessive alcohol use D. Hepatitis C infection E. Smoking
A, C, D Rationale: The leading risk factor for cirrhosis is excessive alcohol use. The use of injected drugs puts the client at risk of contracting viral hepatitis (B, C, or D). Obesity and smoking are not known risk factors for cirrhosis.
The graduate nurse is creating a care plan for a client diagnosed with cirrhosis. Which diagnosis assigned by the graduate nurse to the client should be questioned by the nursing preceptor? A. Skin Integrity: Impaired B. Fluid Volume: Deficient C. Nutrition, Imbalanced: Less than Body Requirements D. Protection: Ineffective
B. Fluid Volume: Deficient Rationale: Appropriate nursing diagnoses for a client with cirrhosis include Skin Integrity: Impaired due to pruritus as a result of bile salt deposits on the skin; Protection: Ineffective due to compromised mental status, and Nutrition, Imbalanced: Less than Body Requirements due to the client's salt and protein restrictions which may make the diet less palatable and appealing. Fluid Volume: Excess, not Fluid Volume: Deficient, is appropriate for a client with cirrhosis. (NANDA-I ©2014)
The nurse determines a client diagnosed with cirrhosis is at risk for bleeding. Which intervention is the priority for the nurse to include in the plan of care? A. Provide nutritional supplements. B. Monitor coagulation studies and platelet count. C. Administer antihistamines as prescribed. D. Administer albumin as prescribed.
B. Monitor coagulation studies and platelet count. Rationale: Monitoring coagulation studies and platelet count help determine if the client is bleeding or is at imminent risk for bleeding, and if there is a need for treatment. Antihistamines are used to reduce itching. Albumin is administered to increase plasma oncotic pressure and reduce edema and ascites. Providing nutritional supplements is important but does not affect the risk for bleeding.
The nurse is caring for a client diagnosed with portal hypertension. For which complication should the nurse monitor? A. Hepatic encephalopathy B. Fatty liver C. Esophageal varices D. Hepatitis C
C. Esophageal varices Rationale: In portal hypertension, the venous drainage of the gastrointestinal tract becomes congested, leading to esophageal varices. Hepatitis C is caused by a viral infection. Hepatic (portal systemic) encephalopathy is due to the accumulation of toxic substances in the bloodstream, related to liver failure. Steatohepatitis, also known as fatty liver, is a condition in which fat cells build up in the liver, leading to liver enlargement and cirrhosis.
The nurse cares for a client diagnosed with cirrhosis. Which clinical manifestation suggests to the nurse that the diagnosis is correct? (Select all that apply.) A. Ascites B. Splenomegaly C. Hepatic encephalopathy D. Hypertension E. Esophageal varices
A, B, C, E Rationale: Complications associated with cirrhosis include esophageal varices, splenomegaly, ascites, and hepatic (portal systemic) encephalopathy. Hypertension is not a complication associated with cirrhosis.
Which metabolic effect should the nurse expect to find in the client with liver disease? (Select all that apply.) A. Impaired bilirubin conversion B. Disrupted glucose metabolism C. Increased plasma oncotic pressure D. Impaired clotting factor production E. Increased blood flow to the liver
A, B, D Rationale: Liver disease causes many metabolic effects. Impaired clotting factor production results in bleeding and bruising. Disrupted glucose metabolism results in either hyperglycemia or hypoglycemia. Impaired bilirubin conversion and excretion result in jaundice. Other effects of liver disease include disrupted blood flow to the liver resulting in portal hypertension and decreased plasma oncotic pressure from impaired protein metabolism. This results in edema and ascites.
The nurse is caring for a client diagnosed with cirrhosis who has developed ascites. Which intervention should the nurse include in the plan of care? (Select all that apply.) A. Monitor intake and output. B. Assess the client's urine specific gravity. C. Measure abdominal girth weekly. D. Encourage fluid consumption. E. Weigh the client daily.
A, B, E Rationale: Ascites occurs because of portal hypertension and hypoalbuminemia. For the client with ascites, measures to counteract fluid volume overload should be taken. These measures include monitoring intake and output, assessing the urine specific gravity (an indicator of hydration status), and weighing the client daily. Abdominal girth should also be measured daily, not weekly, and the client should be placed on a fluid restriction.
The nurse is reviewing the laboratory results for a client suspected of having cirrhosis. Which result suggests to the nurse that the suspicion is correct? (Select all that apply.) A. Elevated serum ammonia levels B. Decreased sodium levels C. Increased albumin levels D. Decreased bilirubin levels E. Prolonged prothrombin time
A, B, E Rationale: In cirrhosis, prothrombin times are prolonged because the liver is unable to manufacture clotting factors. Serum ammonia levels are elevated because the liver lacks the ability to efficiently convert ammonia to ammonium for excretion as urea by the kidneys. Sodium levels are decreased because of hemodilution due to fluid retention. In cirrhosis, bilirubin levels are increased, and albumin levels are decreased.
Which assessment finding of a client diagnosed with cirrhosis should the nurse correlate with expected laboratory findings? (Select all that apply.) A. Peripheral edema B. Spider angiomas C. Confusion D. Frequent infections E. Bruising easily
A, C, D, E Rationale: Assessment findings that correlate with expected laboratory findings in the client with cirrhosis include bruising easily (coagulation studies), frequent infections (WBC count), peripheral edema (albumin levels), and confusion (ammonia levels). Although spider angiomas can be found in clients with cirrhosis, their presence is not associated with any laboratory testing.
A client diagnosed with cirrhosis of the liver states to the nurse, "This itching is driving me crazy." Which intervention is most appropriate for the nurse to implement? A. Apply an emollient lotion. B. Wash the client's skin with cool water and soap daily. C. Turn the client every 4 hours. D. Restrain the client's hands to prevent scratching.
A. Apply an emollient lotion. Rationale: As ammonia levels rise in cirrhosis, bile salt deposits are deposited on the skin, which causes pruritus. To maintain skin integrity and ease itching, the nurse should apply an emollient lotion to moisturize the skin and reduce itching. Warm, not cool, water should be used, and soap should be avoided, as hot water and soap dry out the skin and increase pruritus. To maintain skin integrity, the client should be turned every 2 hours. Restraints should always be a last option to prevent a client from causing self-harm. Mittens are a better option to prevent scratching.
The nurse is teaching a client how to prevent the development of cirrhosis. Which intervention should the nurse include? A. Avoid illegal drugs. B. Get a yearly flu shot. C. Cut down on the use of alcohol. D. Discontinue all medications.
A. Avoid illegal drugs. Rationale: Clients with diagnosed liver disease are at increased risk for cirrhosis. To prevent cirrhosis from occurring, clients should avoid illegal drugs. They should avoid, not just cut down on, all alcohol and continue taking all medications as prescribed. Flu shots are not known to prevent cirrhosis.
The nurse is creating a plan of care for a client diagnosed with cirrhosis who has experienced gastrointestinal bleeding. Which nursing intervention is most important for the nurse to perform for the client? A. Plan for consistent nursing care assignments. B. Monitor coagulation studies and platelet count. C. Apply mittens to the hands to prevent scratching. D. Teach the family the importance of maintaining diet restrictions.
B. Monitor coagulation studies and platelet count. Rationale: The nurse should take steps to minimize bleeding, which includes monitoring coagulation studies and platelet count. Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and the risk for hepatic encephalopathy. Consistent nursing care assignments help clients with impaired mental status; mittens help promote skin integrity in clients with pruritus; and maintaining diet restrictions help promote nutrition. However, these interventions are less urgent for the client who is at risk for bleeding.
A client suspected of having cirrhosis has prolonged prothrombin times. Which medication should the nurse expect to be prescribed? A. Vitamin B B. Vitamin K C. Nitrates D. Diuretics
B. Vitamin K Rationale: Prolonged prothrombin times indicate that the blood is taking longer to clot and the client is at risk for bleeding. Vitamin K is given to reduce the risk of bleeding. Diuretics are used to treat ascites. Nitrates are used along with a beta blocker to prevent rebleeding of esophageal varices. Vitamin B is not used for the treatment of cirrhosis.
The nurse is caring for a client diagnosed with hepatic encephalopathy. Which nursing action is most appropriate for this client? A. Administer medications to treat diarrhea. B. Provide a high-protein diet. C. Observe the client for asterixis. D. Avoid medications that stimulate the central nervous system.
C. Observe the client for asterixis. Rationale: The signs of early encephalopathy are sometimes subtle. It is important to identify neurologic changes early to begin treatment promptly. Asterixis (flapping of the hands) or changes in handwriting are early signs of neurologic impairment. The client should avoid medications that depress the central nervous system. A low-protein diet is prescribed to decrease nitrogenous waste products that accumulate in the blood and lead to hepatic encephalopathy. Regular bowel elimination promotes protein and ammonia elimination; therefore, measures should be taken to prevent constipation.
The nurse is caring for a client diagnosed with cirrhosis. The client asks the nurse, "Why does my skin itch so much?" How should the nurse respond? A. "Your skin itches because your protein levels are low." B. "Your skin itches because your fluid levels are low." C. "Your skin itches because your liver cannot eliminate bile salts." D. "Your skin itches because you have been bleeding internally."
C. "Your skin itches because your liver cannot eliminate bile salts." Rationale: In liver disease, the client becomes jaundiced with bile salts being deposited on the skin. This causes pruritus. Bleeding, low fluid levels, and low protein levels do not cause itching.
A client with a history of cirrhosis presents to the emergency department with bleeding esophageal varices. The healthcare provider inserts a Minnesota tube. Which assessment is most important for the nurse to make on the client? A. Monitor urine output. B. Monitor urine specific gravity. C. Auscultate bowel sounds. D. Auscultate breath sounds.
D. Auscultate breath sounds. Rationale: Following insertion of a Minnesota tube (a multiple lumen nasogastric tube with a gastric and esophageal balloon), it is a priority for the nurse to monitor the client's respiratory status. Balloon tamponade carries a number of risks, including aspiration, airway obstruction, and tissue ischemia and necrosis. Monitoring breath sounds will provide information about the client's respiratory status. Bowel sounds, urine specific gravity, and urine output are not affected by a Minnesota tube.