Chapter 49: Assessment and Management of Patients with Hepatic Disorders

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? A. Following proper hand-washing techniques B. Avoiding chemicals that are toxic to the liver C. Wearing a condom during sexual contact D. Limiting alcohol intake

A. Following proper hand-washing techniques Rationale: Avoiding contact with the hepatitis E virus through good hygiene, including hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecaloral route, principally through contaminated water in areas with poor sanitation. Consequently, none of the other listed preventative measure is indicated.

A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patient's presentation? A. How many alcoholic drinks do you typically consume in a week? B. To the best of your knowledge, are your immunizations up to date? C. Have you ever worked in an occupation where you might have been exposed to toxins? D. Has anyone in your family ever experienced symptoms similar to yours?

A. How many alcoholic drinks do you typically consume in a week? Rationale: Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use. Immunization status, occupational risks, and family history are also relevant considerations, but alcohol use is a more common etiologic factor in liver disease.

A nurse educate is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. A. Immunizations B. Use of standard precautions C. Consumption of vitamin-rich diet D. Annual vitamin K injections E. Annual vitamin B12 injections

A. Immunizations B. Use of standard precautions Rationale: People who are at high risk, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. The consistent use of standard precautions is also highly beneficial. Vitamin supplementation is unrelated to an individual's risk of HBV.

A client reporting shortness of breath is admitted with a diagnosis of cirrhosis. A nursing assessment reveals an enlarged abdomen with striae, an umbilical hernia, and 4+ pitting edema of the feet and legs. What is the most important data for the nurse to monitor?

Albumin With the movement of albumin from the serum to the peritoneal cavity, the osmotic pressure of the serum decreases. This, combined with increased portal pressure, results in movement of fluid into the peritoneal cavity. The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of ascites and edema.

The nurse is assessing a client with hepatic cirrhosis for mental deterioration. For what clinical manifestations will the nurse monitor? Select all that apply.

Alterations in mood Agitation Insomnia The earliest symptoms of hepatic encephalopathy include both mental status changes and motor disturbances. The client appears confused and unkempt and has alterations in mood and sleep patterns. The client tends to sleep during the day and has restlessness and insomnia at night. To assess for mental deterioration, the nurse will assess general behavior, orientation, and speech as well as cognitive abilities and speech patterns.

The nurse completing a plan of care for a client with cirrhosis who has ascites and 4+ pitting edema of the feet and legs identifies a nursing diagnosis of risk for impaired skin integrity. Which nursing intervention is appropriate for this problem?

Arrange for a low air loss bed. Initiating the use of an alternating-pressure mattress or low air loss bed decreases the risk for skin breakdown due to prolonged pressure on bony prominences. The other answers do not apply.

A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patient's plan of care? A. Measurement of abdominal girth and body weight B. Assessment for variceal bleeding C. Assessment for signs and symptoms of jaundice D. Monitoring of results of liver function testing

B. Assessment of variceal bleeding Rationale: Esophageal varices are a major cause of mortality in patients with uncompensated cirrhosis. Consequently, this should be a focus of the nurse's assessments and should be prioritized over the other listed assessments, even though each should be performed.

A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response? A. Ensure that the patient's sodium intake does not exceed recommended levels B. Report this finding to the primary care provider due to the possibility of hepatic encephalopathy C. Inform the primary care provider that the patient should be assessed for alcoholic hepatitis. D. Implement interventions aimed at ensuring a calm and therapeutic care environment.

B. Report this finding to the primary care provider due to the possibility of hepatic encephalopathy Rationale: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patient's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the patient's physiologic deterioration.

A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem? A. Assessment of blood pressure and assessment for headaches and visual changes. B. Assessments for signs and symptoms of venous thromboembolism. C. Daily weights and abdominal girth measurement. D. Blood glucose monitoring q4h.

C. Daily weights and abdominal girth measurement Rationale: Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose of VTE.

A patient with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the patient's treatment? A. Decisional Conflict B. Deficient Knowledge C. Death Anxiety D. Disturbed Thought Processes

C. Death Anxiety Rationale: The sudden hemorrhage that accompanies variceal bleeding is intensely anxiety-provoking. The nurse must address the patient's likely fear of death, which is a realistic possibility. For most patients, anxiety is likely to be a more acute concern than lack of knowledge or decisional conflict. The patient may or may not experience disturbances in thought processes.

A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? A. The patient will obtain measurement of drainage from the T-tube. B. The patient will exercise three times a week. C. The patient will take immunosuppressive agents as required. D. The patient will monitor for signs of liver dysfunction.

C. The patient will take immunosuppressive agents as required. Rationale: The patient is given written and verbal instructions about immunosuppressive agent doses and dosing schedules. The patient is also instructed on steps to follow to ensure that an adequate supply of medication is available so that there is no change of running out of the medication or skipping a dose. Failure to take medications as instructed may precipitate rejection. The nurse would not teach the patient to measure drainage from a T-tube as the patient would;t go home with a T-tube. The nurse may teach the patient about the need to exercise or what the signs of liver dysfunction are, but the nurse would not stress these topics over the immunosuppressive drug regimen.

A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate? A. Infusion of intravenous heparin B. IV administration of albumin C. STAT administration of vitamin K by the intramuscular route D. IV administration of octreotide (Sandostatin)

D. IV administration of octreotide (Sandostation) Rationale: Octreotide (Sandostatin) a synthetic analog of the hormone somatostatin is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not administered and heparin would exacerbate, not alleviate, bleeding.

A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient's increased risk of bleeding. The nurse recognizes that this risk is related to the patient's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolism B. Retention of bile salts C. Inadequate production of albumin by hepatocytes D. Inability of the liver to use vitamin K.

D. Inability of the liver to use vitamin K. Rationale: Decreased production of several clotting factors may be partially due to deficient absorption of vitamin K from the GI tract. This probably is caused by the inability of liver cells to use vitamin K to make prothrombin. This bleeding risk is unrelated to the roles of glucose, bile salts, or albumin.

The nurse is teaching a client who was admitted to the hospital with acute hepatic encephalopathy and ascites about an appropriate diet. The nurse determines that the teaching has been effective when the client chooses which food choice from the menu?

Pancakes with butter and honey, and orange juice Teach clients to select a diet high in carbohydrates with protein intake consistent with liver function. The client should identify foods high in carbohydrates and within protein requirements (moderate to high protein in cirrhosis and hepatitis, low protein in hepatic failure). The client with acute hepatic encephalopathy is placed on a low-protein diet to decrease ammonia concentration. The other choices are all higher in protein. The client's ascites indicates that a low-sodium diet is needed, and the other choices are all high in sodium.

The nurse is completing a morning assessment of a client with cirrhosis. Which information obtained by the nurse will be of most concern?

The client's hands flap back and forth when the arms are extended. Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy. It indicates that the client has hepatic encephalopathy and, if untreated, a hepatic coma may occur.

Which position should be used for a client undergoing a paracentesis?

Upright at the edge of the bed The client should be placed in an upright position on the edge of the bed or in a chair with the feet supported on a stool. The Fowler position should be used for the client confined to bed.

Which is the most common cause of esophageal varices?

Portal hypertension Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

Which liver function study is used to show the size of the liver and hepatic blood flow and obstruction?

Radioisotope liver scan Radioisotope liver scan assesses liver size and hepatic blood flow and obstuction. MRI is used to identify normal structures and abnormalities of the liver and biliary tree. Angiography is used to visualize hepatic circulation and detect the presence and nature of hepatic masses. Electroencephalography is used to detect abnormalities that occur with hepatic coma.

A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patient's fluid volume excess? Select all that apply. A. Administering diuretics B. Administering calcium channel blockers C. Implementing fluid restrictions D. Implementing a 1500 kcal/day restriction E. Enhancing patient positioning

A. Administering diuretics B. Administering calcium channel blockers E. Enhancing patient positioning Rationale: Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize the management of fluid volume excess. Calcium channel blockers and calorie restriction do not address this problem.

A patient's physician has ordered a liver panel in response to the patient's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A. Alanine aminotransferase (ALT) B. C-reactive protein (CRP) C. Gamma-glutamyl transferase (GGT) D. Aspartate aminotransferase (AST) E. B-type natriuretic peptide (BNP)

A. Alanine aminotransferase (ALT) B. C-reactive protein (CRP) D. Aspartate aminotransferase (AST) Rationale: Liver function testing includes GGT, ALT, and AST. CRP addresses the presence of generalized inflammation and BNP is relevant to heart failure; neither is included in a liver panel.

A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A. Asterixis B. Constructional apraxia C. Fector hepaticus D. Palmar erythema

A. Asterixis Rationale: The nurse will document that a patient exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fector hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.

A 55-year-old female patient with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment? A. Destruction of the patient's liver tumor B. Restoration of portal vein patency C. Destruction of a liver abscess D. Reversal of metastasis

A. Destruction of the patient's liver tumor Rationale: Using radiofrequency ablation, a tumor up to 5 cm in size can be destroyed in one treatment session. This technique does not address circulatory function or abscess formation. It does not allow for the reversal of metastasis.

A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? A. Disposing of sharps appropriately and not recapping needles B. Performing meticulous hand hygiene at the appropriate moments in care C. Adhering to the recommended schedule of immunizations D. Wearing an N95 mask when providing care for patients on airborne precautions

A. Disposing of sharps appropriately and not recapping needles Rationale: HCV is blood-borne. Consequently, prevention of needle stick injuries are paramount. Hand hygiene, immunizations and appropriate use of masks are important aspects of overall infection control, but these actions do not directly mitigate the risk of HCV.

A patient with a liver mass is undergoing a percutaneous liver biopsy. What action should the nurse perform when assisting with this procedure? A. Position the patient on the right side with a pillow under the costal margin after the procedure B. Administer 1 unit of albumin 90 minutes before the procedure as ordered C. Administer at least 1 unit of packed red blood cells as ordered the day before the scheduled procedure D. Confirm that the patient's electrolyte levels have been assessed prior to the procedure

A. Position the patient on the right side with a pillow under the costal margin after the procedure. Rationale: Immediately after a percutaneous liver biopsy, assist the patient to turn onto the right side and place a pillow under the costal margin. Prior administration of albumin or PRBC's is unnecessary. Coagulation tests should be performed, but electrolyte analysis is not necessary.

A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A. Two to 3 soft bowel movements daily B. Significant increase in appetite and food intake C. Absence of nausea and vomiting D. Absence of blood or mucus in stool

A. Two to 3 soft bowel movements daily Rationale: Lactulose (Cephulac) is administered to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the patient's appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.

A nurse is teaching a client about the types of chronic liver disease. The teaching is determined to be effective when the client correctly identifies which type of cirrhosis as being caused by scar tissue surrounding portal areas?

Alcoholic cirrhosis Alcoholic cirrhosis, in which the scar tissue characteristically surrounds the portal areas, is most frequently caused by chronic alcoholism and is the most common type of cirrhosis. In postnecrotic cirrhosis, there are broad bands of scar tissue, which are a late result of a previous acute viral hepatitis. In biliary cirrhosis, scarring occurs in the liver around the bile ducts. Compensated cirrhosis is a general term given to the state of liver disease in which the liver continues to be able to function effectively.

Which term is used to describe a chronic liver disease in which scar tissue surrounds the portal areas?

Alcoholic cirrhosis This type of cirrhosis is due to chronic alcoholism and is the most common type of cirrhosis. In postnecrotic cirrhosis, there are broad bands of scar tissue, which are a late result of a previous acute viral hepatitis. In biliary cirrhosis, scarring occurs in the liver around the bile ducts. Compensated cirrhosis is a general term given to the state of liver disease in which the liver continues to be able to function effectively.

A patient has been admitted to the critical care unit with a diagnosis of toxic hepatitis. When planning the patient's care, the nurse should be aware of what potential clinical course of this health problem? Place the following events in the correct sequence. 1. Fever rises 2. Hematemesis 3. Clotting abnormalities 4. Vascular collapse 5. Coma A. 1,2,5,4,3 B. 1,2,3,4,5 C. 2,3,1,4,5 D. 3,1,2,5,4

B. 1,2,3,4,5 Rationale: Recovery from acute toxic hepatitis is rapid if the hepatotoxin is identified early and removed or if exposure to the agent has been limited. Recovery is unlikely if there is a prolonged period between exposure and onset of symptoms. There are no effective antidotes. The fever rises; the patient becomes toxic and prostrated. Vomiting may be persistent, with the emesis containing blood. Clotting abnormalities may be severe, and hemorrhages may appear under the skin. The severe GI symptoms may lead to vascular collapse. Delirium, coma, and seizures develop, and within a few days the patient may die of fulminant hepatic failure unless he or she receives a liver transplant.

A patient with a history of injection drug use has been diagnosed with Hepatitis C. When collaborating with the care team to plan this patient's treatment, the nurse should anticipate what intervention? A. Administration of immune globulins B. A regimen of antiviral medications C. Rest and watchful waiting D. Administration of fresh-frozen plasma (FFP)

B. A regimen of antiviral medications Rationale: There is no benefit from rest, diet, or vitamin supplements in HCV treatment. Studies have demonstrated that a combination of two antiviral agents, Peg-interferon and ribavirin (Rebetol), is effective in producing improvement in patients with hepatitis C and in treating relapses. Immune globulins and FFP are not indicated.

A patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient may have developed liver metastases? A. Persistent fever and cognitive changes B. Abdominal pain and hepatomegaly C. Peripheral edema unresponsive to diuresis D. Spontaneous bleeding and jaundice

B. Abdominal pain and hepatomegaly Rationale: The early manifestations of malignancy of the liver include pain, a continuous dull ache in the right upper quadrant, epigastrium, or back. Weight loss, loss of strength, anorexia, and anemia may also occur. The liver may be enlarged and irregular on palpation. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver. Fever, cognitive changes, peripheral edema, and bleeding are atypical signs.

A patient with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the patient's prioritization for receiving a donor liver be determined? A. By considering that patient's age and prognosis B. By objectively determining the patient's medical need C. By objectively assessing the patient's willingness to adhere to post-transplantation care D. By systematically ruling out alternative treatment options

B. By objectively determining the patient's medical need Rationale: The patient would undergo a classification of the degree of medical need through an objective determination known as the Model of End-Stage Liver Disease (MELD) classification, which stratifies the level of illness of those awaiting a liver transplant. This algorithm considers multiple variables, not solely age, prognosis, potential for adherence and the rejection of alternative options.

A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? A. Keep patient NPO until the results of test are known B. Keep patient NPO until the patient's gag reflex returns C. Administer analgesia until post-procedure tenderness is relieved D. Give the patient a cold beverage to promote swallowing ability

B. Keep patient NPO until the patient's gag reflex returns Rationale: After the examination, fluids are not given until the patient's gag reflex returns. Lozenges and gargles may be used to relieve throat discomfort if the patient's physical condition and mental status permit. The result of the test is known immediately. Food and fluids are contraindicated until the gag reflex returns.

A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? A. Watery, blood-streaked diarrhea B. Orange and foamy urine C. Increased abdominal girth D. Decreased cognition

B. Orange and foamy urine Rationale: If the bile duct is obstructed, the bile will be reabsorbed into the blood and carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy. Bloody diarrhea, ascites, and cognitive changes are not associated with obstructive jaundice.

A nurse is caring for a patient with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL. For what complication is this patient at risk? A. Chronic jaundice B. Pigment stones in portal circulation C. Central nervous system damage D. Hepatomegaly

C. Central nervous system damage Rationale: Prolonged jaundice, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin exceeding 20 to 25 mg/dL) poses a risk for CNS damage. There are not specific risks of hepatomegaly or chronic jaundice resulting from high bilirubin

A nurse has entered the room of a patient with cirrhosis and found the patient on the floor. The patient stated that she fell when transferring to the commode. The patient's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action? A. Remove the patient's commode and supply a bedpan B. Complete an incident report and submit it to the unit supervisor C. Have the patient assessed by the physician due to the risk of internal bleeding D. Perform a focused abdominal assessment in order to rule out injury.

C. Have the patient assessed by the physician due to the risk of internal bleeding Rationale: A fall would necessitate thorough medical assessment due to the patient's risk of bleeding. The nurse's abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate.

A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what? A. IV administration of immune globulins B. Transfusion of packed red blood cells and fresh-frozen plasma (FFP) C. Liver transplantation D. Lobectomy

C. Liver transplantation Rationale: Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery

Diagnostic testing has revealed that a patient's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patient's plan of care will focus on what intervention? A. Cryosurgery B. Liver transplantation C. Lobectomy D. Laser hyperthermia

C. Lobectomy Rationale: Surgical resection is the treatment of choice when HCC is confined to one lobe of the liver and the function of the remaining liver is considered adequate for postoperative recovery. Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While cryosurgery and liver transplantation are other surgical options for management of liver cancer, these procedures are not performed at the same frequency as a lobectomy. Laser hyperthermia is a nonsurgical treatment for liver cancer.

A patient with liver disease has developed jaundice; the nurse is collaborating with the patient to develop a nutritional plan. The nurse should prioritize which of the following in the patient's plan? A. Increased potassium intake B. Fluid restriction to 2L per day C. Reduction in sodium intake D. High-protein, low-fat diet

C. Reduction in sodium intake Rationale: Patient with ascites require a sharp reduction in sodium intake. Potassium intake should not be correspondingly increased. There is no need for fluid restriction or increased protein intake.

A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

C. Stage 3 Rationale: Patients in the third stage of hepatic encephalopathy exhibit the following symptoms: stuporous, difficult to arouse, sleeps most of the time, exhibits marked confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of extremities, marked EEG abnormalities. Patients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3, and patients in stage 4 are comatose. In stage 4, there is an absence of asterixis, absence of deep tendon reflexes, flaccidity of extremities, and EEG abnormalities.

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately?

Change in the client's handwriting and/or cognitive performance The earliest symptoms of hepatic encephalopathy include mental status changes and motor disturbances. The client will appear confused and unkempt and have altered mood and sleep patterns. Neurologic status should be assessed frequently. Mental status is monitored by the nurse keeping the client's daily record of handwriting and arithmetic performance. The nurse should report any change in mental status immediately. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis.

A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding? A. Similar liver size and texture as in younger adults B. A nonpalpable liver C. A slightly enlarged liver with palpably hard edges D. A slightly decreased size of the liver

D. A slightly decreased size of the liver Rationale: The most common age-related change in the liver is a decrease in size and weight. The liver is usually still palpable, however, it is not expected to have hardened edges.

A nurse is amending a patient's plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patient's care plan? A. Mobilization with assistance at least 4 times daily B. Administration of beta-adrenergic blockers as ordered C. Vitamin B12 injections as ordered D. Administration of diuretics as ordered

D. Administration of diuretics as ordered Rationale: Use of diuretics along with sodium restriction is successful in 90% of patients with ascites. Beta-blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B23 injections are not necessary.

A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine? A. The hepatitis A vaccine B. Albumin infusion C. The hepatitis A and B vaccines D. An immune globulin injection

D. An immune globulin injection Rationale: For people who have not been previously vaccinated, hepatitis A can be prevented by the intramuscular administration of immune globulin during the incubation period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will not protect the patient exposed to hepatitis A, as protection will take a few weeks to develop after the first dose of the vaccine. The hepatitis B vaccine provides protection against the hepatitis B virus, but plays no role in protection for the patient exposed to hepatitis A. Albumin confers no therapeutic benefit.

A patient with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the patient's family how to safely perform which of the following actions? A. Aspirating bile from the catheter using a syringe B. Removing the catheter when output is 15 mL in 24 hours C. Instilling antibiotics into the catheter D. Assessing the patency of the drainage catheter

D. Assessing the patency of the drainage catheter Rationale: Families should be taught to provide basic catheter care, including assessment of patency. Antibiotics are not instilled into the catheter and aspiration using a syringe is contraindicated. The family would not independently remove the catheter; this would be done by a member of the care team when deemed necessary.

A patient with liver cancer is being discharged home with a hepatic artery catheter in place. The nurse should be aware that this catheter will facilitate which of the following? A. Continuous monitoring for portal hypertension B. Administration of immunosuppressive drugs during the first weeks after transplantation C. Real-time monitoring of vascular changes in the hepatic system D. Delivery of a continuous chemotherapeutic dose

D. Delivery of a continuous chemotherapeutic dose Rationale: In most cases, the hepatic artery catheter has been inserted surgically and has a prefilled infusion pump that delivers a continuous chemotherapeutic dose until completed. The hepatic artery catheter dose not monitor portal hypertension, deliver immunosuppressive drugs, or monitor vascular changes in the hepatic system

Which is an age-related change of the hepatobiliary system?

Decreased blood flow Age-related changes of the hepatobiliary system include decreased blood flow, decreased drug clearance capability, increased presence of gall stones, and a steady decrease in the size and weight of the liver.

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition?

Hepatic encephalopathy Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with an elevated ammonia concentration that produces changes in mental status, altered level of consciousness, and coma. Portal hypertension is an elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia?

Hypotension Signs of potential hypovolemia include cool, clammy skin; tachycardia; decreased blood pressure; and decreased urine output.

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal?

Maintaining the airway Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway can be compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.

Which assessments are important in a client diagnosed with ascites?

Measurement of abdominal girth, weight, and palpation of the abdomen for a fluid shift are all important assessment parameters for the client diagnosed with ascites.

What initial measure can the nurse implement to reduce risk of injury for a client with liver disease?

Padding the side rails can reduce injury if the client becomes agitated or restless. Restraints would not be an initial measure to implement. Four side rails are considered a restraint, and this would not be an initial measure to implement. Family and friends generally assist in calming a client.

Clients with chronic liver dysfunction have problems with insufficient vitamin intake. Which may occur as a result of vitamin C deficiency?

Scurvy may result from a vitamin C deficiency.

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?

Vasopressin Vasopressin may be the initial therapy for esophageal varices because it produces constriction of the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Spironolactone and cimetidine do not decrease portal hypertension.

Which condition indicates an overdose of lactulose?

Watery diarrhea The client receiving lactulose is monitored closely for the development of watery diarrheal stool, which indicates a medication overdose.

A client with hepatic cirrhosis questions the nurse about the possible use of an herbal supplement—milk thistle—to help heal the liver. Which is the most appropriate response by the nurse?

"Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis. However, you should always notify your primary care provider of any herbal remedies being used so drug interactions can be evaluated." Many clients who have end-stage liver disease (ESLD) with cirrhosis use the herb milk thistle (Silybum marianum) to treat jaundice and other symptoms. This herb has been used for centuries because of its healing and regenerative properties in liver disease. Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis. The natural compound SAM-e (s-adenosylmethionine) may improve outcomes of liver disease by improving liver function, possibly by enhancing antioxidant function. Herbal supplements are used in conjunction with medical treatment and medications. Herbal supplements are not approved by the FDA. Their usage should be discussed with the primary care provider to evaluate their effectiveness and interactions with other treatment regimens.

The nurse is preparing a care plan for a client with hepatic cirrhosis. Which nursing diagnoses are appropriate? Select all that apply.

-Risk for injury related to altered clotting mechanisms -Activity intolerance related to fatigue, general debility, muscle wasting, and discomfort -Disturbed body image related to changes in appearance, sexual dysfunction, and role function

A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurse's most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse's best response to this assessment finding? A. Document the presence of normal bile output. B. Irrigate the drainage system with normal saline as ordered. C. Aspirate a sample of the drainage for culture. D. Promptly report this assessment finding to the primary care provider.

A. Document the presence of normal bile output. Rationale: Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.

A nurse on a solid organ transplant unit is planning the care of a patient who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? A. Implementation of infection-control measures B. Close monitoring of skin integrity and color C. Frequent assessment of the patient's psychosocial status D. Administration of antiretroviral medications

A. Implementation of infection-control measures Rationale: Infection control is paramount following liver transplantation. This is a priority over skin integrity and psychosocial status, even though these are valid areas of assessment and intervention. Antiretrovirals are not indicated.

A patient is being discharged after a liver transplant and the nurse is performing discharge education. When planning the patient's continuing care, the nurse should prioritize which of the following risk diagnoses? A. Risk for infection related to immunosuppressant use B. Risk for injury related to decreased hemostasis C. Risk for unstable blood glucose related to impaired gluconeogensis D. Risk for contamination related to accumulation of ammonia

A. Risk for infection related to immunosuppressant use Rationale: Infection is the leading cause of death after liver transplantation. Pulmonary and fungal infections are common; susceptibility to infection is increased by the immunosuppressive therapy that is needed to prevent rejection. This risk exceeds the threats of injury and unstable blood glucose. The diagnosis of risk for contamination related to environmental toxin exposure.

A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis? A. Finish all prescribed courses of antibiotics, regardless of symptoms resolution. B. Adhere to dosing recommendations of OTC analgesics. C. Ensure that expired medications are disposed of safely. D. Ensure that pharmacists regularly review drug regimens for potential interactions.

B. Adhere to dosing recommendations of OTC analgesics. Rationale: Although any medication can affect liver function, use of acetaminophen (found in many OTC medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Finishing prescribed antibiotics and avoiding expired medications are unrelated to this disease. Drug interactions are rarely the cause of drug-induced hepatitis.

A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient's liver? A. Place hand under the right lower abdominal quadrant and press down lightly with the other hand. B. Place the left hand over the abdomen and behind the left side at the 11th rib. C. Place hand under right lower rib cage and press down lightly with the other hand. D. Hold hand 90 degree to right side of the abdomen and push down firmly.

C. Place hand under right lower rib cage and press down lightly with the other hand. Rationale: To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant.

A patient with esophageal varices is being cared for in the ICU. The varices have begun to bleed and the patient is at risk for hypovolemia. The patient has Ringer's Lactate at 150 cc/hr infusing. What else might the nurse expect to have ordered to maintain volume for this patient? A. Arterial line B. Diuretics C. Foley catheter D. Volume expanders

D. Volume expanders Rationale: Because patients with bleeding esophageal varices have intravascular volume depletion and are subject to electrolyte imbalance, IV fluids with electrolytes and volume expanders are provided to restore fluid volume and replace electrolytes. Diuretics would reduce vascular volume. An arterial line and Foley catheter are likely to be ordered, but neither actively maintains the patient's volume.

Which nursing assessment is most important in a client diagnosed with ascites?

Daily measurement of weight & abdominal girth

A young client with anorexia, fatigue, and jaundice is diagnosed with hepatitis B and has just been admitted to the hospital. The client asks the nurse how long the stay in the hospital will be. In planning care for the client, the nurse identifies impaired psychosocial issues and assigns the highest priority to which client outcome?

Minimizing social isolation The nurse identifies psychosocial issues and concerns, particularly the effects of separation from family and friends if the client is hospitalized during the acute and infective stages. Convalescence may be prolonged, with complete symptomatic recovery sometimes requiring 3 to 4 months or longer. Even if not hospitalized, the client will be unable to attend school and/or work and must avoid sexual contact. Planning is required to minimize social isolation.

A client has undergone a liver biopsy. After the procedure, the nurse should place the client in which position?

On the right side Immediately after the biopsy, assist the client to turn on to the right side; place a pillow under the costal margin, and caution the client to remain in this position. In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded. Positioning the client on the left side is not indicated. Positioning the client in the Trendelenburg position may be indicated if the client is in shock, but it is not the position designed for the client after liver biopsy. The high Fowler position is not indicated for the client after liver biopsy.

Which term describes the passage of a hollow instrument into a cavity to withdraw fluid?

Paracentesis Paracentesis may be used to withdraw fluid (ascites) if the accumulated fluid is causing cardiorespiratory compromise. Asterixis refers to involuntary flapping movements of the hands associated with metabolic liver dysfunction. Ascites refers to accumulation of serous fluid within the peritoneal cavity. Dialysis refers to a form of filtration to separate crystalloid from colloid substances. refers to involuntary flapping movements of the hands associated with metabolic liver dysfunction.

A nurse is gathering equipment and preparing to assist with a sterile bedside procedure to withdraw fluid from a client's abdomen. The procedure tray contains the following equipment: trocar, syringe, needles, and drainage tube. The client is placed in he high Fowler position and a blood pressure cuff is secured around the arm in preparation for which procedure?

Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions. Paracentesis may be used to withdraw ascitic fluid if the accumulated fluid is causing cardiorespiratory compromise.

When caring for a client with cirrhosis, which symptom(s) should the nurse report immediately?

change in mental status When caring for a client with cirrhosis, the nurse should report any change in mental status immediately because they indicate secondary complications. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis.

A client has undergone a liver biopsy. Which postprocedure position is appropriate?

o In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded. Positioning the client on his left side is not indicated. Positioning the client in the Trendelenburg position may be indicated if the client is in shock, but is not the position designed for the client after liver biopsy. The high Fowler position is not indicated for the client after liver biopsy.