Chapter 49 test 2
When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function? Irritability and drowsiness
Although all the options are associated with hepatitis B, the onset of irritability and drowsiness suggests a decrease in hepatic function. To detect signs and symptoms of disease progression, the nurse should observe for disorientation, behavioral changes, and a decreasing level of consciousness and should monitor the results of liver function tests, including the blood ammonia level. If hepatic function is decreased, the nurse should take safety precautions.
A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. A likely cause of these symptoms is: acute cholecystitis
Gallstones are more frequent in women, particularly women who are middle-aged and obese. With acute cholecystitis, clients usually are very sick with fever, vomiting, tenderness over the liver, and severe pain that may radiate to the back and shoulders. The patient profile and symptoms are suggestive of acute cholecystitis.
A physician orders lactulose (Cephulac), 30 ml three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor: Level of consciousness (LOC)
In cirrhosis, the liver fails to convert ammonia to urea. Ammonia then builds up in the blood and is carried to the brain, causing cerebral dysfunction. When this occurs, lactulose is administered to promote ammonia excretion in the stool and thus improve cerebral function. Because LOC is an accurate indicator of cerebral function, the nurse can evaluate the effectiveness of lactulose by monitoring the client's LOC
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.
Gynecomastia is a common side effect of which of the following diuretics? Spironolactone
Gynecomastia is a common side effect caused by spironolactone. Vasopressin is used for bleeding esophageal varices and is not a diuretic. Nitroglycerin (IV) may be used with vasopressin to counteract the effects of vasoconstriction from the vasopressin.
A client with hepatitis who has not responded to medical treatment is scheduled for a liver transplant. Which of the following most likely would be ordered? Tacrolimus
In preparation for a liver transplant, a client receives immunosuppressants to reduce the risk for organ rejection. Tacrolimus and cyclosporine are two immunosuppressants that may be used.
A client with advanced cirrhosis has a prothrombin time (PT) of 15 seconds, compared with a control time of 11 seconds. The nurse expects to administer: phytonadione (Mephyton)
Prothrombin synthesis in the liver requires vitamin K. In cirrhosis, vitamin K is lacking, precluding prothrombin synthesis and, in turn, increasing the client's PT. An increased PT, which indicates clotting time, increases the risk of bleeding. Therefore, the nurse should expect to administer phytonadione (vitamin K1) to promote prothrombin synthesis. Spironolactone and furosemide are diuretics and have no effect on bleeding or clotting time. Warfarin is an anticoagulant that prolongs PT.
Which liver function study is used to show the size of the liver and hepatic blood flow and obstruction? Radioisotope live scan
A radioisotope liver scan assesses liver size and hepatic blood flow and obstruction. 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. EEG is used to detect abnormalities that occur with hepatic coma.
A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal? Albumin
Albumin is an abnormal finding in a routine urine specimen. Ascites present in liver failure contain albumin; therefore, if the bladder ruptured, ascites containing albumin would drain from the indwelling urinary catheter because the catheter is no longer contained in the bladder. Creatinine, urobilinogen, and chloride are normally found in urine.
A client is seeing the physician for a suspected tumor of the liver. What laboratory study results would indicate that the client may have a primary malignant liver tumor? Elevated alpha-fetoprotein
Alpha-fetoprotein, a serum protein normally produced during fetal development, is a marker that, if elevated, can induce a primary malignant liver tumor.
When inspecting the abdomen of a client with cirrhosis, the nurse observes that the veins over the abdomen are dilated. The nurse documents this finding as which of the following? caput medusae
Caput medusa is a term used to denote the appearance of dilated veins over the client's abdomen
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.
A client with gallstones tells the nurse, "The doctor has to do something. Isn't there something he can give me to dissolve them?" What medication does the nurse know may help dissolve the gallstones?
Chenodiol suppresses hepatic synthesis of cholesterol and cholic acid to dissolve gallstones. It is administered orally to dissolve gallstones and may require long-term therapy for effectiveness.
Alcohol, which is toxic to the liver, is a common cause of hepatic disorders. As part of health teaching, the nurse advises a group of women that the amount of daily alcohol use should generally be limited to the equivalent of: 1 drink
Current guidelines from the CDC and the Dietary Guidelines for Americans define moderate alcohol consumption as up to one drink per day for women and up to two drinks per day for men.
A nurse is responsible for monitoring the diet of a client with hepatic encephalopathy. Which daily protein intake should this 185-pound (84-kilogram) male consume? 100-126 grams
Daily protein intake should be maintained at 1.2 to 1.5 g/kg per day.
A client with acute pancreatitis has jaundice with diminished bowel sounds and a tender distended abdomen. Additionally, lab results indicate hypovolemia. What will the physician order to treat the large amount of protein-rich fluid that has been released into the client's tissues and peritoneal cavity? Select all that apply. diuretics albumin
Diuretics are given if circulating fluid is excessive. IV albumin may be given to pull fluid trapped in the peritoneum back into the circulation.
Which type of deficiency results in macrocytic anemia? Folic acid
Folic acid deficiency results in macrocytic anemia. Vitamin C deficiency results in hemorrhagic lesions of scurvy. Vitamin A deficiency results in night blindness and eye and skin changes. Vitamin K deficiency results in hypoprothrombinemia, which is characterized by spontaneous bleeding and ecchymosis.
The nurse is caring for a patient with ascites due to cirrhosis of the liver. What position does the nurse understand will activate the renin-angiotensin aldosterone and sympathetic nervous system and decrease responsiveness to diuretic therapy? Upright
In patients with ascites, an upright posture is associated with activation of the renin-angiotensin-aldosterone system and sympathetic nervous system (Porth & Matfin, 2009). This causes reduced renal glomerular filtration and sodium excretion and a decreased response to loop diuretics.
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.
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
A physician has ordered a liver biopsy for a client with cirrhosis whose condition has recently deteriorated. The nurse reviews the client's recent laboratory findings and recognizes that the client is at risk for complications due to: low platelet cound
Prolonged prothrombin time (PT) and low platelet count place the client at high risk for hemorrhage. The client may receive intravenous (IV) administration of vitamin K or infusions of platelets before liver biopsy to reduce the risk of bleeding.
Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia? Hyptension
Signs of potential hypovolemia include cool, clammy skin; tachycardia; decreased blood pressure; and decreased urine output.
A nurse is assessing a postoperative client for hemorrhage. What responses associated with the compensatory stage of shock should be reported to the healthcare provider? Tachycardia and tachypnea
The compensatory stage is the first stage of shock. During this stage, the sympathetic nervous system (SNS) is activated due to changes in blood volume and blood pressure. The SNS stimulates the cardiovascular system, causing tachycardia, and the respiratory system, causing tachypnea. Thus, tachycardia (not bradycardia) and tachypnea (not bradypnea) occur with the compensatory stage of shock.
The nurse is asking the client with acute pancreatitis to describe the pain. What pain symptoms does the client describe related to acute pancreatitis? Severe mid-abdominal to upper abdominal pain radiating to both sides and to the back
The most common complaint of clients with pancreatitis is severe mid-abdominal to upper abdominal pain, radiating to both sides and straight to the back.
A client is receiving vasopressin for the urgent management of active bleeding due to esophageal varices. What most serious complication should the nurse assess the client for after the administration? Electrocardiogram changes
Vasopressin (Pitressin) is administered during the management of an urgent situation with an acute esophageal bleed because of its vasoconstrictive properties in the splanchnic, portal, and intrahepatic vessels. This medication also causes coronary artery constriction that may dispose clients with coronary artery disease to cardiac ischemia; therefore, the nurse observes the client for evidence of chest pain, ECG changes, and vital sign changes. Vasopressin will does not infer with urinary output, electrolytes, or liver enzymes.
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.
A nurse assesses a patient diagnosed with hepatic encephalopathy. She observes a number of clinical signs, including asterixis and fetor hepaticus; the patient's electroencephalogram (EEG) is abnormal. The nurse documents that the patient is exhibiting signs of which stage of hepatic encephalopathy? Stage 2
The signs listed in the question plus disorientation, mood swings, and increased drowsiness are all indicators of stage 2 hepatic encephalopathy. Refer to Table 25-2 in the text.
During assessment, a patient with chronic liver dysfunction tells the nurse that he is experiencing spontaneous episodes of bleeding and has noticed increased areas of bruising on his chest and arms. The nurse suspects a deficiency in: Vitamin K
A vitamin K deficiency results in hypoprothrombinemia, which is characterized by spontaneous bleeding and ecchymosis
A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should: Wash hands after touching the client
To maintain enteric precautions, the nurse must wash her hands after touching the client or potentially contaminated articles and before caring for another client. A private room is warranted only if the client has poor hygiene — for instance, if the client is unlikely to wash the hands after touching infective material or is likely to share contaminated articles with other clients. For enteric precautions, the nurse need not wear a mask and must wear a gown only if soiling from fecal matter is likely.
