chapter 53

Which action by the nurse would most likely help to relieve symptoms associated with ascites? Monitoring serum albumin levels Lowering the head of the bed Administering oxygen therapy Administering intravenous fluids

Administering oxygen therapy The best action by the nurse caring for a client with ascites is to elevate the head of the bed and provide supplemental oxygen. The enlarged abdomen of ascites limits respiratory excursion. Fowler position will increase excursion and reduce shortness of breath.Monitoring serum albumin levels will detect anticipated decreased levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

The nurse is caring for a patient with cirrhosis who has hepatic encephalopathy. Which assessment finding should the nurse report to the primary health care provider? A. Fatigue B. Difficulty sleeping C. Seizure D. Disorientation

Answer: C Rationale: Choices A, B, and D are associated with early hepatic encephalopathy. However, seizures occur later and indicate that the complication is progressing. Therefore, Choice C is the most concerning and should be reported to the primary health care provider.

The nurse is caring for a client diagnosed with hepatitis A. Which transmission-based precautions are required when providing care for this client? Select all that apply. A. Place client in a private room. B. Wear a mask when handling patient bedpan. C. Wear gloves when touching the client. D. Wear a gown when providing personal care to this patient. E. Wear eye goggles when providing care.

Answer: D Rationale: Hepatitis A is transmitted via the fecal-oral route. Therefore, the nurse needs to use gloves and a gown when providing care to the client and having contact with the client's stool Choice D). Gloves are not needed to touch the client unless the nurse is cleaning after the client has a stool (Choice C). A mask and googles are not needed because hepatitis of any type is not transmitted as an airborne or droplet disease (Choice B and E). Therefore, a private room is not necessary (Choice A).

The nurse is caring for a client who is diagnosed with cirrhosis? Which serum laboratory values will the nurse expect to be abnormal? Select all that apply. A. Prothrombin time B. Serum bilirubin C. Albumin D. Aspartate aminotransferase (AST) E. Lactate dehydrogenase (LDH) F. Acid phosphatase

Answers: A, B, C, D, E Rationales: Acid phosphatase is not usually affected by liver disease (Choice F). However, serum liver enzymes including AST and LDH are elevated (Choices D and E). Serum bilirubin increase due to the inability of the liver to excrete bile (Choice B). Prothrombin time is prolonged because the diseased liver decreases prothrombin production (Choice A). Serum albumin decreases due to the inability of the diseased liver to produce it (Choice C).

.A client is receiving adefovir for management of hepatitis B. What health teaching will the nurse provide for the client about this drug? Select all that apply. A. "Avoid places with crowds and individuals who have infection." B. "Report increased bruising to your doctor because the drug can cause bleeding." C. "Get your lab work done regularly because the drug can affect your kidneys." D. "Be careful and avoid falls because the drug can cause fractures." E. "Follow up with the dietitian to ensure that you adhere to your special diet."

Answers: A, C Rationales: Adefovir is an immune modulating drug and therefore can weaken a client's immune system. Therefore, teaching the client to avoid sources of infection is a correct response (Choice A). Almost all immune modulating drugs are excreted via the kidneys and kidney function may be impaired. Regular follow-up with lab work for monitor renal function is essential (Choice C). The other choices are not associated with this medication.

The nurse is caring for a client in end-stage liver failure. Which interventions should implemented when observing for hepatic encephalopathy? Select all that apply. A. Assess the client's neurologic status as prescribed. B. Monitor the client's hemoglobin and hematocrit levels. C. Monitor the client's serum ammonia level. D. Monitor the client's electrolyte values daily. E. Prepare to insert an esophageal balloon tamponade tube. F. Make sure the client's fingernails are short.

Answers: A, C Rationales: The client experiencing encephalopathy has chronic confusion and other mental status changes caused by increased ammonia levels. Therefore, monitoring the serum ammonia levels and the client's neurologic status during treatment can help determine the effectiveness of the treatment plan (Choices A and C). Monitoring electrolytes is appropriate for patients who have ascites (Choice D). Preparing to insert an esophageal tamponade tube and monitoring the client's hemoglobin and hematocrit are interventions for clients experiencing bleeding varices (Choices B and E). Choice F is appropriate to prevent tissue damage when clients have pruritus as a result of jaundice.

When preparing a client to undergo paracentesis, which action is necessary to reduce potential injury as a result of the procedure? Assist the provider to insert a trocar catheter into the abdomen. Position the client with the head of the bed flat. Encourage the client to take deep breaths and cough. Ask the client to void prior to the procedure.

Ask the client to void prior to the procedure. To avoid injury to the bladder during a paracentesis, the client would be asked to void prior to the procedure. Taking deep breaths and coughing does not prevent complications or injury as a result of paracentesis. Clients would be positioned with the head of the bed elevated. The trocar catheter is used to drain the ascetic fluid and does not reduce the risk of damage to the bladder.

It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? Right shoulder pain Bone marrow suppression Polyuria Bleeding

Bleeding A potential complication of hepatic artery embolization for hepatic cancer is bleeding. Prompt detection of hemorrhage is the priority.Discomfort such as right shoulder pain may be present, but the priority is to assess for hemorrhage. The nurse must assess for signs of shock, not polyuria. Embolization does not suppress the bone marrow. If chemotherapy or immune modulators is used, the nurse then assesses for bone marrow suppression.

The nurse is teaching a client and family about home care following a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. Which client finding would the nurse teach the family to report to the primary health care provider immediately? Decreased ascitic fluid Changes in consciousness or behavior Fatigue and weakness Decreased pulse rate

Changes in consciousness or behavior Although serious complications of the TIPS are not common, the client needs to be monitored for hepatic encephalopathy. This complication is manifested by changes in consciousness, mental status, and/or behavior. A decreased pulse rate and ascitic fluid are expected and clients with cirrhosis are usually fatigued and weak.

The nurse is caring for a client who was recently diagnosed with Laennec cirrhosis. What is the nurse's priority assessment during client care? Cardiovascular assessment Abdominal assessment, including bowel sounds Respiratory assessment Cognitive and neurologic assessment

Cognitive and neurologic assessment The type of cirrhosis that this client has is caused by alcoholism. Withdrawal from alcohol can cause cognitive and neurologic changes, such as confusion and delirium tremens (DTs).

The nurse is caring for a client who just had a paracentesis. Which client finding indicates that the procedure was effective? Increased blood pressure Decreased weight Increased pulse Decreased pain

Decreased weight A paracentesis is performed to remove ascitic fluid from the abdomen. Therefore, the client should weigh less after the procedure than before. Blood pressure should decrease due to less fluid volume and the pulse rate may not be affected. The client may report less abdominal discomfort or ease in breathing, but pain is not a common problem for cirrhotic clients.

The nurse is assessing a client who is diagnosed as having Hepatitis A and asks how someone gets this disease. What is the most likely cause of the client's Hepatitis A? Being exposed to blood or blood products Eating contaminated food or water Having unprotected sex Sharing needles for illicit drugs

Eating contaminated food or water Hepatitis A is transmitted through the fecal-oral route rather than via blood. Therefore, contaminated food or water with Escherichia coli or other microbes can cause this liver infection.

When caring for a client with portal hypertension, the nurse assesses for which potential complications? (Select all that apply.) Select all that apply. Esophageal varices Ascites Hematuria Hemorrhoids Fever

Esophageal varices Ascites Hemorrhoids Potential complications of portal hypertension include esophageal varices, ascites, and hemorrhoids. Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid).Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

The nurse is caring for a client who has been diagnosed with cirrhosis. Which laboratory result(s) would the nurse expect for this client? (Select all that apply.) Select all that apply. Increased serum bilirubin Increased lactate dehydrogenase Decreased serum albumin Increased serum alanine aminotransferase Increased aspartate aminotransferase Increased serum ammonia

Increased serum bilirubin Increased lactate dehydrogenase Decreased serum albumin Increased serum alanine aminotransferase Increased aspartate aminotransferase Increased serum ammonia Cirrhosis is a chronic disease in which the liver progressively degenerates. As a result, liver enzymes and bilirubin increase. Additionally, the liver is unable to synthesize protein leading to decreased serum albumin. Elevated serum ammonia results from the inability of the liver to detoxify protein by-products.

The nurse is caring for a client who had a liver transplant last week. For which complication will the nurse teach the client and family to monitor? Acute kidney injury Hypertension Pulmonary edema Infection

Infection The client is at the most risk for rejection of the transplant which can be the result of an infection if not identified and managed effectively. Therefore, the nurse would teach the client and family to report cough, fever, skin redness, and other signs of infection.

What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? Drink only bottled water and avoid ice. Avoid sharing the bathroom with the client. Members of the household must not share toothbrushes. The client must not consume alcohol.

Members of the household must not share toothbrushes. The nurse teaches the family of a client with hepatitis C that toothbrushes, razors, towels, and any other items may spread blood and body fluids and must not be shared.The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water needs to be avoided.

When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B? Clients who work with shellfish. Clients with elevations of aspartate aminotransferase and alanine aminotransferase. Men who engage in sex with men. Clients traveling to a third-world country.

Men who engage in sex with men. Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity.Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A. Hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? "The scars on my liver create problems with blood circulation." "My liver is scarred, but the cells can regenerate themselves and repair the damage." "Because of the scars on my liver, blood clotting and blood pressure are affected." "Cirrhosis is a chronic disease that has scarred my liver."

My liver is scarred, but the cells can regenerate themselves and repair the damage."The client's statement that, although his liver is scarred, the cells can regenerate and repair the damage indicates that further instruction is needed. Although cells and tissues will attempt to regenerate, destroyed liver cells will result in permanent scarring and irreparable damage.

How would the home care nurse best modify the client's home environment to manage side effects of lactulose? Obtains a walker for the client. Rearranges furniture to declutter the home. Removes throw rugs to prevent falls. Requests a bedside commode for the client.

Requests a bedside commode for the client. The home care nurse would modify the client's home environment to manage side effects of lactulose by making a bedside commode available to the client. Lactulose therapy increases the frequency of stools. A bedside commode is especially necessary if the client has difficulty reaching the toilet.

When assessing a client with hepatitis B, the nurse anticipates which assessment findings? (Select all that apply.) Select all that apply. Right upper quadrant tenderness Itching Recent influenza infection Brown stool Tea-colored urine

Right upper quadrant tenderness Itching Tea-colored urine Assessment findings the nurse expects to find in a client with hepatitis B include brown, tea-, or cola-colored urine; right upper quadrant pain due to inflammation of the liver; and itching, irritating skin caused by deposits of bilirubin on the skin secondary to high bilirubin levels and jaundice.Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored, not typically brown.

The nurse teaches the client who has cirrhosis about foods and other substances that should be avoided to prevent worsening of the disease. Which substance(s) will the nurse include in that health teaching? (Select all that apply.) Select all that apply. Smoking Alcohol Illicit drugs Acetaminophen Sodium Protein

Smoking Alcohol Illicit drugs Acetaminophen Protein and sodium should be moderately restricted but not completely avoided. The other substances can worsen the disease process, especially drugs and alcohol which are normally metabolized by the liver.

The nurse collaborates with the registered dietitian nutritionist in providing teaching for a client who has ascites from cirrhosis. What daily dietary restriction would the nurse include in the health teaching? Calcium Potassium Magnesium Sodium

Sodium Mild to moderate sodium restriction is often tried as the first intervention to decrease body fluid retention, including ascites.

When caring for a client with Laennec cirrhosis, which of these findings does the nurse expect to find on assessment? (Select all that apply.) Select all that apply. Elevated magnesium Swollen abdomen Prolonged partial thromboplastin time Elevated amylase level Currant jelly stool Icterus of skin

Swollen abdomen Prolonged partial thromboplastin time Icterus of skin Clients with Laennec cirrhosis have damaged clotting factors, so prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity.Elevated magnesium is not related to cirrhosis. Amylase is typically elevated in pancreatitis. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. It is also consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase.

The family of a client who has hepatic encephalopathy asks why the client is restricted to moderate amounts of dietary protein and has to take lactulose. What is an appropriate response by the nurse? "These interventions help to reduce the ammonia level." "These interventions help to prevent heart failure." "These interventions help the client's jaundice improve." "These interventions help to prevent nausea and vomiting."

These interventions help to reduce the ammonia level." The client's high ammonia level has caused encephalopathy which can become so severe that it causes death. These interventions help to reduce ammonia in the body so that this condition does not worsen.

The nurse is caring for a client who has cirrhosis of the liver. The client's latest laboratory testing shows a prolonged prothrombin time. For what assessment finding would the nurse monitor: deep vein thrombosis. jaundice. hematemesis. pressure injury.

hematemesis. The client who has cirrhosis is at risk for bleeding due to decreased production of prothrombin by the liver. Portal hypertension that occurs in clients with cirrhosis causes esophageal blood veins to become fragile, distended, and tortuous. Therefore, these veins tend to bleed as evidenced by either hematemesis or melena.