Chapter 53: Liver Problems

17. Which symptoms in a client with cirrhosis and encephalopathy indicate to the nurse that the prescribed lactulose therapy is effective? Select all that apply. A. Decreased confusion B. Increased urine output C. Musty odor to the breath D. Two to three soft stools daily E. Lower serum bilirubin levels F. Lower serum ammonia levels

17. A, D, F Lactulose helps reduce encephalopathy by increasing stools, which causes the loss of some nitrogen-producing bacteria in the intestinal tract. This loss reduces ammonia levels and helps decrease confusion. Lactulose does not affect serum bilirubin levels or increase urine output. A musty odor of the breath (fetor hepaticus) is an indication of worsening encephalopathy.

22. Which clients will the nurse suggest to be immunized against hepatitis B (HBV)? Select all that apply. A. People who have unprotected sex with more than one partner B. Men who have sex with men C. Any client scheduled for a surgical procedure D. Firefighters E. Health care providers F. Clients prescribed immunosuppressant drugs

22. A, B, D, E, F HBV can be spread by both the parenteral and sexual routes. Exposures are more likely to result in infection in clients who are immunosuppressed for any reason. Individuals who are exposed to blood and other bodily fluids in the workplace are at risk for exposure.

23. How will the nurse interpret a client's laboratory finding of the presence of immunoglobulin G antibodies directed against hepatitis A (HAV)? A. Active, infectious HAV is present. B. Permanent immunity to HAV is present. C. This is the client's first infection to HAV. D. The risk for infection if exposed to HAV is high.

23. B Immunoglobulin G (IgG) directed against HAV are antibodies that indicate the client was previously exposed to HAV and developed immunity against it.

25. What is the nurse's best first action when a client who just had a liver transplant develops oozing around two IV sites as well as has some new bruising? A. Applying pressure to the IV sites B. Checking the client's platelet levels C. Notifying the surgeon immediately D. Documenting the findings as the only action

25. C Bleeding around the IV sites is a strong indicator of clotting problems. Such problems are an indicator of impaired function of the transplanted liver and may be an early sign of transplant rejection. Immediate action is needed to prevent harm in the form of graft loss.

1. Which client's previous health history will the nurse most associate with a risk for developing postnecrotic cirrhosis of the liver? A. 28-year-old woman who had gallstones 1 year ago and has recently lost 20 lb (9 kg) on a low-calorie, low-fat diet B. 45-year-old man with hepatitis C infection and chronic use of acetaminophen C. 50-year-old man who has many years of excessive alcohol consumption D. 55-year-old woman who has chronic biliary obstruction

1. B Postnecrotic cirrhosis of the liver is caused by viral hepatitis, especially hepatitis C, and drugs that are liver toxic, such as acetaminophen. Cirrhosis caused by chronic alcoholism is Laennec cirrhosis. Chronic biliary obstruction can result in biliary cirrhosis. Gallstones are not associated with cirrhosis unless chronic biliary obstruction is also present.

10. Which neuromuscular assessment change indicates to the nurse that a client who has late-stage liver cirrhosis now has encephalopathy? A. Asterixis B. Positive Chvostek sign C. Increased deep tendon reflex responses D. Decreased deep tendon reflex responses

10. A A late finding in clients who have late-stage liver cirrhosis and encephalopathy is asterixis, which is a coarse tremor that is characterized by rapid, nonrhythmic extensions and flexions in the wrists and fingers (hand-flapping).

11. Which new-onset assessment findings in a client with Laennec cirrhosis indicates to the nurse that the client may be starting to have delirium tremens (DTs) from alcohol withdrawal? Select all that apply. A. Anxiety B. Tachycardia C. Hypotension D. Hypertension E. Cool, clammy skin F. Psychotic behavior

11. A, B, D, F Alcohol withdrawal occurs sometimes as soon as 6 to 8 hours after stopping alcohol intake after heavy and prolonged use and can lead to DTs. Cognitive, behavioral, and autonomic changes that occur may include acute confusion, anxiety, and psychotic behaviors, such as delusions and hallucinations, along with autonomic changes of tachycardia, elevated blood pressure, and diaphoresis.

12. What is the nurse's priority action when a client with ascites reports increased abdominal pain and chills? A. Applying oxygen and making the client NPO B. Notifying the primary health care provider immediately C. Assessing for abdominal rigidity and taking the client's temperature D. Applying a heating blanket and raising the head of the bed to a 45-degree angle

12. C Increasing abdominal pain and the presence of chills in a client who has ascites indicate possible spontaneous bacterial peritonitis. The nurse would perform a complete abdominal assessment and assess for a temperature elevation before notifying the primary health care provider.

13. Which assessment findings will the nurse expect in a client with late-stage liver cirrhosis whose total serum albumin level is low? Select all that apply. A. Ascites B. Hypotension C. Hyperkalemia D. Hyponatremia E. Dependent edema F. Decreased serum ammonia levels

13. A, B, D, E Serum albumin maintains plasma oncotic pressure and sodium levels in the normal range. When albumin levels are low, plasma volume decreases as fluid leaks into the abdomen and dependent areas, forming ascites and dependent edema. Sodium follows the albumin, making serum sodium levels low. The decreased plasma volume results in hypotension.

14. Which actions are appropriate for the nurse to perform to prevent harm in a client with cirrhosis and ascites who has just undergone an esophagogastroduodenoscopy (EGD)? Select all that apply. A. Measuring oxygen saturation B. Checking for leakage from the site C. Assessing for return of the gag reflex D. Monitoring heart rate and blood pressure E. Auscultating bowel sounds in all four quadrants F. Comparing weight with that obtained before the procedure

14. A, C, D A client with cirrhosis and ascites is at risk for bleeding and hemorrhage as a result of reduced blood clotting factor synthesis. The endoscope placement for an EGD can irritate or rupture any varices in the esophagus, stomach, or duodenum and lead to hemorrhage. The client must be closely monitored for indications of bleeding and hemorrhage by examining for changes in oxygen saturation, heart rate, and blood pressure. In addition, the procedure is performed under local anesthesia or light sedation and the client's gag reflex is affected.

15. Which serum electrolyte value in a client with early-stage ascites from chronic liver disease who is taking spironolactone will the nurse report immediately to the primary health care provider? A. Sodium 133 mEq/L (mmol/L) B. Potassium 6.4 mEq/L (mmol/L) C. Chloride 101 mEq/L (mmol/L) D. Calcium 8.9 mg/dL (2.2 mmol/L)

15. B Although the sodium and calcium levels are slightly low, they do not pose a significant risk at this time. The serum potassium level is well above normal, which may be related to the spironolactone therapy because it causes sodium excretion and potassium retention, and must be reported to the primary health care provider immediately. The serum chloride level is normal.

16. Which actions will the nurse perform when preparing a client for paracentesis? Select all that apply. A. Obtaining informed consent B. Maintaining the client on NPO status C. Asking the client to void before the procedure D. Placing the client in the flat supine position E. Weighing the client before the procedure F. Assessing the respiratory rate and blood pressure

16. C, E, F Vital signs, including weight, are taken before the procedure to use as a baseline for changes after the procedure. Weight is important because it can help determine the volume of fluid removed (clients are expected to weigh less after a paracentesis). Having the client void before procedure helps prevent injury to the bladder. The health care provider performing the paracentesis is responsible for obtaining informed consent, not the nurse. The client does not need to be NPO before the procedure. The client is positioned with the head of the bed elevated.

18. Which precaution is most important for the nurse to instruct a client with cirrhosis and his or her family about continuing care in the home? A. Avoid taking acetaminophen or drinking alcohol. B. Maintain one-floor living to prevent excessive fatigue. C. Use cool baths to reduce the sensation of itching. D. Report any change in cognition to the health care provider.

18. A Although all of the listed precautions are important, the most important is the avoidance of acetaminophen and alcohol. These substances are toxic to the liver and will worsen the client's liver disease.

19. For clients with which types of hepatitis will the nurse teach about prevention of infection spread through the oral-fecal contamination route? Select all that apply. A. Hepatitis A (HAV) B. Hepatitis B (HBV) C. Hepatitis C (HCV) D. Hepatitis D (HDV) E. Hepatitis E (HEV) F. Toxic hepatitis

19. A, E HAV and HEV are spread by the oral-fecal route from contaminated food and water sources. HBV, HCV, and HDV are spread primarily by the parenteral route although sexual contact can also result in infection spread. Toxic hepatitis is not infectious and is caused by exposure to hepatotoxic chemicals.

2. What liver problem does the nurse suspect in a client whose liver is hard with a nodular texture and the hepatic enzymes remain normal? A. Prenecrotic inflammation B. Postnecrotic inflammation C. Compensated cirrhosis D. Decompensated cirrhosis

2. C In compensated cirrhosis, the liver is scarred with physical changes and cellular regulation is impaired, but the organ can still perform essential functions, including maintaining normal liver enzyme levels without causing major symptoms. In decompensated cirrhosis, liver function is impaired with obvious signs and symptoms of liver failure, including elevated liver enzymes.

20. What is the nurse's best response to a client who fears he may have been exposed to hepatitis A while attending a banquet last week after which three restaurant workers were diagnosed with hepatitis A? A. "Which types of food did you eat at the banquet?" B. "If you have no symptoms at this time, you are probably safe." C. "You can receive an immunoglobulin injection to prevent the infection." D. "Contact your primary health care provider about receiving the hepatitis A vaccine."

20. C Receiving immunoglobulin with a high concentration of antihepatitis A antibodies within 2 weeks of exposure can prevent an exposed person from developing the infection. Receiving the vaccination at this time takes too long to develop sufficient immunity to prevent an infection from this exposure.

21. Which actions are most effective for nurses and other health care workers to prevent occupational transmission of viral hepatitis? Select all that apply. A. Washing hands before and after contact with all clients B. Using needleless systems for parenteral therapy C. Using Standard Precautions with all clients regardless of age or sexual orientation D. Obtaining an immunoglobulin injection after exposure to hepatitis A E. Being fully vaccinated with the hepatitis B vaccine F. Wearing gloves during direct contact with all clients

21. A, B, C, D, E With the exception of F, all actions are effective in preventing or reducing transmission of infectious hepatitis among health care workers as a result of occupational exposure (see the Best Practices for Patient Safety and Quality Care: Prevention of Viral Hepatitis in Health Care Workers box). Wearing gloves during direct contact with all clients may give a false sense of security and does not prevent transmission if gloves are contaminated and then come into contact with another person. Gloves are not needed for all client contact.

24. Which precaution is most important for the nurse to instruct clients with hepatitis C (HCV) who are receiving drug therapy with any second-generation protease inhibitor? A. Avoid crowds and people who are ill. B. Do not touch these drugs with your bare hands. C. Alternate periods of activity with periods of rest. D. Be sure to take vitamin K supplements with this drug.

24. A All of these drugs cause some degree of immunosuppression and increase the client's risk for infection.

3. What will the nurse recognize as the cause of splenomegaly in a client who has cirrhosis? A. Increased pressure in the portal vein causing backflow of blood into the spleen B. The loss of cellular regulation in the liver spreading to the spleen and causing extensive scarring C. Chronic inflammation and infection increasing the spleen's maturation and release of white blood cells D. Direct destruction of spleen cells from alcohol or other toxins causing replacement with scar tissue formation

3. A Portal hypertension caused by stiffened liver tissue results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. This increased portal vein pressure causes backflow of blood into the spleen, resulting in splenomegaly.

4. Which activities are most important for the nurse to teach a client with esophageal varices to prevent harm from bleeding or hemorrhage? Select all that apply. A. Avoid alcoholic beverages. B. Eat soft foods and cool liquids. C. Do not engage in strenuous exercise or heavy lifting. D. Try to eat six smaller meals daily instead of three larger ones. E. Be sure to keep your mouth open when sneezing or coughing. F. Cross your legs only at the ankles when sitting, rather than the knees.

4. B, C Esophageal varices are thin-walled blood vessels that bleed easily with mechanical irritation or any increase in pressure within the portal system. Clients must avoid any activity that increases intra-abdominal pressure such as strenuous exercise and heavy lifting. Hard or rough foods can mechanically open the varices and cause bleeding. Avoiding alcohol may prevent worsening of the liver problems but does not directly prevent bleeding or hemorrhage. None of the other activities alter intra-abdominal pressure or prevent direct injury to the varices.

5. Which essential nutrient will the nurse expect to be deficient in a client who has liver cirrhosis and ascites? A. Sodium B. Potassium C. Vitamin C D. Vitamin K

5. D Clients with advanced liver disease, such as cirrhosis with ascites, are unable to metabolize fats and absorb fat-soluble vitamins from the GI tract. As a result, vitamin K is deficient. (Vitamin C is water-soluble.)

6. Which signs and symptoms will the nurse expect to find on assessment of a client with chronic liver disease who has an elevated serum bilirubin level? Select all that apply. A. Pruritus B. Icterus C. Hypertension D. Jaundice E. Pale, clay-colored stools F. Dark, coffee-colored urine

6. A, B, D, E, F Bilirubin is a bile pigment. Elevated serum bilirubin levels stain the skin yellow (jaundice) and the eyes yellow (icterus). Jaundice is accompanied by intense itching. The excess bilirubin is excreted in the urine, turning it dark and coffee-colored. With liver disease and reduced function, the bilirubin does not reach the intestinal system where it is normally broken down to give stool its dark brown color. Because the bilirubin does not reach the GI tract, stools are light with a gray or clay color.

7. Which common factors will the nurse recognize as contributing to or worsening of hepatic encephalopathy in clients with liver cirrhosis? Select all that apply. A. Anorexia B. Infection C. Opioids D. Diarrhea E. GI bleeding F. High-protein diet G. Diabetes mellitus H. Chronic confusion

7. B, C, E, F Factors that may contribute to or worsen hepatic encephalopathy in patients with cirrhosis include high-protein diet, infection, hypovolemia (decreased fluid volume), hypokalemia (decreased serum potassium), constipation, GI bleeding (causes a large protein load in the intestines), and some drugs, especially hypnotics, opioids, sedatives, analgesics, diuretics, illicit drugs.

8. Which client will the nurse recognize as having the greatest risk for nonacoholic fatty liver disease (NAFLD)? A. 45-year-old Latino man who is 30 lb (13.9 kg) overweight and has type 2 diabetes B. 50-year-old white woman who drinks one glass of wine daily and has breast cancer C. 60-year-old black woman who is hypertensive and takes a diuretic daily D. 70-year-old Asian man who has gastroesophageal reflux disease (GERD)

8. A Obesity and type 2 diabetes with metabolic syndrome are risk factors for NAFLD. In addition, a genetic variation in the PNPLA3 gene increases the risk. This variation is much more common among Latinos.

9. Which assessment technique will the nurse use to most accurately determine increasing ascites in a client with advanced liver cirrhosis and portal hypertension? A. Interpreting the serum albumin value B. Measuring the client's abdominal girth C. Testing stool for the presence of occult blood D. Weighing the client daily at the same time of the day

9. D Although measuring abdominal girth can show increases in girth that can be interpreted as more ascites, weighing the client provides more accurate information of water retention in the abdominal and dependent areas.