Concept Synthesis Exam #1 (ALF, Pre-eclampsia, HELLP)

A patient with acute hepatic dysfunction is having difficulty completing his menu and "can't seem to remember" how to use the bed controls. The nurse realizes these changes might indicate which stage of hepatic encephalopathy? 1. I 2. II 3. III 4. IV

1 1. Manifestations of stage I hepatic encephalopathy are subtle and include impaired handwriting and intellectual function changes. 2. Manifestations of stage II hepatic encephalopathy include a decreased level of consciousness and disorientation to time and place. 3. In stage III hepatic encephalopathy, the nurse would assess stupor and abnormal posturing. 4. Stage IV hepatic encephalopathy is manifested by coma, seizures, and severe electroencephalogram abnormalities.

Infants of women with preeclampsia during pregnancy tend to be small for gestational age (SGA) because of which condition? 1. Intrauterine growth restriction 2. Oliguria 3. Proteinuria 4. Hypertension

1 Infants of women with preeclampsia during pregnancy tend to be small for gestational age (SGA) because of intrauterine growth restriction. The cause is related specifically to maternal vasospasm and hypovolemia, which result in fetal hypoxia and malnutrition.

A pregnant woman is admitted to the high-risk maternity unit with HELLP syndrome. The nurse would provide which interventions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Protect the woman from inadvertent injury. 2. Monitor IV sticks for bleeding. 3. Monitor the woman for development of seizure. 4. Monitor the patient for the development of hypernatremia. 5. Prepare the woman for immediate intubation and mechanical ventilation.

123 1. The woman with HELLP syndrome has a low platelet count. She should be protected from injury. 2. The woman with HELLP syndrome has a low platelet count. Invasive lines should be monitored for bleeding. 3. HELLP syndrome is associated with preeclampsia. This patient should be monitored for development of seizure, which would indicate development of eclampsia. 4. Monitoring for hypernatremia is not associated with HELLP syndrome. 5. There is nothing in the scenario that indicates the woman is not breathing well on her own. Intubation is not necessary.

When blood pressure and other signs indicate that the preeclampsia is worsening, hospitalization is necessary to monitor the woman's condition closely. At that time, which of the following should be assessed? Select all that apply. 1. Fetal heart rate 2. Blood pressure 3. Temperature 4. Urine color 5. Pulse and respirations

1235 1. Determine the fetal heart rate along with blood pressure, or monitor continuously with the electronic fetal monitor if the situation indicates. 2. Determine blood pressure every 1 to 4 hours, or more frequently if indicated by medication or other changes in the woman's status. 3. Determine temperature every 4 hours, or every 2 hours if elevated or if premature rupture of the membranes (PROM) has occurred. 5. Determine pulse rate and respirations along with blood pressure.

A patient has been admitted to the intensive care unit with the diagnosis of hyperacute liver failure. Which assessment findings would the nurse anticipate in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. INR (international normalized ratio) greater than 1.5 2. History of alcohol abuse 3. Jaundice 4. Mental status changes 5. Serum glucose greater than 125 mg/dL

134 1. By definition, acute liver failure results in an INR greater than 1.5. 2. Acute liver failure has many etiologies. The nurse should not assume this patient has abused alcohol. 3. The designation of hyperacute liver failure is based on the amount of time between onset of jaundice and another finding. Therefore, jaundice exists in this patient. 4. The designation of hyperacute liver failure is based on the amount of time between onset of an assessment finding and the development of hepatic encephalopathy. Mental status changes are found in hepatic encephalopathy. 5. Serum glucose is not a factor in determining the classification of acute liver failure.

A patient with acute hepatic dysfunction demonstrates slow slurred speech and cold clammy skin. The nurse would collaborate with the primary care provider for treatment of which condition? 1. Cerebral embolism 2. Hypoglycemia 3. Bleeding esophageal varices 4. Increased ammonia level

2 1. Cerebral embolism is not a common occurrence in acute hepatic dysfunction and is not supported by these assessment findings. 2. Since liver failure interferes with normal carbohydrate metabolism, the patient may develop hypoglycemia secondary to decreased gluconeogenesis. The patient should be closely monitored for the development of hypoglycemic symptoms, which include slow thinking, slurred speech, nervousness, tachycardia, and cold clammy skin. 3. If esophageal varices exist and begin bleeding, the patient will experience hematemesis. 4. Liver failure can result in increased serum ammonia levels, which will cloud mentation. It will not result in cold clammy skin at the level in which the patient will still be able to speak.

A patient with a history of chronic liver disease is admitted with acute hemorrhage from esophageal varices. The nurse would expect treatment interventions for which causative condition? 1. The patient has developed gallstones as a result of poor liver function. 2. The patient has portal hypertension with shunting of blood. 3. The nonsteroidal anti-inflammatory drug (NSAID) use that caused the patient's chronic liver failure has also resulted in gastritis. 4. The abdominal distention caused by ascites has resulted in reflux esophagitis.

2 1. Esophageal varices are not associated with gallstones. 2. Esophageal varices are a complication of portal hypertension. Since the esophageal veins in the lower part of the esophagus are a common collateral flow diversion, any rapid increase in pressure of the engorged veins will lead to an acute hemorrhage. 3. Gastritis is not associated with esophageal varices. 4. Esophageal varices are not caused by reflux esophagitis.

The nurse is monitoring a patient for progression through the grades of hepatic encephalopathy (HE). This morning the patient is exhibiting a positive Babinski reflex. The nurse would conduct additional assessment about which HE grade? 1. I 2. II 3. III 4. IV

2 1. Reflexes are likely to be normal in HE grade I. 2. A positive Babinski reflex may be seen in grade II HE. 3. A positive Babinski reflex occurs in a grade before HE grade III. 4. By grade IV reflexes are decreased to absent.

A patient reports taking two 500-mg acetaminophen tablets "at least 3 or 4 times a day" to treat muscle pain in his back. What nursing assessment question is priority? 1. "Do you drink plenty of water when you take these pills?" 2. "What other medications do you take?" 3. "Have you had your back reassessed lately?" 4. "What other measures do you take to relieve your back pain?"

2 1. The patient should drink a full glass of water with these pills, but this is not the priority assessment question. 2. The nurse should assess this patient for unintended acetaminophen overdose by asking about other medications the patient takes. If these other medications also contain acetaminophen, the patient may be in danger of overdose. 3. The nurse would ask questions to follow up on chronic back pain, but this is not the highest priority. 4. The nurse should ask about additional pain relief measures and may discover problems such as alcohol use. This question is a priority, but it is not the highest priority.

The nurse is assessing a patient admitted with acute liver failure of unknown etiology. Which statement made by the family requires additional investigation? 1. "I thought her skin color change was due to going to the indoor tanning booth." 2. "She has been exercising by gathering wild berries and greens for salads." 3. "We went to the mall last week and she got pretty tired while shopping." 4. "She was exposed to influenza last week when she went to visit her sister."

2 1. There is no association with indoor tanning booths and acute liver failure. 2. This statement may reveal that the patient has ingested mushrooms that can cause liver toxicity. The nurse should ask additional assessment questions. 3. Being tired and intolerant of exercise would be expected if the patient was in acute liver failure. 4. Exposure to influenza is not a significant risk factor for development of acute liver failure.

While assessing a patient admitted with acute hepatic dysfunction, the nurse notes abnormal involuntary movements of the patient's hands. How should the nurse document this finding? 1. As seizure activity 2. As asterixis 3. As decorticate posturing 4. As hyperreflexia

2 1. This abnormal movement does not represent a seizure. 2. Asterixis, or liver flap, refers to an involuntary tremor that is particularly noted in the hands but may also be seen in the feet and tongue. 3. Abnormal posturing would affect all four extremities. 4. This finding represents a tremor, not a reflex.

A patient will be given rifaximin (Xifaxan) to reduce ammonia production by intestinal bacteria. The nurse would add which intervention to this patient's plan of care? 1. Monitor IV site for infiltration. 2. Monitor for development of abdominal cramping. 3. Increase fluids to reduce risk of constipation. 4. Monitor serum potassium levels daily.

2 1. This medication is given orally. 2. An adverse effect of ammonia-reducing agents is the development of abdominal cramping. 3. Diarrhea is the more common adverse reaction from these medications. 4. There is no indication that serum potassium levels will be affected by this medication.

The nurse is assessing a client who has severe preeclampsia. What assessment finding should be reported to the physician? 1. Excretion of less than 300 mg of protein in a 24-hour period 2. Platelet count of less than 100,000/mm3 3. Urine output of 50 mL per hour 4. 12 respirations

2 HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) complicates 10% to 20% of severe preeclampsia cases and develops prior to 37 weeks' gestation 50% of the time. Vascular damage is associated with vasospasm, and platelets aggregate at sites of damage, resulting in low platelet count (less than 100,000/mm3).

A client is being admitted to the labor area with the diagnosis of eclampsia. Which actions by the nurse are appropriate at this time? Select all that apply. 1. Tape a tongue blade to the head of the bed. 2. Pad the side rails. 3. Have the woman sit up. 4. Provide the client with grief counseling. 5. The airway should be maintained and oxygen administered.

25 2. Side rails should be up and padded. 5. Suctioning may be necessary to keep the airway clear.

A patient admitted with general malaise, nausea, and vomiting tells the nurse that he started to feel sick a few weeks after getting a new tattoo on his leg. Which type of hepatitis should the nurse suspect is causing this patient's symptoms? 1. A 2. E 3. C 4. A combination of A and D

3 1. Hepatitis A (HAV) is transmitted through the fecal-oral route. Tattooing is not considered a risk factor for HAV. 2. Hepatitis E is transmitted by contaminated water and fecal-oral routes. It is most prevalent in India, China, and Southeast Asia. 3. Hepatitis C is transmitted primarily through blood and blood products. Risk factors for the development of the illness include tattoos conducted in nonprofessional settings. 4. There is no indication that HAV and Hepatitis D (HDV) are associated with receiving a tattoo.

A teenage girl is admitted to the intensive care unit after taking an overdose of acetaminophen. What nursing assessment question is priority? 1. "Did you take the pills on purpose?" 2. "Do you have diabetes?" 3. "Could you be pregnant?" 4. "Do you feel at all sick to your stomach?"

3 1. It is important to determine intent to harm oneself, but this is a question better left until later. 2. The knowledge of whether or not the patient has diabetes is not essential at this point. 3. This is an important question and will be followed up by a pregnancy test. 4. Nausea may occur with acetaminophen overdose, but this is not a priority question.

A patient is prescribed N-acetylcysteine (NAC) 140 mg/kg via nasogastric tube. What is the priority nursing intervention? 1. Give the dose slowly over at least 15 minutes. 2. Warn the patient that the medication smells like burning rubber. 3. Give all follow-up doses exactly on time. 4. Ask the patient what he weighs.

3 1. There is no indication that this medication must be given slowly. 2. This medication smells like rotten eggs. 3. It is very important that the remaining 17 doses of NAC be given every 4 hours as directed and on time. 4. The nurse should weigh the patient, not depend on an estimated weight.

A patient with severe ascites has undergone abdominal paracentesis with removal of 2 liters of fluid. The nurse anticipates administration of which product? 1. 2 liters of normal saline 2. 4 liters of lactated ringer's solution 3. 16 to 20 grams of albumin 4. 6 to 10 units of platelets

3 1. There is no indication that this patient requires 2 liters of normal saline. 2. There is no indication that this patient requires lactated Ringer's (LR) solution. 3. Removing this much fluid may result in profound fluid shifts, which alter hemodynamics. The patient should receive 8 to 10 grams of albumin for each liter of ascites fluid removed. 4. There is no indication that this patient requires platelets.

The community nurse is working with a client at 32 weeks' gestation who has been diagnosed with preeclampsia. Which statement by the client would indicate that additional information is needed? 1. "I should call the doctor if I develop a headache or blurred vision." 2. "Lying on my left side as much as possible is good for the baby." 3. "My urine could become darker and smaller in amount each day." 4. "Pain in the top of my abdomen is a sign my condition is worsening."

3 Oliguria is a complication of preeclampsia. Specific gravity of urine readings over 1.040 correlate with oliguria and proteinuria and should be reported to the physician.

A woman is hospitalized with severe preeclampsia. The nurse is meal-planning with the client and encourages a diet that is high in what? 1. Sodium 2. Carbohydrates 3. Protein 4. Fruits

3 The client who experiences preeclampsia is losing protein.

A patient with acute hepatic dysfunction has abdominal ascites. The nurse would anticipate which laboratory finding? 1. Serum sodium less than 135 mEq/L 2. Hematocrit less than 36% 3. High-density lipoprotein (HDL) level greater than 40 mg/dL 4. Albumin level lower than 3.5 g/L

4 . Hyponatremia is not associated with abdominal ascites. 2. Hematocrit will generally rise as fluid is shifted out of the circulating system and into the abdomen. 3. An elevated HDL level is not typically associated with ascites. 4. Ascites, an abnormal collection of fluid in the abdominal cavity, develops from decreased colloid osmotic pressure and portal hypertension. Colloid osmotic pressure decreases as a result of a reduction in albumin. Hypoalbuminemia is caused by the inability of the liver to carry out its usual protein metabolism functions, causing a drop in colloid osmotic pressure and shifting fluid from the intravascular compartment into other body compartments.

The nurse is caring for a patient admitted with acute hepatic dysfunction caused by acetaminophen toxicity. Which clinical findings would indicate that the patient's condition is deteriorating? 1. Sweet odor on the breath 2. Tachycardia 3. Hyperresponsive pupillary responses 4. Change in level of consciousness

4 1. A sweet odor on the breath is not associated with liver failure. 2. Bradycardia, not tachycardia, is a finding associated with Cushing's triad, which indicates increased intracranial pressure. 3. Pupillary responses typically become sluggish. 4. In acute hepatic dysfunction caused by fulminant hepatic failure, manifestations are the result of cerebral edema and include elevated intracranial pressure and could result in brainstem herniation. One of the first indications that the patient is deteriorating would be a change in level of consciousness.

A patient in acute liver failure has developed increased intracranial pressure. Hypothermia has been induced. Which nursing intervention should be added to the patient's plan of care? 1. Keep the patient's temperature below 33°C. 2. Monitor the patient for development of frostbite. 3. Stimulate the patient at least every hour to assess for neurological changes. 4. Monitor for the development of infection.

4 1. The patient's temperature should not be allowed to go below 33°C. 2. The patient's temperature will not be low enough for development of frostbite. 3. The patient has increased intracranial pressure. Sedation, not stimulation, is indicated. 4. Induced hypothermia increases risk for infection.

A patient with acute hepatic dysfunction is experiencing a gastrointestinal bleed. The nurse should be prepared to administer which products? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Mannitol 2. Antibiotics 3. Albumin 4. Vitamin K 5. Fresh frozen plasma

45 1. Mannitol would be administered for increased cerebral edema, not bleeding. 2. The patient may require antibiotics, but this is not the immediate priority. 3. Albumin is not administered to treat GI bleed. 4. Treatment for an acute gastrointestinal bleed due to acute hepatic dysfunction includes the administration of vitamin K. 5. Since this patient is actively bleeding, the administration of fresh frozen plasma is indicated.

A patient with acute hepatic dysfunction is prescribed lactulose (Cephulac) 45 mL by mouth four times a day. Which findings will the nurse evaluate as indicating the medication is having its desired effect? Select all that apply. 1. The patient's abdominal girth is smaller. 2. The patient has no more oozing from esophageal varices. 3. The patient's hemoglobin has increased. 4. The patient's mentation is clearer. 5. The patient has had three stools in the last 24 hours.

45 1. Reduction in abdominal girth is not the intended effect of administration of lactulose; however, some reduction may occur. 2. Decrease in oozing from esophageal varices is not the intended effect of administration of lactulose. 3. Lactulose is not intended to increase the patient's hemoglobin. 4. Lactulose helps to decrease ammonia, which will result in clearer mentation. 5. Lactulose, a synthetic disaccharide, helps prevent the absorption of ammonia through the bowel by moving the stool through the intestines more rapidly to prevent bacteria from breaking down. Three to five stools daily is the intended effect.

A patient is admitted with suspected acute hepatic failure. Which findings would the nurse evaluate as supporting this suspected diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient complains of thirst. 2. The patient has a dry cough. 3. The patient's hemoglobin is elevated. 4. The patient's international normalized ratio (INR) is elevated. 5. The patient has new onset of confusion.

45 1. Thirst is not a documented effect of acute hepatic failure on any major body system. 2. Crackles and tachypnea are respiratory effects of acute hepatic failure and not a dry cough. 3. Elevation of hemoglobin is not an expected effect of acute liver failure. 4. Within the hematologic system, assessment findings would include impaired coagulation with an elevated INR. 5. Development of encephalopathy is a hallmark of acute liver failure. New onset confusion may herald development of hepatic encephalopathy.

The nurse is caring for a client who was just admitted to rule out ectopic pregnancy. Which orders are the most important for the nurse to perform? 1. Assess the client's temperature. 2. Document the time of the client's last meal. 3. Obtain urine for urinalysis and culture. 4. Report complaints of dizziness or weakness. 5. Have the lab draw blood for B-hCG level every 48 hours.

45 Reporting complaints of dizziness and weakness is important, as it can indicate hypovolemia from internal bleeding. Having the lab draw blood for B-hCG levels every 48 hours is important, as the level rises much more slowly in ectopic pregnancy than in normal pregnancy.

The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse? A) Blood pressure of 142/92 B) Pulse of 92 beats per minute C) Respiratory rate of 24 per minute D) Weight gain of 16 oz per week

A A pregnant client's blood pressure should not be greater than 140/90, and if it is elevated, it could be a sign of gestational hypertension or preeclampsia. The pregnant client's heart and respiratory rates will increase slightly as a result of an increased circulatory volume and a decrease in intrathoracic space. Weight gain should average a pound per week in the second and third trimesters.

The nurse is concerned that a client with potential hepatic failure is at risk for developing ascites. Which assessment finding would indicate this development? A) Increased abdominal girth B) Gallbladder pain C) Yellow-tinged skin D) Bleeding and bruising easily

A Ascites is the accumulation of the fluid in the abdomen, and is a result of liver failure. The client with ascites would have an increased abdominal girth. Jaundice is manifested as yellow-tinged skin, and is the result of hepatic disorders. The client experiencing hepatic problems might have bleeding and bruising issues due to inadequate vitamin K. Obstructed biliary flow could be the cause of gallbladder pain.

The nurse is caring for a client with severe pregnancy-induced hypertension who is in the hospital on a magnesium sulfate drip. The nurse monitors the client for which sign of magnesium toxicity? a) Diminished reflexes b) Awkward movements c) Decreased appetite d) Slurring of speech

A Diminished reflexes signify magnesium toxicity. Slurred speech, decreased appetite, and awkward movements indicate a therapeutic magnesium level.

A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for: a) Hand tremors b) Weight loss c) Urinary urgency d) Stomatitis

A Hepatic encephalopathy results from cerebral edema, the accumulation of neurotoxins in the blood; therefore, the nurse wants to assess for signs of neurological involvement. Tremoring or flapping of the hands (asterixis) when the arms are extended and wrists dorsiflexed, agitation, confusion, and changes in mentation are common. These clients typically have ascites and edema, so they also experience weight gain, although they may actually be malnourished due to compromised liver functioning and nutrient absorption. Urinary urgency and stomatitis are not related to hepatic encephalopathy.

The community nurse is caring for a client who is 32 weeks pregnant and diagnosed with preeclampsia. Which statement indicates that the client requires additional teaching? A) "My urine may become darker and smaller in amount each day." B) "I should call the doctor if I develop a headache or blurred vision." C) "Pain in the top of my abdomen is a sign my condition is worsening." D) "Lying on my left side as much as possible is good for the baby."

A Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the condition is worsening. It is not an expected outcome and should be reported to the physician. Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia, and should be reported to the physician. Left lateral position maximizes uterine and renal blood flow, and therefore is the optimal position for a client with preeclampsia. Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported to the physician.

The nurse is caring for a client with severe preeclampsia who is showing signs of bleeding and oozing from intravenous sites and who is bruising under the skin. The nurse suspects this is a sign of which clinical manifestation? a) Hemolysis, elevated liver enzymes, low platelet count syndrome (HELLP) b) Eclampsia c) Chronic hypertensive disease d) Transient hypertension

A Pregnant women with severe preeclampsia may develop HELLP syndrome, which has a very poor prognosis. HELLP presents with nausea, vomiting, flu-like symptoms, and bleeding due to liver involvement and platelet aggregation. Eclampsia presents with seizures, blurred vision, and high blood pressure. Chronic and transient hypertension may lead to HELLP syndrome.

A nurse is caring for a client who was recently admitted for treatment of cirrhosis. The client is currently experiencing BP of 200/100, +3 pitting edema, and shortness of breath. Which diagnosis should the nurse select as a priority for this client? A) Excess Fluid Volume B) Ineffective Tissue Perfusion C) Deficient Fluid Volume D) Impaired Skin Integrity

A The client experiencing shortness of breath, edema, and hypertension should have a care plan for fluid volume excess. Hypertension, shortness of breath, and edema are manifestations of fluid excess. Hypotension and dry mucous membranes are associated with deficient fluid volume. Ineffective Tissue Perfusion would be the appropriate diagnosis for a client experiencing cyanosis or tissue necrosis. Edema can cause an alteration in skin integrity, but there is no evidence of such problems with this client.

The nurse would evaluate teaching as effective when a client with chronic viral hepatitis progressing to cirrhosis states which of the following? a) "The medications that help to regulate how my body handles protein will help me have a pretty normal lifespan." b) "I understand that the fibrosis and loss of liver cells can be reversed if I'm really careful with my diet and avoid alcohol and drugs." c) "I know I should only use acetaminophen for pain relief." d) "Since this is caused by an infection, not lifestyle, I'm glad to hear that I won't need to reduce my alcohol intake.

A The client with chronic viral hepatitis resulting in cirrhosis should avoid alcohol and medications like acetaminophen that will further damage the liver. Because the liver becomes fibrotic and there is an extensive loss of liver cells, treatments will not cure or reverse the disease, but they can help to slow the progression to liver failure. Use of medications to regulate protein metabolism is one form of supportive therapy that can help to reduce complications and delay liver failure but these, of course, do not guarantee a long life.

A nurse working in Labor and Delivery cares for clients with preeclampsia. The nurse understands that the exact cause of this condition is not known; however, research suggests: A) It is a disorder of placental dysfunction. B) It is a disorder of fetal liver compromise. C) It is a disorder of maternal hyporesponsiveness to vasoactive peptides. D) It is a disorder of excess trophoblast invasion within the placenta.

A The exact cause of preeclampsia is unknown. However, it has been identified as a disorder of placental dysfunction leading to a syndrome of endothelial dysfunction with associated vasospasm.

During a routine prenatal visit, a client who is 24 weeks pregnant has an increased blood pressure. The nurse identifies which nursing diagnosis as appropriate for the client at this time? A) Fluid Volume Excess B) Anxiety C) Excess Fluid Volume D) Ineffective Coping

A The rise in blood pressure could be caused by fluid retention as seen in preeclampsia. The client would be at risk for fluid volume excess. Not enough information is provided to determine if the client is experiencing fluid volume overload. There is no information to support ineffective coping or anxiety in the client.

A client with liver disease presents to the hospital with severe ascites. The nurse caring for the client understands that the pathophysiology involved in the development of ascites includes: Select all that apply. A) Presence of portal hypertension. B) Presence of hyperalbuminemia. C) Increased colloidal osmotic pressure. D) Sodium and water retention. E) Presence of hypoaldosteronism.

AD Ascites is the accumulation of plasma-rich fluid in the abdominal cavity. Although portal hypertension is the primary cause of ascites, decreased serum proteins and increased aldosterone also contribute to the fluid accumulation. Hypoalbuminemia (low serum albumin) decreases the colloidal osmotic pressure of plasma. This pressure normally holds fluid in the intravascular compartment, but when the plasma colloidal osmotic pressure decreases, fluid escapes into extravascular compartments. Hyperaldosteronism (an increase in aldosterone) causes sodium and water retention, contributing to ascites and generalized edema.

A pregnant client with preeclampsia delivers the fetus. What care will the client need within the first 48 hours after delivery? Select all that apply. A) Antihypertensives as prescribed B) Frequent assessment of serum electrolytes C) Oxygen 2 liters nasal cannula as prescribed D) Seizure precautions E) Vital sign assessment every 4 hours

ADE Even though the client with preeclampsia usually improves rapidly after giving birth, seizures can still occur during the first 48 hours postpartum. The client may also continue to receive antihypertensives as prescribed. Nursing management during the postpartal period also includes vital sign assessment every 4 hours for 48 hours. The client's hematocrit should be assessed and not necessarily serum electrolytes. Oxygen is not usually indicated after delivery.

Which clinical consideration should the nurse implement for the client in labor who has been diagnosed with preeclampsia? A) Place the client in the room closest to the nurse's station, even if it is a shared room. B) Place the client in left lateral position when the client feels the urge to push. C) Monitor client's fetus intermittently while client is in first stage of labor. D) Encourage the client to be alone in the room without family in order to maintain a quiet environment.

B A laboring client with preeclampsia is at risk for the development of eclampsia with subsequent seizures. The nurse should place the client in left lateral position when the client feels the urge to push because this position improves circulation to the placenta and fetus. If possible, the nurse should place the client in a private room to promote a non-stimulating environment. However, the client should always have support with her, not be alone during labor. The nurse will monitor the client's fetus continuously during labor.

The nurse is evaluating a woman at 48 hours postpartum who experienced pregnancy-induced hypertension (PIH). Which assessment would lead the nurse to conclude that the PIH has not resolved? a) Client complains of perineal pain. b) Client complains of headache and blurred vision. c) Urine output is increasing. d) Blood pressure is returned to baseline.

B Headache and blurred vision are symptoms of the disorder, indicating that the PIH has not resolved. Baseline blood pressure and increasing urine output are signs that PIH is resolving. Perineal pain is unrelated to PIH.

The nurse determines that a client is at risk for contracting hepatitis B because of intravenous drug use. What should the nurse teach to reduce the client's risk for this health problem? A) Avoid contaminated food and water. B) Avoid sharing needles. C) Avoid alcohol consumption. D) Wash hands frequently, as the disease is transmitted via the fecal-oral route.

B Hepatitis B is contracted through contaminated blood and body fluids. The client will increase the risk of contracting hepatitis B by sharing needles. Hepatitis A is transmitted via the fecal-oral route. Laënnec's cirrhosis is the result of alcohol and hepatitis B and C. Contaminated food and water causes hepatitis A, not B.

The nurse is caring for client recovering from a liver transplant necessitated by cirrhosis of the liver. Which postoperative outcome would be a priority for this client? A) Moist membranes of the mouth B) Normal serum bilirubin levels C) Ability to move the legs D) Normal pupil reaction

B Normal bilirubin levels would indicate that the transplanted liver is functioning correctly. Normal pupil reaction, leg movement, and moist mouth membranes are all normal findings for any postoperative client.

The nurse is caring for a client with cirrhosis of the liver. Which information in the client's health history supports this diagnosis? A) Smokes two packs of cigarettes per day. B) Drinks a six-pack of beer each evening. C) Eats salads for lunch every day. D) Plays on an adult softball team several times a week.

B Risk factors for the development of cirrhosis of the liver include excessive alcohol intake. Smoking, ingestion of salads, and exercise are not risk factors for the development of this health problem.

A client with preeclampsia begins to seize. What should the nurse should do to protect the client and fetus from injury? A) Elevate the client's legs. B) Place the client on the left side and protect the airway. C) Place the client in the supine position. D) Elevate the head of the bed.

B The client should be placed on the side to aid in circulation to the placenta. The airway needs to be maintained to ensure oxygenation throughout the seizure. The client should not be placed in the supine position. The head of the bed should not be elevated. The client's legs should not be elevated.

The nurse is caring for a woman who has been admitted with early pregnancy-induced hypertension (PIH) that has progressed to eclampsia. The priority intervention by the nurse is to: a) administer oxygen. b) maintain a patent airway. c) check the blood pressure and fetal heart tones. d) prepare to administer magnesium sulfate

B The woman experiencing eclampsia is at great risk for seizures, and the highest priority of care is a patent airway. Checking blood pressure, fetal heart tones, and administering magnesium sulfate and oxygen are all components of care but are of lower priority than maintaining a patent airway.

A nurse is caring for a client with end-stage liver disease. Which hematological alterations might the nurse anticipate with this client? Select all that apply. A) Elevated serum albumin levels due to increased protein synthesis B) Decreased clotting factor levels due to impaired clotting mechanisms C) Hyperglycemia due to disrupted glucose metabolism D) Increased serum vitamin K due to impaired clearance of fat-soluble vitamins E) Increased plasma oncotic pressure due to impaired protein metabolism

BC Impaired function of liver cells has multiple effects. Impaired protein metabolism with decreased production of albumin and clotting factors occurs. Low albumin levels contribute to edema in peripheral tissues and ascites (accumulation of fluid in the abdomen), as plasma oncotic pressure is reduced, not increased. Impaired clotting-factor production increases the risk for bleeding. Disrupted glucose metabolism and storage may result in hyperglycemia. Also, serum vitamin K is decreased due to impaired absorption of fat-soluble vitamins.

The community health nurse is planning education for a group of individuals from Alcoholics Anonymous on the risk factors for liver disease. The group has a high number of Native Americans in attendance. What should the nurse explain as the reasons for the high incidence of cirrhosis in this ethnic group? Select all that apply. A) Pollution B) Variations in alcohol metabolism C) Stress due to socioeconomic factors D) Consuming alcohol with food E) Climate

BC Alcohol consumption is the sixth-leading cause of death for Native Americans, particularly Alaskans. It is thought that contributing factors include variations in alcohol metabolism, socioeconomic factors that lead to stress, and, consuming alcohol without food. Climate and pollution are not factors.

12) A nurse invited to present to high school adolescents in a biology class about health issues would identify which factors as having the greatest risk for developing cirrhosis and chronic liver disease? (Select all that apply.) a) Exposure to food handlers who may or may not be immunized against hepatitis b) Being of Native American descent c) Being of Hispanic/Latino descent d) Excessive alcohol consumption e) Having high triglyceride levels

BCD In the United States, the greatest risk factors for developing cirrhosis and chronic liver disease include high rates of alcohol use and abuse and being of Native American or Hispanic/Latino origin. Rather than higher triglycerides causing cirrhosis, excessive alcohol consumption causes metabolic changes in the liver, which leads to higher triglyceride synthesis. While hepatitis can be contracted from food handlers with the disease, this is not a primary risk factor for developing cirrhosis/chronic liver disease.

10) A client diagnosed with chronic cirrhosis has jaundice, ascites, and pitting peripheral edema as well as hepatic encephalopathy. Which nursing interventions are most appropriate to prevent skin breakdown? (Select all that apply.) a) Using hot water to bathe to relieve pruritus b) Turning and repositioning every 2 hours c) Range of motion every 4 hours d) Alternating air pressure mattress e) Asking client to sit in a chair for 30 minutes each shift

BD Edematous tissue must receive meticulous care to prevent tissue breakdown. When jaundice is present, bile salts can deposit on the skin, causing pruritus and scratching by the client to relive itching, which promotes skin breakdown. Warm water should be used for bathing rather than hot water as the latter increases itching. An air pressure mattress and careful repositioning can prevent skin breakdown, and having the client in different positions, such as chair-sitting, can relieve pressure on the skin. However, having the client sit in a chair for 30 minutes each shift may be too disruptive to rest and sleep and may not be possible for the severely ill bedridden individual. Range of motion exercises preserve joint function but do not prevent skin breakdown.

The nurse concludes that a client is at risk for pregnancy-induced hypertension (PIH) when the vital signs taken during pregnancy show that the blood pressure increases from: a) 134/80 to 140/88. b) 90/56 to 110/70. c) 100/60 to 130/76. d) 122/80 to 138/86.

C An increase of 30 mmHg systolic and 15 mmHg diastolic on two occasions is diagnostic for PIH. The other examples do not meet these criteria.

A client with liver cirrhosis begins to drain bright red blood through the nasogastric tube. What should the nurse prepare to administer to this client? A) Vitamin K B) Ferrous sulfate C) Platelets D) Folic acid

C Ferrous sulfate and folic acid are given as indicated to treat anemia. Vitamin K may be ordered to reduce the risk of bleeding. When bleeding is acute, packed RBCs, fresh frozen plasma, or platelets may be administered to restore blood components and promote hemostasis.

A pregnant client is diagnosed with HELLP syndrome. The client's nurse understands that which clinical finding is not a manifestation of this condition? A) Elevated liver enzymes B) Hemolysis C) Elevated lipid panel D) Decreased platelet count

C HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) is thought to be related to severe preeclampsia. Elevated lipid panel is not a characteristic of HELLP syndrome.

4) The nurse is performing a routine prenatal assessment of a 36-year-old renal client at 23 weeks' gestation, with suspected pregnancy-induced hypertension (PIH). Which factor is indicative of PIH? a) Complaints of low back pain b) A baseline blood pressure of 122/80 c) Proteinuria d) Glucose in the urine

C PIH begins to occur at 20 weeks' gestation, and proteinuria is one sign that the client is experiencing PIH; pre-existing renal disease is a risk factor for preeclampsia with symptoms often occurring before 32 weeks' gestation. A baseline pressure is not a determining factor for PIH. Glucose in the urine indicates possible gestational diabetes, which puts the client at risk for PIH, but is not diagnostic for PIH. Back pain is unrelated to PIH.

The nurse identifies assessment findings for an African-American client with preeclampsia. Blood pressure is 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 1+; 1+ edema hands, feet, ankles. On the next hourly assessment, which new assessment finding would indicate worsening of the condition? A) Blood pressure 158/100 B) Platelet count 150,000 C) Urinary output 20 mL/hour D) Reflexes 2+

C The decrease in urine output is an indication of decrease in glomerular filtration rate, which indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is the urine output change. The blood pressure increase is not significant. The reflexes are normal at 2+. The platelet count is normal, though it is at the lower end.

The nurse is instructing a client with mild pregnancy-induced hypertension (PIH) who is about to be discharged home. The nurse teaches the client's spouse to call the physician if the client experiences which symptom? a) Appetite increases. b) Back pain increases. c) Fetal movement slows or stops. d) Edema decreases.

C The fetus is affected by PIH due to maternal vasospasms that decrease blood flow and nutrients to the fetus, which may cause the baby to die if PIH worsens. Back pain and increased appetite are not signs of worsening PIH. Edema increases as PIH progresses.

The family of a client with cirrhosis of the liver asks what symptoms they need to look for while the client is being cared for in their home. What should the nurse teach the family that indicates portal hypertension in this client? A) Muscle wasting B) Hypothermia C) Bleeding gums D) Hemorrhoids

D Obstruction to portal blood flow causes a rise in portal venous pressure, resulting in splenomegaly, ascites, and dilation of collateral venous channels predominately in the paraumbilical and hemorrhoidal veins and the cardia of the stomach, and extending into the esophagus. Bleeding gums indicate insufficient vitamin K production in the liver. Muscle wasting is commonly associated with the poor nutritional intake seen in clients with cirrhosis. Hypothermia is an unrelated finding.

A nurse working in Labor and Delivery is caring for a client with preeclampsia. Which clinical manifestation is the nurse most likely to find in this client? A) Increased nitric oxide production B) Decreased serum sodium C) Decreased blood urea nitrogen (BUN) D) Increased serum creatinine

D Preeclampsia decreases renal perfusion, causing an increase in both serum creatinine and blood urea nitrogen (BUN). Preeclampsia also causes a decrease in nitric oxide production and the retention of serum sodium.

The nurse is assessing a client who is 20 weeks pregnant. Which health issue should the nurse recognize as increasing this client's risk for the development of eclampsia? A) Treatment for vitamin D deficiency B) Surgery for ruptured appendix 1 year prior C) Fibrocystic breast disease D) Obesity

D Risk factors for the development of eclampsia include obesity. The other choices will not predispose the client to developing eclampsia.

A nurse working in Labor and Delivery is teaching a group of pregnant clients regarding seizures associated with eclampsia. The nurse will include which statement? A) "The tonic phase of a grand mal seizure is evidenced by alternate contraction and relaxation of the muscles." B) "The clonic phase of a grand mal seizure is evidenced by muscular contraction and rigidity." C) "Seizures are rare in eclampsia, but they occur sometimes." D) "Seizures do not occur in preeclampsia."

D Seizures do not occur in preeclampsia; eclampsia is diagnosed once a client has a seizure, so seizures are not rare in eclampsia. The tonic phase of a grand mal seizure is evidenced by muscular contraction and rigidity. The clonic phase of a grand mal seizure is evidenced by alternate contraction and relaxation of the muscles.

The nurse identifies the diagnosis of Risk for Injury as appropriate for a client with preeclampsia. What should the nurse include in this client's plan of care? A) Suggest family and friends phone frequently. B) Place in a semiprivate room. C) Provide stimulation with television and visitors. D) Limit phone calls and visitors.

D The client with preeclampsia who is at risk for injury needs to be placed in a private room near the nurses' station. The room should be a quiet, with phone calls and visitors limited. The semiprivate room might provide too much stimulation. Television and visitors should be limited to reduce stimulation. Frequent phone calls would provide too much stimulation and should be limited.

A client hospitalized with cirrhosis and bleeding varices is being treated with esophageal balloon and gastric balloons using a multiple-lumen nasogastric tube to apply pressure to the varices. An endotracheal tube has already been inserted/is being treated. Which of the following is the priority action by the nurse if the client develops respiratory distress? A) Remove the nasogastric tube. B) Place the client supine. C) Contact the physician. D) Deflate the esophageal balloon

D The highest priority is protecting the airway so if the client develops respiratory distress, the nurse would deflate the esophageal balloon to avoid compression on the airway. The physician would be notified following this action. The nurse would not remove the NG tube, and the client would not be placed in a supine position. An appropriate syringe should be kept at the bedside to deflate the esophageal balloon in case respiratory distress occurs.

A client hospitalized with severe ascites due to cirrhosis develops abdominal pain, fever, and confusion. As part of the initial plan for care, the nurse should first: a) Measure abdominal girth and percuss for shifting dullness. b) Observe for neck vein distention and auscultate lung sounds. c) Inquire about headache and check for nuchal rigidity. d) Auscultate bowel sounds and palpate the abdomen for tenderness.

D The nurse should assess bowel sounds and palpate for tenderness since spontaneous bacterial infection (spontaneous bacterial peritonitis) can develop with ascites, producing abdominal discomfort, fever, and worsening encephalopathy. Headache and nuchal rigidity are symptoms of meningitis. Neck vein distention is associated with right-sided heart failure. Abdominal girth and shifting dullness are important in monitoring progress of ascites, not infection.

The nurse caring for a client recently undergoing abdominal paracentesis for ascites would expect all of the following indicators of successful treatment except: a) a reduction in abdominal girth of 1-2 cm/day. b) improved oxygen saturation. c) a respiratory rate within normal range. d) reduction in excess flatulence

D The nurse would expect the client's respiratory rate and oxygen saturation to fall within normal limits, and the client's abdominal girth should decrease by 1-2 cm/day. A decrease in flatulence is unrelated to this procedure.

Paracentesis is prescribed for an adult client with chronic cirrhosis and ascites that is not responding to diuretic therapy. The nurse should monitor the client for which complications of this procedure? (Select all that apply.) a) Constipation b) Tachycardia c) Jaundice d) Drop in blood pressure e) Electrolyte imbalance

DE Clients undergoing paracentesis for the manual removal of excess fluid from the abdomen should be monitored closely for electrolyte imbalance and a drop in intravascular volume (blood pressure) as the pressure of the ascites fluid is relieved. Tachycardia, jaundice, and constipation are not expected complications of paracentesis.

The nurse is caring for a pregnant woman who is admitted with preeclampsia. The nurse plans care based on the nursing diagnosis of deficient fluid volume related to fluid shifts from vasospasms. Which nursing intervention is a priority for this client? (Select all that apply.) a) Assess blood pressure every 8 hours. b) Weigh client weekly. c) Monitor for increased urine output. d) Assess deep tendon reflexes. e) Place client in the left lateral recumbent position.

DE The left lateral position reduces pressure on the vena cava, thereby increasing venous return. Hyperreflexia indicates central nervous involvement and is a sign of progression toward eclampsia. Blood pressure is assessed every 1-4 hours. Urine output is decreased in preeclampsia; the client is weighed daily for fluid status.