Exam 4- Cirrhosis NCLEX

A pt with type 2 diabetes and cirrhosis asks if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge? a. milk thistle may affect liver enzymes and thus alter drug metabolism b. milk thistle is generally safe in recommended doses for up to 10 yrs c. there is unclear scientific evidence for the use of milk thistle in treating cirrhosis d. milk thislte may elevate the serum glucose level and is thus contraindicated in diabetes.

A There is evidence that there is no real benefit from using milk thistle to protect liver enzyme from toxic damage. Milk thistle does affect liver enzyme and could alter drug metabolism. Pt will need to be monitored for drug interactions. It is dafe for up to 6 yrs not 10, and it may lower, not elevate, blood glucose levels.

The pt with cirrhosis is being taught self care. which statement indicates the pt needs MORE teaching? a. if i notice a fast heart rate and irregular beats, this is normal for cirrhosis b. i need to take good care of my belly and ankle skin where it is swollen. c. a scrotal support may be more comfortable when i have scrotal edema d. i can use pillows to support my head to help me breathe when i am in bed.

A This may indicative of hypokalemia and should be reported to healthcare provider, this is not normal for cirrhosis.

The pt with cirrhosis has increased ab girth from ascites. The nurse should know that this fluid gathers in the ad for which reasons? Select all that apply. a. there is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. b. hyperaldosteronsim related to damaged hepatocytes increases sodium and fluid retention c. portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity d. osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluid orally e. overactivity of the enlarged spleen results in increased removal of blood cells from the circulation, which decreases the vascular pressure.

A, B, C Ascites related to cirrhosis is caused by decreased colloid oncotic pressure from the lack of albumin form liver inability to synthesize it and the portal hypertension shifts protein into peritoneal cavity, and hyperaldosteronism which increases sodium and fluid retention.

When caring for a pt with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome? Select all that apply. a. use smallest gauge needle possible when giving injections or drawing blood. b. teach pt to avoid straining at stool, vigorous blowing of nose, and coughing c. advise pt to use soft-bristle toothbrush and avoid ingestion of irritating food. d. apply gentle pressure for the shortest possible time period after performing venipuncture e. instruct pt to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.

A, B, C, E - small gauge minimize risk of bleeding into tissues. - avoiding strain reduces hemorrhage - soft bristle reduce injury to highly vascular mucous membranes - apply gentle but prolonged pressure to venipuncture - aspirin and NSAIDs should not be used in pt with liver disease b/c they interfere w/ platelet aggregation, increasing bleeding risk

A nurse is caring for a client with cirrhosis. Which assessment finding warrants immediate​ attention? Pulse of 60 bpm Oxygen saturation of​ 92% Blood pressure of​ 110/72 mmHg Abdominal distention

Abdominal distention Rationale Abdominal​ distention, which is an imbalance of fluid within the portal​ system, might mean ascites in a client with cirrhosis. The vital signs are all within normal limits.

The nurse is reviewing the record of a client with a dx of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? Dorsiflex the foot Measure abdominal girth Ask pt to extend the arms Instruct pt to lean forward

Ask the pt to extend the arms Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. It is the most common and reliable sign that hepati encephalopathy is developing.

The pt with advanced cirrhosis asks why his abdomen is so swollen. The nurse's best response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity b. portal hypertension and hypoalbuminemia cause fluid shift into the peritoneal space. c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid.

B Ascites is accumulation of serious fluid in peritoneal cavity. With portal hypertension, protein shifts from the blood into the lymph. When the lymph system is unable to carry excess, it leaks thru the liver into the peritoneal cavity. osmotic pressure of the proteins pulls additional fluid into cavity. Second mechanism of ascites if hypoalbuminemia from the liver unable to synthesize albumin, resulting in decreased colloidal oncotic pressure.

A pt has been told she has NAFLD. The nursing teaching plan should include a. having genetic testing done b. recommend a heart healthy diet c. the necessity to reduce weight rapidly d. avoiding alcohol until liver enzymes return to normal

B NAFLD can progress to cirrhosis. NO definitive treatment; therapy directed at reducing risk like diabetes, body weight, and harmful medications.

The condition of the pt who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the pt has developed liver cancer? a. serum a-fetoprotein level b. ventilation/perfusion scan c. hepatic structure ultasound d. abdominal girth measurement

C

The nurse provides discharge instructions for a 64 y.o. women with ascites and peripheral edema related to cirrhosis. Which statement, if made by the pt, indicates teaching WAS effective? a. it is safe to take acetaminophen up to four times a day for pain b. lactulose (cephulac) should be taken everyday to prevent constipation c. herbs and other spices should be used to season my foods instead of salt d. i will eat foods high in potassium while taking spironolactone (aldactone)

C low sodium diet is indicated for pt with ascites and edema related to cirrhosis

When planning care for a pt with cirrhosis, the nurse will give highest priority to which nursing diagnosis? a. impaired skin integrity related to edema, ascites, and pruritis b. imbalanced nutrition: less than body requirements related to anorexia c. excess fluid volume related to portal hypertension and hyperaldosteronism d. ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

D airway and breathing are always highest priority.

The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this pt by assessing what? a. relief of constipation b. relief of ab pain c. decreased liver enzymes d. decreased ammonia levels

D hepatic encephalopathy is associated with elevated ammonia levels. Lactulose traps ammonia in the intestinal tract. It's laxative effect then expels ammonia from the colon, resulting in decreased ammonia levels, correcting hepatic encephalopathy.

Which nursing diagnosis is not appropriate for a client with​ cirrhosis? Decreased fluid volume Diminished protection Impaired nutrition Impaired skin integrity

Decreased fluid volume Appropriate nursing diagnoses for a client with cirrhosis include impaired skin​ integrity, diminished protection and impaired nutrition.​ Increased, not​ decreased, fluid volume is appropriate for a client with cirrhosis.

A client diagnosed with liver cirrhosis is being treated for an infection. For which complication should the nurse monitor the​ client? Portal hypertension Hepatic encephalopathy Esophageal varices Wilson disease

Hepatic encephalopathy Hepatic encephalopathy may be aggravated by sepsis secondary to​ infection, due to increased buildup of toxic​ substances, in clients with cirrhosis. Portal​ hypertension, esophageal​ varices, and Wilson disease (an inherited disorder that causes too much copper to accumulate in the organs) are not caused or aggravated by infection.

Which nursing diagnosis supports a medical diagnosis of​ cirrhosis? Increased risk for acute confusion Anxiety Activity intolerance Fatigue

Increased risk for acute confusion Clients with cirrhosis deal with a variety of​ problems, but​ fatigue, activity​ intolerance, and anxiety are not among them. A few nursing diagnoses that are appropriate include impaired skin​ integrity, increased risk for acute​ confusion, diminished​ protection, increased fluid​ volume, and reduced​ nutrition, less than body requirements.

Which laboratory test is prescribed for a client with suspected​ cirrhosis? O2 level CO2 level WBC count Liver biopsy

Liver biopsy Liver biopsy helps distinguish cirrhosis from other forms of liver disease. The O2 ​level, CO2 ​level, and WBC count are not relevant to establishing the diagnosis of cirrhosis.

The nurse is reviewing the lab results for a pt with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be presribed for this pt? Low-protein High-protein Moderate-fat High-carb

Low-protein diet Protein provided by the diet is transported to the liver via the portal vein. The liver breaks down protein, which results in the formation of ammonia.

The nurse observes a distinct change in the Mr.​ Dontay's level of consciousness during a routine assessment during a scheduled physical examination. Mr. Dontay is 55 years​ old, a recovering​ alcoholic, and has a primary diagnosis of cirrhosis. Which intervention is appropriate for Mr. Dontay while providing​ care? Encouraging large meals Measuring abdominal girth Providing a diet high in sodium Using hot water for bathing

Measuring abdominal girth The client with cirrhosis is at risk for​ ascites; therefore it is important to measure the​ client's abdominal girth while providing care. The nurse should encourage small​ meals, provide a diet low in​ sodium, and use warm water for bathing.

Ms. Charlotte is​ 66-years-old and admits to being an alcoholic for most of her adult life. She is brought to the emergency department with bleeding esophageal varices. Which therapy should be the most effective for Ms. Charlotte at this​ time? ​Beta-blocker Minnesota tube Paracentesis Transjugular intrahepatic portosystemic shunt​ (TIPS)

Minnesota tube While a​ beta-blocker can be used for esophageal​ varices, the best therapy at this time is a balloon tamponade​ (either a​ Sengstaken-Blakemore or Minnesota​ tube). A paracentesis is done to relieve severe ascites. A transjugular intrahepatic portosystemic shunt​ (TIPS) relieves portal hypertension and reduces the onset of esophageal varices and ascites.

A client is at risk for infectious sepsis through which portals of​ entry? ​(Select all that​ apply.) Peptic ulcerations Surgical wounds Sexually transmitted infections Pulse oximetry monitoring Intravenous catheters

Peptic ulcerations Surgical wounds Sexually transmitted infections Intravenous catheters Portals of entry for infection that may lead to sepsis​ include, but are not limited​ to, intravenous​ catheters, surgical​ wounds, sexually transmitted​ infections, and peptic ulcerations. Pulse oximetry is not an invasive procedure and is not a portal of entry for infectious sepsis.

Which therapy for cirrhosis is considered nutritional​ therapy? Increasing fluid intake Restricting sodium intake Administering vitamin K Recommending antacids

Restricting sodium intake Nutritional support for cirrhosis includes restricting sodium intake to 2 g per day. Administering vitamin K and recommending antacids is pharmacologic therapy. Decreasing fluid​ intake, not increasing​ it, is considered a nutritional therapy for cirrhosis.

For which manifestation should the nurse assess in a client with hepatorenal​ syndrome? Fever Esophageal varices Sodium retention Asterixis

Sodium retention Hepatorenal syndrome causes sodium​ retention, oliguria, and hypotension. Asterixis develops with hepatic​ encephalopathy, and fever with bacterial peritonitis. Esophageal varices are a complication of cirrhosis.

A nurse is caring for a client with ascites secondary to cirrhosis. Which medication is the treatment of​ choice? Spironolactone​ (Aldactone) Neomycin sulfate Oxazepam​ (Serax) Furosemide​ (Lasix)

Spironolactone​ (Aldactone) Diuretics are used to reduce fluid retention and ascites. While furosemide​ (Lasix) may be​ used, the drug of choice is spironolactone​ (Aldactone) because it is also an Aldosterone Antagonist. Neomycin sulfate reduces the number of​ ammonia-forming bacteria in the​ bowel, and oxazepam​ (Serax) is used for acute agitation.

What is the purpose of liver functions tests in diagnosing​ cirrhosis? To determine the presence of anemia To determine the prothrombin time To determine glucose and lipid metabolism To determine the degree of elevation of liver enzymes

To determine the degree of elevation of liver enzymes The purpose of liver functions tests in diagnosing cirrhosis is to determine the degree of elevation of liver enzymes. A CBC is used to determine the presence of anemia. Coagulation studies are used to determine the prothrombin time. Serum glucose and cholesterol levels are used to determine the effect cirrhosis is having on glucose and lipid metabolism.

The nurse assesses for which item during the health history for a client with​ cirrhosis? Skin color Mental status Weight loss Vital signs

Weight loss For a client with​ cirrhosis, the nurse assesses recent weight loss during the heath history portion of the nursing assessment. Vital​ signs, mental​ status, and skin color are assessed during the physical examination portion of the nursing assessment.

During assessment of a pt with obstructive jaundice, the nurse would expect to find: clay colored stools dark urine and stool pyrexia and pruritis elevated urinary urobilinogen

clay colored stool