Hepatic 2 Nursing IV Test 2

Which of the following would the nurse expect to assess in a client with hepatic encephalopathy?

Asterixis

A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching?

"How did this happen? I've been faithful my entire marriage."

A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client's plan of care?

Assessment for variceal bleeding

A client who has just been diagnosed with hepatitis A asks, "How did I get this disease?" What is the nurse's best response?

"You may have eaten contaminated restaurant food."

A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

Asterixis

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as?

Asterixis

An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is:

Acetaminophen

Which term is used to describe a chronic liver disease in which scar tissue surrounds the portal areas?

Alcoholic cirrhosis

A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine?

An immune globulin injection

The nurse completing a plan of care for a client with cirrhosis who has ascites and 4+ pitting edema of the feet and legs identifies a nursing diagnosis of risk for impaired skin integrity. Which nursing intervention is appropriate for this problem?

Arrange for a low air loss bed.

When caring for a client with cirrhosis, which symptom(s) should the nurse report immediately?

Change in mental status

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately?

Change in the client's handwriting and/or cognitive performance

A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments?

Daily weights and abdominal girth measurement

A group of nurses have attended an in-service on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace?

Disposing of sharps appropriately and not recapping needles

The mode of transmission of hepatitis A virus (HAV) includes which of the following?

Fecal-oral

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations?

Hepatic encephalopathy

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition?

Hepatic encephalopathy

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include?

Hepatitis C increases a person's risk for liver cancer.

A client has developed drug-induced hepatitis from a drug reaction to antidepressants. What treatment does the nurse anticipate the client will receive to treat the reaction?

High-dose corticosteroids

A nurse is participating in the emergency care of a client who has just developed variceal bleeding. What intervention should the nurse anticipate?

IV administration of octreotide (Sandostatin)

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply.

Immunization Use of standard precautions

A client has ascites. Which of the following interventions would the nurse prepare to assist with implementing to help the client control this condition? Select all that apply.

Instructing the client to remove salty and salted foods from the diet Administering prescribed spironolactone (Aldactone) Assisting with placement of a transjugular intrahepatic portosystemic shunt

A client with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform?

Keep client NPO until the patient's gag reflex returns.

A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the client has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this client is what?

Liver transplantation

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal?

Maintaining the airway

The nurse is caring for a patient who has ascites as a result of hepatic dysfunction. What intervention can the nurse provide to determine if the ascites is increasing? (Select all that apply.)

Measure abdominal girth daily. Perform daily weights.

A young client with anorexia, fatigue, and jaundice is diagnosed with hepatitis B and has just been admitted to the hospital. The client asks the nurse how long the stay in the hospital will be. In planning care for the client, the nurse identifies impaired psychosocial issues and assigns the highest priority to which client outcome?

Minimizing social isolation

A client is admitted to the hospital with acute hemorrhage from esophageal varices. What medication should the nurse anticipate administering that will reduce pressure in the portal venous system and control esophageal bleeding?

Octreotide

Which is the most common cause of esophageal varices?

Portal hypertension

A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response?

Report this finding to the primary provider due to the possibility of hepatic encephalopathy.

The nurse is concerned about potassium loss when a diuretic is prescribed for a patient with ascites and edema. What diuretic may be ordered that spares potassium and prevents hypokalemia?

Spironolactone (Aldactone)

The nurse is completing a morning assessment of a client with cirrhosis. Which information obtained by the nurse will be of most concern?

The client's hands flap back and forth when the arms are extended.

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from:

The digestion of dietary and blood proteins.

A patient with bleeding esophageal varices has had pharmacologic therapy with Octreotide (Sandostatin) and endoscopic therapy with esophageal varices banding, but the patient has continued to have bleeding. What procedure that will lower portal pressure does the nurse prepare the patient for?

Transjugular intrahepatic portosystemic shunting (TIPS)

A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

Two to three soft bowel movements daily

Which of the following is the most effective strategy to prevent hepatitis B infection?

Vaccine

A client with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this client's treatment, the nurse should anticipate what intervention?

A regimen of antiviral medications

A patient who had a recent myocardial infarction was brought to the emergency department with bleeding esophageal varices and is presently receiving fluid resuscitation. What first-line pharmacologic therapy does the nurse anticipate administering to control the bleeding from the varices?

Octreotide (Sandostatin)

A female client with chronic hepatitis B has been prescribed recombinant interferon alfa-2b in combination with ribavirin. Which of the following instructions should a nurse provide this client?

Use strict birth control methods.

The nurse is administering Cephulac (lactulose) to decrease the ammonia level in a patient who has hepatic encephalopathy. What should the nurse carefully monitor for that may indicate a medication overdose?

Watery diarrhea

A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. What is an important education topic regarding ingestion of medications?

metabolism of medications

The nurse is preparing to interview a client with cirrhosis. Based on an understanding of this disorder, which question would be most important to include?

"How often do you drink alcohol?"

A client is receiving vasopressin for the urgent management of active bleeding due to esophageal varices. What most serious complication should the nurse assess the client for after the administration?

Electrocardiogram changes

A nurse is taking health history data from a client. Use of which of the following medications would especially alert the nurse to an increased risk of hepatic dysfunction and disease in this client? Select all that apply.

Acetaminophen Ketoconazole Valproic acid

What health promotion teaching should the nurse prioritize to prevent drug-induced hepatitis?

Adhere to dosing recommendations of over-the-counter analgesics.

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus?

Following proper hand-washing techniques

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?

Loss of 2.2 lb (1 kg) in 24 hours

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?

Measure abdominal girth according to a set routine.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?

The client's hepatic function is decreasing.

When caring for a client with cirrhosis, which symptoms should a nurse report immediately? Select all that apply.

change in mental status signs of GI bleeding

A physician orders lactulose (Cephulac), 30 ml three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor:

level of consciousness (LOC).