Liver
A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor? "You must have the second one in 2 weeks and the third in 1 month." "You must have the second one in 1 month and the third in 6 months." "You must have the second one in 6 months and the third in 1 year." "You must have the second one in 1 year and the third the following year."
"You must have the second one in 1 month and the third in 6 months." Explanation: Both forms of the hepatitis B vaccine are administered intramuscularly in three doses; the second and third doses are given 1 and 6 months, respectively, after the first dose.
A nurse is reviewing laboratory test results from a client. The report indicates that the client has jaundice. What serum bilirubin level must the client's finding exceed? Enter the correct number only.
2.5
A nurse is responsible for monitoring the diet of a patient with hepatic encephalopathy. The nurse knows that the 185-pound male should have a daily protein intake between __________. 17 and 50 grams 25 and 75 grams 34 and 100 grams 42 and 126 grams
42 and 126 grams Explanation: Daily protein intake should be limited to 0.5 to 1.5 g/kg. Therefore, a person who weighs 185 lbs weighs 84 kg. To calculate protein intake, multiply the 84 kg by the low and high ranges: (84 kg × 0.5 = 42 g; 84 kg × 1.5 = 126 g). This patient would require a daily protein range from 42 to 126 g.
A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis? A liver biopsy A CT scan A prothrombin time Platelet count
A liver biopsy Explanation: A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding.
Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? Polyuria Bradycardia Hypotension Warm moist skin
Hypotension Explanation: Signs of potential hypovolemia include cool, clammy skin, tachycardia, decreased blood pressure, and decreased urine output.
Which of the following is the most effective strategy to prevent hepatitis B infection? Vaccine Barrier protection during intercourse Covering open sores Avoid sharing toothbrushes
Vaccine Explanation: The most effective strategy to prevent hepatitis B infection is through vaccination. Recommendations to prevent transmission of hepatitis B include vaccination of sexual contacts of individuals with chronic hepatitis, use of barrier protection during sexual intercourse, avoidance of sharing toothbrushes, razors with others, and covering open sores or skin lesions.
A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder? Coagulation studies Magnetic resonance imaging Radioisotope liver scan Liver biopsy
Liver biopsy Explanation: A liver biopsy which reveals hepatic fibrosis is the most conclusive diagnostic procedure. Coagulation studies provide information about liver function but do not definitively confirm the diagnosis of cirrhosis. Magnetic resonance imaging and radioisotope liver scan help to support the diagnosis but do not confirm it. These tests provide information about the liver's enlarged size, nodular configuration, and distorted blood flow.
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? Serum potassium level of 3.5 mEq/L Loss of 2.2 lb (1 kg) in 24 hours Serum sodium level of 135 mEq/L Blood pH of 7.25
Loss of 2.2 lb (1 kg) in 24 hours Explanation: Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.
The most common cause of esophageal varices includes which of the following? Jaundice Portal hypertension Ascites Asterixis
Portal hypertension Explanation: Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.
Which of the following would be the least important assessment in a patient diagnosed with ascites? Foul-smelling breath Measurement of abdominal girth Weight Palpation of abdomen for a fluid shift
foul-smelling breath Explanation: Foul-smelling breath would not be considered an important assessment for this patient. Measurement of abdominal girth, weight, and palpation of the abdomen for a fluid shift are all important assessment parameters for the patient diagnosed with ascites.
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 Ibuprofen Dextromethorphan Benadryl
Acetaminophen Explanation: Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Other medications commonly associated with liver injury include anesthetic agents, medications used to treat rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsants, and antituberculosis agents.
Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following? Ammonia Calcium Bicarbonate Alcohol
Ammonia Explanation: Lactulose (Cephulac) is administered to reduce serum ammonia levels. Cephulac does not influence calcium, bicarbonate, or alcohol levels.
When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report? Yellow-green Black and tarry Blood tinged Clay-colored or whitish
Clay-colored or whitish Explanation: Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.
A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice? Straw-colored urine Reduced hematocrit Clay-colored stools Elevated urobilinogen in the urine
Clay-colored stools Explanation: Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen.
Which of the following is an age-related change of the hepatobiliary system? Increased drug clearance capability Decreased blood flow Liver enlargement Decreased prevalence of gallstones
Decreased blood flow Explanation: Age-related changes of the hepatobiliary system include decreased blood flow, decreased drug clearance capability, increased presence of gall stones, and a steady decrease in size and weight of the liver.
A client with cirrhosis has been referred to hospice care. Assessment data reveal a need to discuss nutrition with the client. What is the nurse's priority intervention? Discuss meals that include low-fat high-carbohydrate content. Discuss the importance of drinking at least 64 oz (1,893 ml) of water daily. Discuss meals that have a high-fiber, high-protein content. Discuss the importance of eliminating caffeine in the diet.
Discuss meals that include low-fat high-carbohydrate content. Explanation: In cirrhosis, the liver's metabolic function is compromised, increasing the client's need for carbohydrates and other energy sources for cellular metabolism. The nurse should limit the client's fat intake to prevent satiation and should restrict protein intake because a cirrhotic liver can't metabolize protein effectively. A client with cirrhosis may have increased edema as a result of reduced plasma albumin, so he should restrict fluid intake rather than drink 64 oz of water daily. Increasing fiber intake isn't a priority intervention for a client with cirrhosis. A client with cirrhosis doesn't need to eliminate caffeine from his diet.
What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct? Colonoscopy Abdominal x-ray Cholecystectomy Endoscopic retrograde cholangiopancreatography (ERCP)
Endoscopic retrograde cholangiopancreatography (ERCP) Explanation: ERCP locates stones that have collected in the common bile duct. A colonoscopy will not locate gallstones but only allows visualization of the large intestine. Abdominal x-ray is not a reliable locator of gallstones. A cholecystectomy is the surgical removal of the gallbladder.
The mode of transmission of hepatitis A virus (HAV) includes which of the following? Fecal-oral Blood Semen Saliva
Fecal-oral Explanation: The mode of transmission of hepatitis A virus (HAV) occurs through fecal-oral route, primarily through person to person contact and/or ingestion of fecal contaminated food or water. Hepatitis B virus (HBV) is transmitted primarily through blood. HBV can be found in blood, saliva, semen, and can be transmitted through mucous membranes and breaks in the skin.
The nurse identifies which of the following types of jaundice in an adult experiencing a transfusion reaction? Hemolytic Hepatocellular Obstructive Nonobstructive
Hemolytic Explanation: Hemolytic jaundice occurs because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. This type of jaundice is encountered in patients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.
A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions? Hepatic encephalopathy Portal hypertension Asterixis Cirrhosis
Hepatic encephalopathy Explanation: Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness, and coma. Portal hypertension is an elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.
A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? Hepatitis B is transmitted primarily by the oral-fecal route. Hepatitis A is frequently spread by sexual contact. Hepatitis C increases a person's risk for liver cancer. Infection with hepatitis G is similar to hepatitis A.
Hepatitis C increases a person's risk for liver cancer. Explanation: Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.
The nurse is administering medications to a patient that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent? Spironolactone (Aldactone) Cholestyramine (Questran) Lactulose (Cephulac) Kanamycin (Kantrex)
Lactulose (Cephulac) Explanation: Lactulose (Cephulac) is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients. Potassium-sparing diuretics such as spironolactone (Aldactone) are used to treat ascites. Cholestyramine (Questran) is a bile acid sequestrant and reduces pruritus. Kanamycin (Kantrex) decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.
A patient with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade therapy is used temporarily to control hemorrhage and stabilize the patient. In planning care, the nurse gives the highest priority to which of the following goals? Controlling bleeding Maintaining the airway Maintaining fluid volume Relieving the patient's anxiety
Maintaining the airway Explanation: Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway is compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.
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? Report the condition to the physician immediately. Measure abdominal girth according to a set routine. Provide the client with nonprescription laxatives. Ask the client about food intake.
Measure abdominal girth according to a set routine. Explanation: If the abdomen appears enlarged, the nurse measures it according to a set routine. The nurse reports any change in mental status or signs of gastrointestinal bleeding immediately. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis.
A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. Which of the following is an important education topic regarding ingestion of medications? Metabolism of medications The need for increased drug dosages The need for more frequently divided doses Medications will no longer be effective in clients with liver disease.
Metabolism of medications Explanation: Careful evaluation of the client's response to drug therapy is important because the malfunctioning liver cannot metabolize many substances.
A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. Which of the following is an important education topic regarding ingestion of medications? Metabolism of medications The need for increased drug dosages The need for more frequently divided doses Medications will no longer be effective in clients with liver disease.
Metabolism of medications Explanation: Careful evaluation of the client's response to drug therapy is important because the malfunctioning liver cannot metabolize many substances.
A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? Cure the cirrhosis. Treat the esophageal varices. Reduce fluid accumulation and venous pressure. Promote optimal neurologic function.
Reduce fluid accumulation and venous pressure. Explanation: Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.
A patient with hepatic cirrhosis questions the nurse about the possible use of an herbal supplement—milk thistle—to help heal the liver. Which of the following would be the most appropriate response from the nurse? You should not use herbal supplements in conjunction with medical treatment. Herbal supplements are approved by the FDA, so there should be no problem with their usage if you check with your primary care provider. Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis.However, you should always notify your primary care provider of any herbal remedies being used so drug interactions can be evaluated. You can use milk thistle instead of the medications you have been prescribed.
Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis.However, you should always notify your primary care provider of any herbal remedies being used so drug interactions can be evaluated. Explanation: Many patients who have end-stage liver disease (ESLD) with cirrhosis use the herb milk thistle (Silybum marianum) to treat jaundice and other symptoms. This herb has been used for centuries because of its healing and regenerative properties for liver disease. Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis. The natural compound SAM-e (s-adenosylmethionine) may improve outcomes in liver disease by improving liver function, possibly through enhancing antioxidant function. Herbal supplements are used in conjunction with medical treatment and medications. Herbal supplements are not approved by the FDA. Their usage should be discussed with the primary care provider to evaluate their effectiveness and interactions with other treatment regimens.
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? Furosemide (Lasix) Spironolactone (Aldactone) Acetazolamide (Diamox) Bumetanide (Bumex)
Spironolactone (Aldactone) Explanation: Potassium-sparing diuretic agents such as spironolactone or triamterene (Dyrenium) may be indicated to decrease ascites, if present; these diuretics are preferred because they minimize the fluid and electrolyte changes commonly seen with other agents.
A nurse is assessing a postoperative client for hemorrhage. What responses associated with the compensatory stage of shock should be reported to the healthcare provider? Tachycardia and tachypnea Tachycardia and bradypnea Bradycardia and bradypnea Bradycardia and tachypnea
Tachycardia and tachypnea Explanation: With shock, the sympathetic nervous system (SNS) is activated due to changes in blood volume and blood pressure. The SNS stimulates the cardiovascular system, causing tachycardia, and the respiratory system, causing tachypnea. Tachycardia is associated with shock, but the patient will have tachypnea, not bradypnea. Tachycardia (not bradycardia) and tachypnea (not bradypnea) occur with the compensatory stage of shock. Although tachypnea is associated with shock, tachycardia, not bradycardia, occurs with shock.
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. Excessive diuresis and dehydration. Severe infections and high fevers. Excess potassium loss subsequent to prolonged use of diuretics.
The digestion of dietary and blood proteins. Explanation: Circumstances that increase serum ammonia levels tend to aggravate or precipitate hepatic encephalopathy. The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. Ammonia from these sources increases as a result of GI bleeding (ie, bleeding esophageal varices, chronic GI bleeding), a high-protein diet, bacterial infection, or uremia.
Which of the following medications is used to decrease portal pressure, halting bleeding of esophageal varices? Spironolactone (Aldactone) Vasopressin (Pitressin) Nitroglycerin Cimetidine (Tagamet)
Vasopressin (Pitressin) Explanation: Vasopressin may be the initial therapy for esophageal varices, because it constricts the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Aldactone and Tagamet do not decrease portal hypertension.
Which of the following indicates an overdose of lactulose? Watery diarrhea Constipation Hypoactive bowel sounds Fecal impaction
Watery diarrhea Explanation: Lactulose (Cephulac) is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients. Monitor closely for the development of watery diarrheal stool, which indicates a medication overdose.
A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: cirrhosis peptic ulcer disease. appendicitis. cholelithiasis.
cirrhosis. Explanation: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver.
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? Constructional apraxia Fetor hepaticus Ataxia Asterixis
sterixis Explanation: Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy
A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: elevated liver enzymes and low serum protein level. subnormal serum glucose and elevated serum ammonia levels. subnormal clotting factors and platelet count. elevated blood urea nitrogen and creatinine levels and hyperglycemia.
subnormal serum glucose and elevated serum ammonia levels. Explanation: In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.