NURS 241 Exam 4- Cirrhosis, Liver Cancer, Drug & Alcohol Abuse

What are the likely cancers & initial treatment/drug for the oncologic emergency Increased ICP?

*Brain, lung*, breast, kidney, & skin CA; treat with craniotomy, shunt, mannitol, removal of tumor/fluid

What are the likely cancers & initial treatment/drug for the oncologic emergency *sepsis/septic shock*?

*Leukemia or tx devices*; treat with *ATB*

What are the likely cancers & initial treatment/drug for the oncologic emergency *DIC*?

*Leukemia*; treat with *clotting factors & blood thinners*

What are the likely cancers & initial treatment/drug for the oncologic emergency *Malignant pericardial effusion*?

*Lung CA*; treat with *pericardiocentesis*

What are the likely cancers & initial treatment/drug for the oncologic emergency *superior vena cava syndrome*?

*Lung*, breast, *chest*, & Non Hodgkins CA; treat by removing tumor, device, or EOL care :(

What are the likely cancers & initial treatment/drug for the oncologic emergency *spinal cord compression*?

*Lung, breast*, prostate, & multiple myeloma CA; treat with *surgery, chemo, steroids, & radiation*

What are the likely cancers & initial treatment/drug for the oncologic emergency *Hypercalcemia*?

*Lung, breast, chest*, renal, & multiple myeloma CA; treat with *calcitonin & IVF*

What are the nursing assessments for alcohol withdrawal?

*MILD: 6-24 hrs after last drink*: -Anxiety -Tremors -Restlessness -Insomnia -Palpitations -High BP -Headache -Diaphoresis -Low grade fever *SEVERE: 24-72 hrs after last drinks*: -all mild symptoms and... -HTN -Tachycardia -Agitation -Delirium tremendous -Hallucinations -Disorientation -Vomiting/Nausea

What is the patient & family education for cirrhosis? Refer to Chart 58-2 Iggy

*Nutritional Therapy*: -diet per physician guidelines -low sodium diet if excess fluid in abdomen -eat small, frequent meals that are nutritionally well balanced -supplemental liquids daily (ex: ensure, ensure plus) & a multivitamin *Drug Therapy*: -take diuretic or preventative beta blocker prescribed; contact provider if experience muscle weakness, irregular heartbeat, & lightheadedness -takes meds prescribed that help prevent GI bleeding -take lactulose syrup as prescribed to maintain 2-3 bowel movements everyday -do NOT take any other meds unless specifically prescribed *Alcohol Abstinence*: -do NOT consume any alcohol -seek support services for help if needed

What are the likely cancers & initial treatment/drug for the oncologic emergency *SIADH*?

*SC Lung CA*; treat with *3% saline, meds, diuretics, VRA's*

What are potential oncologic emergencies? *extreme version of what can happen with cancer; not all cancers cause every type

-*SIADH* -*DIC* -*sepsis/septic shock* -tumor lysis -*hypercalcemia* -*spinal cord compression* -*superior vena cava syndrome* -increased ICP -hyperviscosity -hyperleukocytosis -neutropenia/ neutropenia syndrome -*malignant pericardial effusion* -upper airway obstruction -pericardial tamponade -adrenal crisis -thrombocytopenia/hemorrhage -immunosuppression/infection

What are the normal liver functions?

-*storing vitamins, minerals, & sugar* -*produces proteins* -*protein synthesis* of albumin & prothrombin -*produces bilirubin & bile salts* to digest fat & absorb vitamins A, D, E, K -*fat oxidation* for energy synthesis of cholesterol -produces substances that *regulate blood clotting* -helps *body fight infection* by removing bacteria from the blood -*metabolizes nutrients* (breaks down) from food to produce energy -*drug detoxification* by removes potentially toxic byproducts of certain meds -metabolic *detoxification of ammonia* turned into urea & excreted in urine -*steroid inactivation* & metabolism of testosterone, cortisone, & aldosterone -*maintain normal blood glucose* -*activating vitamin K*

What are the different blood alcohol level ranges?

-80 to 200 = mild to moderate -250 to 400 = marked intoxication - >500 = respiratory depression & possible death from alcohol intoxication/poisoning

What is the nursing assessment for potential alcoholism?

-Blood alcohol level (BAC) -physical assessment for symptoms ex: neuro, tremors, pain -hx of presenting illness: qs for use, last drink, what happens when stop drinking, family hx, current life stressors, ability to complete ADLs -Rubrics & scales: CAGE, T-ACE (prenatal), AUDIT, MAST, etc

What is used to diagnosis alcoholism?

-Blood alcohol level (BAL): 80-200 is mild to moderate, 250-400 is marked intoxication, >500 is respitoary depression & possible death from alcohol intoxication -breathalyzer: 0.08 is legal limit; 0.0 is no alcohol

How does cancer evade the body's defenses?

-CA cells hide or defend themselves from the immune system' recognition -CA cells mix up the signals between immune cells & send out its own messages to confuse the immune system & prevent it from responding effectively -chronically irritated tissues undergo frequent mitosis & are at an increased risk for spontaneous DNA mutation causing cells to keep changing & evade treatments -CA cells have unregulated growth & limitless replication -create their own blood supply aka angiogenesis -evade apoptosis, the natural cell death & clean up normally

How is lung cancer diagnosed?

-CXR -CT -bronchoscopy -sputum cytology -lung biopsy

What are the the general steps of the paracentesis procedure:

-Clean -prep skin -prep patient -baseline assessment -lidocaine @ site by doctor -small incision -drain fluid -pain meds: versed, Ativan, not part of prep

Your patient is going home. What do you teach them after having a paracentesis?

-Daily weight -Site assessment -Take temp at home to monitor for infection -Diet changes —> protein, alcohol, vitamins -Take meds as ordered at home (ABX/pain meds)

Liver dysfunction can cause an alteration in protein metabolism. What will the patient's symptoms be?

-Decreased albumin makes water go into third spaces= ascited & edema -Increased ammonia levels= changes in LOC, confusion, & hepatic encephalopathy

How is liver dysfunction/cirrhosis diagnosed?

-Elevated liver enzymes: AST, ALT, GGT, alkaline phosphatase -Elevated total bilirubin, indirect bilirubin, & direct bilirubin -Elevated clotting factors -Elevated WBC if infection -Elevated ammonia -Elevated PT/INR, & vitamin K clotting factors II, VII, IX, X -Decreased Albumin -Liver Biopsy: stage 0-4 for scarring & tissue changes -clustered data of labs, pt hx, & other assessment findings

What are examples of opioids and what they are used for?

-Examples: morphine, dilaudid, hydromorphone, hydrocodone, fentanyl, oxycodone -Appropriately used for moderate to severe pain -Common treatment for cancer pain, burn pts, trauma, & post op

What is the incidence of misuse in HC workers?

-HC workers are as likely to abuse drugs as anyone else -situational increase to access to controllers substances in HC -HC workers are under stress & may self-medicate as a method of coping -substance misuse is a *medical condition* not a psychological failing

How can naloxone be administered?

-Intranasal= emgency workers, out of hospital setting -IM/ IV with syringe & needle= health care setting -IM with Evzio auto-administrator= out of hospital

What are my responsiblities & what should you do if someone you know has an addiction problem?

-Legal & ethical responsibility to uphold the law & help protect pts & society from drug abuse -Professional responsibility to prescribe & dispense controlled substances appropriately, guarding against abuse while ensuring pts have meds available when they need it -Personal responsibility to protect your practice from becoming an easy target for drug diversion. You must become aware of potential situations where drug diversion can occur & help creat safeguards that can be enacted to prevent this diversion Call National Drug Helpline: 1-888-633-3239

What is the onset of liver vs lung cancer?

-Liver cancer onset is slow: Normal liver —> Hepatic steatosis (fatty liver) —> Steatohepatitis + fibrosis (fat + hepatocellular injury & inflammation) —> Cirrhosis —> Liver Cancer -Small cell lung cancer (SCLC) onset is fast: tends to spread early -Non small cell lung cancer(NSCLC) onset is slower

What are potential complications of opioid abuse?

-Opioids are useful in the context, opioid misuse & dependency is a complication **Opioid overdose & death!

What needs to happen before the patient undergoes a paracentesis?

-Physician order: consent (actual language) -Patient preparation the morning of: vs, void, BS, wt, NPO -Baseline labs needed: BUN, creat, WBC, CBC, glucose, liver enz -Nursing actions: VS right before the procedure then frequent Q5-Q15 depending on how stable patient is , start IV of NS or LR, grab general supplies like drape, scub, kit, extra gloves (servile), specimen containers with patient labels (more than 1)

What needs to be documented after a parcentesis?

-Specimen color & amount -how pt tolerated

What are the different stages of liver biopsy for the diagnosis of cirrhosis?

-Stage 0: no fibrosis/scarring or liver damage -Stage 1: beginning of liver damage started with slight scarring -Stage 2: moderate liver damage; scarring advances in the liver & surrounding -Stage 3: significant liver damage; liver becomes fibrotic/scarred & connects with other scarred areas -Stage 4: Final stage of liver damage/cirrhosis; the liver is no longer functioning properly & severely damaged

What are the 5 strategies to avoid overdose deaths?

-Strategy 1: encourage providers, persons at risk, family members, & others to learn how to vent & manage opioid overdose -Strategy 2: ensure access to treatment for individuals who are misusing opioids or have substance use disorder -Strategy 3: ensure ready access to naloxone -Strategy 4: Encourage public to call 911 -Strategy 5: Encourage prescribers to use state prescription drug monitoring programs (PDMPs)

What's the treatment of lung cancer?

-Surgery -Radiation -Chemotherapy -Target therapy -Immunotherapy -Vaccine therapy

What's the treatment of liver cancer?

-Surgery (preferred intervention) -Radiofrequency ablation -Cryosurgery -Non traditional chemo like cisplatin injection & general transarterial chemoembolization -Liver transplant & anti-rejection meds -Pain meds like analgesics, narcotics, morphine, nerve blocks, implantable dug delivery

How is liver cancer diagnosed?

-Ultrasound -CT -MRI -Biopsy (grade/stage cell differentiation, cell regression, cellular organization) -hx of presenting illness, vaccinations, hep B exposure, drug use, alcohol use -high Alpha-fetoprotein (AFP) -high Bilirubin -high PT/INR -high Alkaline phosphatase -low Albumin

What is used for diagnosis of opioid abuse?

-Use hx gathering & screening tools, NOT CXR, CT, MRI -need appropriate Qs by HC providers -blood & urine testing for drugs & drug levels -Screening tools: CAGE-AID & DAST, DSM-5

During the paracentesis procedure what should the nurse be monitoring?

-VS: BP, HR SpO2 -Color -Neuro -Pain -Monitor for breaks in sterile procedure! -Monitor for patient response to procedure

What are the expected outcomes for alcoholism? *must know!

-abstinence -recovery -reduced use -controlled use -reversal of side effects (short term) -resolution of side effects (long term) -long term care -patient driven -psychiatric support & help

What are examples of substance abuse?

-alcohol -nicotine -food -narcotics/opioids -prescription meds ex: muscle relaxants, anti anxiety, etc -non prescription meds ex: laxatives, mouthwash, vitamins, etc -household chemicals ex: glue, cleaners, air freshener, paint, etc **family hx of substance abuse increases risk

What is the pathophysiology of alcoholism?

-alcohol stimulates release of dopamine (feel good neurochemical) -neuroplasticity rewards the body for feeling good = seeks it out next time (addiction) -enhances GABA activity, enhances glutamate= more excitability -more excitability= progresses to hyperexcitability when alcohol removed = negative side effects of alcohol withdrawal -long term exposure to alcohol damages GI, CV, pancreas, immune, & nervous systems -increases & speeds cellular destruction -liver metabolism of alcohol can lead to fatty liver disease —> hepatitis —> cirrhosis —> liver cancer

What are the demographics & causes of cirrhosis?

-alcoholism (leading cause) -inflammation from hepatitis B & C, infections -non alcoholic steatohepatitis (NASH) -autoimmune hepatitis -non alcoholic fatty liver disease (NAFLD), obesity -some drugs -R. Sided CHF

What are interventions for opioid abuse & substance misuse?

-assess hx of prescription & nonprescription drug use, physical symptoms, signs of withdrawal (CIWA scale) -monitor labs & provide fluids, electrolytes, & nutrition as needed -withdrawal & treatment meds as ordered -educate on plan of care -long term treatment meds ex: naltrexone, buprenorphine (suboxone), methadone *only few meds for treatment; inconsistent treatment success, high relapse rate w opioids, relapse more likely if maintanence meds used <=3 mos

What are interventions for alcoholism?

-assess hx, physical symptoms (pertinent +/-), signs of withdrawal (CIWA) -monitor labs -provide meds (acamprosate, naltrexone, nalmefene, olanzapine, sertraline, fluoxetine, gabapentin) -educate on plan of care -AA & cognitive behavioral therapy

What are the extreme versions of cirrhosis?

-bleeding/clotting (like DIC) -changes in LOC & neurotoxicity (can be permanent) -fluid overload *Permanent scarring=liver cancer

What happens to cells to make them cancerous?

-cells under stress can replicate faster or differently -cells grow faster in number (hyperplasia) or size (hypertrophy) -cells change in organization or arrangement (architecture) -change in type of cell; still differentiated (metaplasia) -dysfunctional arrangement of cells; less differentiated (dysplasia) -without differentiation; cells have lost original structure & arrangement & often regress to more immature state

What are the transplantation anti-rejection meds?

-cyclosporine (Sandimmune) -cyclosporine modified (Neoral) -Tacrolimus (Prograf) -Azathioprine (Imuran) -Mycophenolate mofetil (CellCept) -prednisone (Deltasone)

Which of the following should be included in education for overall liver cancer prevention?

-decrease/discontinue use of alcohol -get vaccinated against hepatitis B -get tested & treated for hepatitis C esp. 1945-1968 VIV drug use -decrease/discontinue IV drug use -decrease BMI -control & prevent DM

What nursing assessment should be performed for a patient with cirrhosis/liver dysfunction?

-employment like health care workers ex: hepatitis B -risky behaviors for hepatitis -any exposure to chemicals or inflammation -hx alcoholism -hx of hepatitis -hx of heart disease ex: CAD, R. Sided CHF, cholesterol -family hx of alcoholism or liver damage -weakness, fatigue -RUQ pain or tenderness -jaundice of skin or mucous membranes -spider angiomas or other skin changes -ascites or fluid in abdomen, hands, or feet; measure abd girth daily & daily weight -facial hair in women, breast development in males -asterixis: tremor in hands, fingers, wrist

What are the extreme versions/ complications of alcoholism?

-esophageal irritation/varices -folic acid & vitamin deficiency -gastritis/GERD -falls/injuries -hypercortisolism (cushings signs) -HTN **cirrhosis!** **liver cancer!**

What are the best practices for pt safety & quality care with a patient with paracentesis? Refer to Chart 58-1 Iggy

-explain the procedure & answer pt questions -obtain VS & wt -ask pt to void before the procedure to prevent injury to the bladder -position pt in bed with HOB elevated -monitor VS per protocol -measure the drainage & record accurately -describe the collected fluid -label & send the fluid for lab analysis; document in the pt record that specimens were sent -after the physician removes the catheter, apply dressing to the site; session for leakage -maintain bed rest tear protocol -weigh the pt after paracentesis; document pt record weight both before & after paracentesis

What is the development of cancer/carcinogenesis influenced by?

-extrinsic factors ex: chemicals like smoke, alcohol, diet, pesticides -intrinsic factors ex: genetic predisposition, age, increased BMI -change in immune function ex: HIV & transplantation pts -hormonal factors ex: too much estrogen & breast cancer -chronic trauma/irritation ex: smoking, alcohol use, sun exposure, workplace chemicals -viruses ex: HPV causes cervical cancer

What increases the likelihood of addiction to drugs or alcohol?

-family & relatives struggled with addiction -abusive ,neglectful, or traumatizing upbringing -mental health disorders -drug or alcohol use early in life

What are the symptoms and behaviors of Addiction? Refer to Box 37-1 Giddens

-fatigue -insomnia -headaches -seizures -changes in mood -anorexia & weight loss -vague physical complaints -overabundant use of mouthwash or toiletries -appearing older than stated age -unkempt appearance -leisure activities that involve alcohol & other drugs -sexual dysfunction, decreased libido, erectile dysfunction -trauma secondary to falls, auto accidents, fights, or burns -driving while intoxicated -failure of standard doses of sedatives to have to have therapeutic effect -financial problems, including those r/t spending for substances -frequent reference to alcohol -problems in areas of life function like frequent job changes, marital conflict, separation, & divorce, work related accidents, tardiness, absenteeism, legal problems, arrest, social isolation, estrangement from friends

What is Alcoholic Anonymous?

-fellowship for men & women -Apolitical -available everywhere -no age limit -no education requirements -open to anyone who wants to come & do something about drinking problem -group therapy setting -12 steps of AA -12 traditions of AA

What are the demographics/statistics of opioid abuse?

-fentanyl misuse rising outside HC setting -West virginia, ohio, & New Hampshire highest death rates from synthetic opioids -opioid misuse & overdose increased across all demographics -women become more dependent of prescription pain killers bc more likely have chronic pain, be prescribed, higher doses, & use longer time -men die more from opioid overdose -white people die more than any other race from opioid overdose -drug overdose is the leading cause of accidental death in the US

What she you look for that indicates potential HC worker substance misuse?

-frequently absent from work -frequently not present when at work "disappearances" -work performance widely varies (ex: barely stay awake one day, then the next day wide awake) -volunteers to drug handle: pts needing pain meds, narcotic counts, med pick up from pharmacy -increased wasting of drugs above average rates -increased 'errors' with meds such as dropped, contaminated, med not available, wrong dose sent -ask for narcotic orders inappropriately on pts to have accesss to 'locked' meds -personality change & changed relationship -physical changes: mood swings, anxiety, depression, lack of impulse control, suicidal thoughts, anger, agitation, -change in appearance, inappropriate clothing, wearing long sleeves when inappropriate -unrealiability in keeping appointments & meeting deadlines -confusion, memory loss, difficulty concentrating -ordinary tasks require greater effort or consume more time -interpersonal relations with colleagues suffer; rarely admits errors or accepts blame -sloppy record keeping & suspect ledger entries & drug shortages -insistent on personal administration of injected narcotics to pts -progressive deterioration of personal appearance, hygiene, handwriting, & charting -pt & staff complaints about changing attitude/behavior -increasing personal & professional isolation

What are the demographics for alcoholism?

-higher in Native American -higher in Latinex populations -higher in acculturated latinex (lived in US for a while) vs nonacculturated latinex (recently migrated) -higher SES Americans more likely to drink vs lower SES Americans more likely have drinking problems -Iceland highest amount of AA, but consumes less alcohol -Bolivia drink more & potent alcohol but no less problems

What are the symptoms of lung cancer?

-hoarse voice -persistent cough -fatigue -SOB -wheezing -difficulty swallowing -a loss of appetite -chest pain/discomfort -blood in mucus brought up by coughing -welling in the veins of the face and neck

What are the liver transplantation risks?

-liver graft rejection -infection: pneumonia, surgical site infection, great infection, opportunistic infection -need to be on massive ATB & immunosuppressants -thrombosis from liver involvement & immobility; long recovery -abscess from lack of adequate fluid/bile drainage -renal failure from anti-rejection meds -multisystem organ failure

What is the demographic & prognosis for liver cancer?

-liver is multi-functional so it's hard to treat -5 year survival is 14% -blacks have lower survival rates -increased liver cancer deaths while overall cancer death rates decreasing -men 2x more likely to die from liver cancer -hepatitis B causes 60-80% of primary liver CA -hepatitis C causes 20% of liver CA; people born between 1945-1965 & IV drug users more likely to have hep c -about 70-90% of cirrhotic livers cause liver CA

What is substance abuse characterized by?

-loss of control of substance use & dosing -use of substance even while aware of/or experiencing adverse effects -presence of cognitive, physcal, & behavioral disturbances with the abuse of the substance

Where can lung cancer spread to?

-lymph nodes -bones -adrenal glands -brain

What are the interventions of cirrhosis/liver dysfunction? *mostly used to treat side effects

-monitor VS esp BP -monitor neuro changes -monitor liver enzymes, coagulation, bilirubin (conjugated/unconjugated), protein/albumin, steroid levels, glucose, drug levels -monitor physical appearance for cushings signs, bleeding, jaundice -monitor stool for color changes like tan/gray color -monitor liver area for tenderness, swelling, pain -monitor weight & abdominal girth -document changes -recommend timely lab follow up -paracentesis for ascites -shunt for ongoing fluid drainage -biopsy -transplant -glucose monitoring & control -support protein -treat infections -control bleeding & treat clotting factors -treat excess or deficient steroids -treat portal HTN & resultant esophageal varices -correct electrolyte embalances (Na+, K+) -liver transplant to regain viable tissue -blood product transfusion for coagulopathy -treat high BP/portal HTN with meds like vasopressin, lopressor -NG tube for GI bleeding -NPO for esophageal varices

What is the nursing assessment of liver cancer?

-monitor weight -monitor for ascites & abdominal girth -monitor labs (BUN, PT/INR, albumin, AST, ALT, alkaline phosphatase, ammonia) -monitor skin & mucous membranes for jaundice & petechiae -monitor stool for color/consistency changes (tan/gray color) -assess abdomen for swelling, enlargement, tenderness in RUQ liver & spleen area -monitor neuro status -monitor VS esp BP -monitor for hormonal changes (gynecomastica, unwanted fascial hair, Cushing's symptoms)

What are the causes of lung cancer?

-most related to smoking (current, former, or secondary) -radon -occupational exposure -asbestos -pesticides -heavy metals -diesel exhaust -air pollution -family history -genetics

What are the symptoms & presentation of alcohol ingestion is stopped?

-nausea -shaking -sweating -disorientation -changes in mood, speech, postural stability

What are the potential side effects of chemo patients? *think about nontraditional chemo used for liver cancer like cisplatin injection isn't liver & general transarterial chemoembolization injection into liver veins

-pancytopenia -anemia -thrombocytopenia -immunosuppressive -alopecia -nausea -N/V -diarrhea

What stages are nurses involved with for nursing care & cancer?

-prevention by teaching avoidance of known or potential carcinogens ex: stop smoking & drinking, wear sunscreen, colonoscopy, skin checks -educate on decreasing use of alcohol, get vaccinated against hepatitis B, get tested & treated for hepatitis C, decrease IV drug use, decrease BMI, control & prevent DM -providing treatments & interventions -set goals & plan for recovery -physical & psychological care during terminal illness

What are the requirements for liver transplantation?

-reserved for patient who has not responded to resection or other treatments -must be able to adhere to strict anti-rejection drug regimen afterwards -must not have metastases or other severe disease ex: COPD or CAD/CHF -most donor livers are human from trauma victims; no artificial livers yet -not done at every hospital/area -living donors can be used for partial liver transplant (donor & recipient livers can regenerate)

What are the normal lab values for: electrolytes, CBC, BUN/creat, PT/INR/aPTT

-sodium: 135-145 -potassium: 3.5-5 -calcium: 9-10.5 -magnesium: 1.2-2 -hgb : 12-18 -hct : 37-52% -rbc: 4.2-6.1 -wbc: 5,000-10,000 -platelets: 150,000-400,000 -BUN : 10-20 -Creatinine: 0.5-1.2 -PT: 11-13 secs -INR: 0.8-1.1 or 2-3 with treatment -aPTT: 30-40 secs

How can you intervene if another HC worker has substance misuse?

-state what you observe to the individual -state what you observe to the supervisor -provide for pt safety at all times even if it means intervening in med passes of assignments -involve law enforcement/security as needed *Goal for individual is no punishment, but treatment; It can be very hard to approach colleagues. The reporter may fear retribution, anger, or false accusation. May times absences & poor performance are often excused or tolerated long before intervention which is enabling. So must report

What will a patient with alcohol abuse/dependence experience?

-strong craving or need to consume alcohol -unable to limit or stop alcohol use; loss of control over substance -physical dependence after habitual use is stopped -tolerance (need to increase the amount used to achieve the desired effect

What's the nursing focus for liver cancer interventions?

-treating chemo side effects -surgical care pre & post -monitor BUN, PT, INR, albumin -meds as ordered like anti-rejection with transplantation -pain control like analgesics, narcotics, morphine, nerve blocks, implantable drug delivery

What are the different grades and sign of hepatic encephalopathy?

0- unimpaired LOC, personality change, & neuro symptoms 1- altered sleep, shortened attention span, recognizable cognitive or behavior decay, euphoria, anxiety, dysphoria, irritability, tremor, dyscoordination, impaired handwriting 2- lethargy, apathy, increased fatigue, disorientation, short term amnesia, gross personality change, tremor, asterixis, dysarthria, ataxia, strong reflexes, dyspraxia 3- somnolence, confusion, marked disorientation, aggression, bizarre behavior, rigor, weak reflexes 4- coma, limp, no response to pain stimulus

What is the normal dose of naloxone?

0.4-0.8 mg IM *also known as Narcan used for opioid overdose; do NOT get confused with naltrexone (50-100mg daily) for alcohol dependence

What is the normal dose of multivitamin?

1 dose daily PO/IV *adjunctive med for alcohol; refer to CIWA

Match the following definitions to their term: 1) ____ as an excessive use of a chemical substance resulting in physical & mental dependence that interferes with ADL 2) ____ habitual & uncontrollable urge to use a substance 3) ____ taking substance for pleasure without dependence 4) ____ occurs when people use chemicals for other than their intended action 5) ____ uncontrollable substance craving, seeking, & using. Stems from physiologic changes in the brain A. Dependence B. Substance use C. Addiction D. Substance misuse E. Substance abuse

1) __E. substance abuse__ as an excessive use of a chemical substance resulting in physical & mental dependence that interferes with ADL 2) __A. Dpenedence__ habitual & uncontrollable urge to use a substance 3) __B. Substance use__ taking substance for pleasure without dependence 4) __D. Substance misuse__ occurs when people use chemicals for other than their intended action 5) __C. Addiction__ uncontrollable substance craving, seeking, & using. Stems from physiologic changes in the brain

Cancer is the disorder of too many growing cells known as 1)______ & too many different types/nonspecific of cells known as 2) ____

1) proliferation 2) differentiation

What is the normal dose for Lorazepam?

1-4 mg IVP/PO/NG Q30mins- 4H *Benzodiazepine used in alcohol withdrawal; refer to CIWA score

What are the different progressions of cirrhosis & their symtpoms

1. *Liver failure*: jaundice, coagulopathy, encephalopathy 2. *Portal HTN*: esophageal varice, ascites, spontaneous bacterial peritonitis 3. *Hepatocellular carcinoma*: changes in bowel/bladder, sore doesn't heal, unusual bleeding, lump or thickening, indigestion or GI changes, new cough, hoarseness, new wt loss or gain, new unexplained pain, jaundice, RUQ pain, ascites, abd pain, lump or tenderness RUQ, differences in bleeding or bruising, N/V, wt loss, neuro changes, encephalopathy, or no symptoms

Match the following liver lab tests definitions to their name: 1. ALT 2 AST 3. GGT 4. Alkaline phosphatase 5. Albumin 6. PT 7. Bilirubin 8. Total bilirubin 9. Indirect bilirubin 10. Direct bilirubin 11. Ammonia A) Buildup/elevated if liver not able to metabolize causing hepatic encephalopathy B) A liver enzyme found in the liver & a few other organs, particularly the heart & other muscles in the body C) the liver produces proteins involved in the clotting/coagulation of blood; the PT measures clotting function & if abnormally high may indicate liver damage D) A liver enzyme r/t bile ducts, but also produced by the bones, intestines, & during pregnancy by the placenta; often increased when bile ducts are blocked E) produced when hemoglobin breaks down: liver supposed to remove this product from the body & these levels are measured of how well liver is working F) A liver enzyme mainly found in the liver; the best test for detecting hepatitis G) measures all of the bilirubin in the blood H) measures conjugated/metabolized bilirubin (combined with another compound) in the liver & is pre-excretion or post liver damage I) A liver enzyme found mainly in the liver cell J) also called unconjugated bilirubin & is not bound & is pre-liver metabolized bilirubiin K) measures the main protein made by the liver; the level can be affected by liver & kidney function & by decreased production or increased loss

1. ALT= F) A liver enzyme mainly found in the liver; the best test for detecting hepatitis 2 AST= B) An enzyme found in the liver & a few other organs, particularly the heart & other muscles in the body 3. GGT= I) A liver enzyme found mainly in the liver cell 4. Alkaline phosphatase= D) A liver enzyme r/t bile ducts, but also produced by the bones, intestines, & during pregnancy by the placenta; often increased when bile ducts are blocked 5. Albumin= K) measures the main protein made by the liver; the level can be affected by liver & kidney function & by decreased production or increased loss 6. PT=C) the liver produces proteins involved in the clotting/coagulation of blood; the PT measures clotting function & if abnormally high may indicate liver damage 7. Bilirubin= E) produced when hemoglobin breaks down: liver supposed to remove this product from the body & these levels are measured of how well liver is working 8. Total bilirubin= G) measures all of the bilirubin in the blood 9. Indirect bilirubin= J) also called unconjugated bilirubin & is not bound & is pre-liver metabolized bilirubiin 10. Direct bilirubin= H) measures conjugated/metabolized bilirubin (combined with another compound) in the liver & is pre-excretion or post liver damage 11. Ammonia= a) Buildup/elevated if liver not able to metabolize causing hepatic encephalopathy

Define the following oncologic emergencies & how can be prevented 1. Acute Spinal Cord compression 2. Adrenal crisis 3. Hypercalcemia 4. Hyperviscosity syndrome 5. Hyperleukocytic syndrome 6. Immunosuppression/infection 7. Pericardial tamponade 8. Superior vena cava syndrome 9. SIADH 10. Thrombocytopenia/hemorrhage 11. Upper airway obstruction a) Blockage of any portion of the airway causing changes in voice like stridor b) Compression of the heart caused by fluid collecting in the space surrounding the heart c) Obstruction of blood flow through the superior vena cava— by lung, breast, chest CA, & Non Hodgkin d) Surgical emergency where compression occurs anywhere from the cervical spine down to lumbar spine e) Extra calcium in blood, affecting many body systems— by lung, breast, chest, renal CA, & multiple myeloma f) Condition in which blood isn't able to flow freely through the arteries— by leukemia g) Life threatening complication characterized by an excess amount of white blood cells in the bloodstream— by leukemia h) Condition in which high levels of the hormone aldosterone, causing the body to retain water —by SC lung cancer i) Adrenal glands stop working properly & there is not enough cortisol in th embody causing weakness, extreme tiredness, & drops in BP J) Low number of platelets in the blood K) Suppression of the immune response

1. Acute Spinal Cord compression = d) Surgical emergency where compression occurs anywhere from the cervical spine down to lumbar spine 2. Adrenal crisis = i) Adrenal glands stop working properly & there is not enough cortisol in the embody causing weakness, extreme tiredness, & drops in BP 3. Hypercalcemia = e) Extra calcium in blood, affecting many body systems— by lung, breast, chest, renal CA, & multiple myeloma 4. Hyperviscosity syndrome = f) Condition in which blood isn't able to flow freely through the arteries— by leukemia 5. Hyperleukocytic syndrome = g) Life threatening complication characterized by an excess amount of white blood cells in the bloodstream— by leukemia 6. Immunosuppression/infection = Suppression of the immune response 7. Pericardial tamponade = b) Compression of the heart caused by fluid collecting in the space surrounding the heart 8. Superior vena cava syndrome = c) Obstruction of blood flow through the superior vena cava— by lung, breast, chest CA, & Non Hodgkin 9. SIADH = h) Condition in which high levels of the hormone aldosterone, causing the body to retain water —by SC lung cancer 10. Thrombocytopenia/hemorrhage = J) Low number of platelets in the blood 11. Acute Spinal Cord compression = a) Blockage of any portion of the airway causing changes in voice like stridor

What are abnormal lab findings indicating liver disease? Refer to Table 58-3 Iggy

1. Elevated AST 2. Elevated ALT 3. Elevated LDH 4. Elevated alkaline phosphatase 5. Elevated GGT 6. Elevated total bilirubin, direct conjugated bilirubin, indirect unconjugated bilirubin 7. Elevated ammonia 9. Elevated PT/INR 10. Decreased total protein 11. Decreased albumin

What are the 4 criteria for CAGE, a screening tool for alcohol use problems?

1. Have you ever felt you needed to *Cut down* on your drinking? 2. Have people *Annoyed* you by criticizing your drinking? 3. Have you ever felt *Guilty* about your drinking? 4. Have you ever felt you needed a drink first thing in the morning (*Eye-opener*) to steady your nerves or get rid of a hangover? *scores of 2 or more are a typical cut off as "screening positive"; but not intended to provided a diagnosis

Match the term to the definition 1. Hyperplasia 2. Hypertrophy 3. Architecture 4. Meta plasma 5. Dysplasia 6. Anaplasia 7. Proliferation 8. Differentiation 9. Carcinogenesis A) too many growing amounts of cells B) cancer development C) cells change in organization or arrangement D) too many different types/nonspecific cells E) without differentiation; cells lose original structure & arrangement & often regress to a more immature state F) cells grow fast in number G) cells grow fast in size H) dysfunctional arrangement of cells; less differentiated I) change in type of cells; still differentiated

1. Hyperplasia= F) cells grow fast in number 2. Hypertrophy= G) cells grow fast in size 3. Architecture= C) cells change in organization or arrangement 4. Metaplasia= I) change in type of cells; still differentiated 5. Dysplasia= H) dysfunctional arrangement of cells; less differentiated 6. Anaplasia= E) without differentiation; cells lose original structure & arrangement & often regress to a more immature state 7. Proliferation= A) too many growing amounts of cells 8. Differentiation= D) too many different types/nonspecific cells 9. Carcinogenesis= B) cancer development

What are the 3 main analgesic groups?

1. Non opioids ex: acetaminophen, NSAIDs 2. Opioids ex: morphine, dilaudid, hydromorphone, hydrocodone, fentanyl, oxycodone 3. Adjuvant analgesics ex: muscle relaxants, local anesthetics, anticonvulsants, & antidepressants

What is the normal dose of Diazepam?

10-20 mg (20 rarely used) IV/PO Q6H, 8H, 12H, daily (each for one day) *Benzodiazepines med used in alcohol will be tapered as symptoms improve ex: diazepam & chlordiazepoxide; refer to CIWA

What is the normal dose of Thiamine?

100mg PO/IV/IM Q8H/TID during alcohol withdrawal, then reduce 100mg daily *adjunctive med for alcohol; refer to CIWA

What is the normal dose of folic acid?

1mg PO/IV daily *adjunctive med for alcohol; refer to CIWA

What supplies for a paracentesis would the procedure nurse want?

2 of everything and leave 1 of everything outside the room so doesn't get contaminated if need to use like the kits, o2 tubing, IVF, blackup tray/gloves

What is the normal dose for Chloradiazepoxide?

50-100mg (100 rarely used) PO Q6H, 8H, 12H, daily (each for one day) *Benzodiazepines med used in alcohol will be tapered as symptoms improve ex: diazepam & chlordiazepoxide; refer to CIWA

What is the normal dose of naltrexone?

50-100mg daily to every other day *also known as suboxone used for alcohol dependence; do NOT get confused with naloxone (0.4-0.8 mg IM) used for opioid overdose

Which of the following shows that the nurse most needs more education when delegating care to UAP for pt with liver failure? (Select all that apply) A) "Go empty his Foley and let me know what you charted and what it looked like" B) "You can get his accucheck anytime you want" C) "He may need electric razor to shave" D) "He may need help with ambulatory: i walked him this morning with a gait belt"

A) "Go empty his Foley and let me know what you charted and what it looked like" (empty foley fine; chart okay; assess not okay) B) "You can get his accucheck anytime you want" (follow glucose with liver dysfunction & nutrition) *A) incorrect bc emptying foley & charting is fine, but assessing is NOT okay; B) incorrect bc need to follow glucose closely 4x/day Q6H with liver dysfunction & nutrition; C) is okay bc risk for bleeding so want to use electric razor to decrease risk; D) is okay bc it's pretty specific delegation like what devises to use when ambulating. Pt should be assisted bc BS could be up or down & disorientation with ammonia toxicication & neuro changes, then if pt had a procedure they'll need help/assistance; maybe use bed alarm

What meds may be given for alcoholism? (Select all that apply) A) acamprosate B) buprenorphine C) naltrexone D) naloxone E) olanzapine F) fluoxetine G) gabapentin H) sertraline

A) acamprosate C) naltrexone E) olanzapine F) fluoxetine G) gabapentin H) sertraline *the antipsychotics (olanzapine, sertraline, & fluoxetine) are under investigation for alcoholism to see if decrease alcohol craving

Which is the following are symptoms of alcohol withdrawal that the nurse should monitor for? Select all that apply A) agitation B) auditory & visual disturbances C) anxiety D) N/V E) tactile disturbances F) paroxysmal sweats G) unconscious H) tremors I) fullness in head J) clouding of sensorium

A) agitation B) auditory & visual disturbances C) anxiety D) N/V E) tactile disturbances F) paroxysmal sweats H) tremors I) headache/fullness in head J) orientation/clouding of sensorium

Which of the following meds may be used for alcohol withdrawal? Select all that apply A) diazepam B) naloxone C) lorazepam D) naltrexone E) chlordiazepoxide F) clopidogrel

A) diazepam C) lorazepam E) chlordiazepoxide *naloxone (narcan) used for opioid overdose; naltrexone used for alcohol dependence; clopidogrel blood thinner not used

Which of the following are potential symptoms of alcohol withdrawal after 48 hrs after last drink? (Select all apply) A) disorientation B) tremors C) palpitations D) HTN E) tachycardia F) restlessness G) diaphoresis H) bradypnea I) hallucinations

A) disorientation B) tremors C) palpitations D) HTN E) tachycardia F) restlessness G) diaphoresis I) hallucinations *more severe symptoms 24-72 hrs after last drink: will have mild symptoms like restlessness, anxiety, low grade fever, diaphoresis, tremors, headache, palpitations, high BP, insomnia & severe symptoms like delirium tremens, hallucinations, disorientation, tachycardia, HTN, agitation, & vomiting

Which of the following are examples of substance abuse? (Select all that apply) A) food B) water C) muscle relaxants D) anti-anxiety meds E) cleaners F) laxatives G) mouth wash H) vitamins I) gum

A) food C) muscle relaxants D) anti-anxiety meds E) cleaners F) laxatives G) mouth wash H) vitamins *also alcohol, nicotine, narcotics/opioids, glue, air freshener, paint. Family hx increases person's risk

Which of the following are likely symptoms after 72 hrs after last use of opioids? (Select all that apply) A) nausea B) tremors C) diarrhea D) palpations E) decreased BP F) vomiting G) tactile hallucinations H) stomach cramps

A) nausea B) tremors C) diarrhea D) palpations F) vomiting G) tactile hallucinations H) stomach cramps *E) is incorrect bc have increased BP; *mild symptoms occur 6-12 hrs after ex: muscle cramping, depression, restlessness, anxiety, low grade fever, diaphoresis, sweating, tremors, headache, palpitations, increased BP, insomnia, craving for substance, need substance for 'normal' function; more sever is 72 hrs to 7 days after last use ex: mild symptoms + N/V, diarrhea, stomach cramps, tactile hallucination

Which of the following are potential liver transplantation risks? (Select all that apply) A) pneumonia B) SIADH C) thrombosis D) renal failure E) abscess F) DIC G) liver graft rejection H) multisystem organ failure

A) pneumonia C) thrombosis D) renal failure E) abscess G) liver graft rejection H) multisystem organ failure *other infections like surgical site infection, graft infection, opportunistic infections

The nurse is teaching the patient with opioid misuse about the risk for liver cancer. Which of the following is the best definition of the connection between opioid misuse and liver cancer? A. "Injecting opioids especially with unclean or shared needles can increase your risk and exposure to Hepatitis B & especially Hepatitis C, both which can lead to liver cancer" B. "Injecting opioids can introduce substances to your liver, which irritates it and can eventually cause liver cancer" C. "Smoking heroin is irritating to your liver as it tries to process the foreign chemical and that can cause cancer". D. 'Smoking heroin can lead to lung cancer and a secondary or metastasis site for lung cancer is liver cancer"

A. "Injecting opioids especially with unclean or shared needles can increase your risk and exposure to Hepatitis B & especially Hepatitis C, both which can lead to liver cancer"

The nurse knows that which of the following statements is the best descriptor of alcohol use disorder recovery goals? A. "You should find treatment and support with others that works for you" B. "You should never relapse" C. "If your family is screwed up, you should not include them in your treatment plan and focus on you" D. "You should never use alcohol again" E. "You should cut down on alcohol use"

A. "You should find treatment and support with others that works for you" *This is the best answer. Both medical monitoring by a physician, possible medications and group therapy have been proven to be the most successful in alcohol use disorder recovery.

What is the best definition of TIPS procedure? A. A balloon is used to increase the portal vein diameter or to connect the portal vein to hepatic vein. A stent can be placed. B. Removal of fluid accumulation in the peritoneal cavity by direct, temporary aspiration with or without fluroscopy (radiologic guidance) C. Procedure to visualize bile ducts and to place stents in the biliary tract D. Direct visualization of the upper GI tract with a camera down the espohagus

A. A balloon is used to increase the portal vein diameter or to connect the portal vein to hepatic vein. A stent can be placed. *Yes. TIPS stands for Transjugular Intrahepatic Portosystemic Shunt. This is used to control bleeding especially in the esophagus and stomach. It is an inpatient procedure, but not really surgery. However, many surgical preparations are the same such as NPO status, etc. The 'shunt' is the new tract that is created. It is commonly used with patients who have portal hypertension.

The nurse knows that which of the following are signs of healthcare worker substance use disorder? A. A change in appearance or affect B. Volunteering to deliver pain meds for other patients C. Charting or medication entries that do not match medication dispensation information D. Offering to waste narcotics for other nurses E. Hiding, avoiding or not talking to other staff members

A. A change in appearance or affect B. Volunteering to deliver pain meds for other patients C. Charting or medication entries that do not match medication dispensation information D. Offering to waste narcotics for other nurses E. Hiding, avoiding or not talking to other staff members *Yes, this could be a sign of substance impairment.

Which of the following CIWA orders would the nurse questions? (Select all that apply) A. Chloradiazepoxide 75 mg orally every 2 hours​ B. Chloradiazepoxide 75 mg orally every 12 hours ​C. Chlordiazepoxide 75 mg orally every 8 hours

A. Chloradiazepoxide 75 mg orally every 2 hours​ *Normal dose: 50-100mg (100 rarely used) PO Q6H, 8H, 12H, daily(each for one day) so A) incorrect bc would no give it over 2H. Also note that Benzodiazepines meds will be tapered as symptoms improve ex: diazepam & chlordiazepoxide

The nurse knows that which of the following are sign that a liver transplant is being rejected? Select all that apply. A. Flank pain B. Tachycardia C. Oliguria D. Abdominal pain E. Hypertension F. Parathesias

A. Flank pain B. Tachycardia C. Oliguria D. Abdominal pain E. Hypertension Yes, this can be a sign of liver transplant rejection.

The nurse knows that which of the following are included on a CAGE survey for alcohol use? Select all that apply. A. Have you ever felt you needed to cut down on your drinking? B. Have people annoyed you by criticizing your drinking? C. Have you ever felt guilty about drinking? D. Have you ever felt you needed a drink first thing in the morning (eye-opener) to steady your nerves or to get rid of a hangover? E. Have you ever been injured as a result of your drinking? F. Have you ever not been able to stop drinking once you started?

A. Have you ever felt you needed to cut down on your drinking? B. Have people annoyed you by criticizing your drinking? C. Have you ever felt guilty about drinking? D. Have you ever felt you needed a drink first thing in the morning (eye-opener) to steady your nerves or to get rid of a hangover? *Yes. This is the C on CAGE = Cut down Yes. This is the A in CAGE = Annoyed Yes. This is the G in CAGE = Guilty Yes. This is the E in CAGE = eye opener.

Which of the following orders would the nurse questions? (Select all that apply) A. Naloxone 0.4-0.8 mg IM for treatment of opioid dependence B. Naltrexone 4-8 mg for treatment of opioid overdose ​C. Naloxone 0.4-0.8 mg IM for treatment of opioid overdose

A. Naloxone 0.4-0.8 mg IM for treatment of opioid dependence B. Naltrexone 4-8 mg for treatment of opioid overdose -Normal dose: NalOXONE is Narcan used for opioid overdose 0.4-0.8 mg IM -Normal dose: NalTREXone is suboxone for alcohol dependence 50-100mg daily to every other day -A) NaloXONE is incorrect bc it is used for opioid overdose not dependence -B) NalTREXone is incorrect bc its NalOXONE is 0.4-0.8mg IV used for opioid overdose

The nurse knows that which criteria are measured on the Clinical Institute Withdrawal Assessment (CIWA)? Select all that apply. A. Nausea/vomiting B. Tremor C. Sweats D. Anxiety/agitation E. Mood changes F. Change in family relationships G. Auditory/visual disturbances

A. Nausea/vomiting B. Tremor C. Sweats D. Anxiety/agitation G. Auditory/visual disturbances *Note on the CIWA that the scales are used help to measure frequency and severity both of each symptom.

The nurse knows that which of the following are likely treatments for liver cancer? A. Possible radiation, especially targeted radiation B. Possible surgery/resection C. Liver transplantation D. Artificial liver implantation E. Liver chelation; removing toxins through chemical binding F. Possible chemotherapy

A. Possible radiation, especially targeted radiation B. Possible surgery/resection C. Liver transplantation F. Possible chemotherapy *Yes, radiation might be tried, but usually the liver does not respond well to radiation Yes, this might be used to remove a tumor or area. Yes, this is definitely a thing. All or part of a liver can be used! Transplanted liver tissue can regenerate! Yes, this could be an intervention, but is not as likely.

What is a 10-item screening tool developed by WHO to assess alcohol consumption, drinking behaviors, & alcohol related problems? A score of 8 or more is considered to indicate hazardous or harmful alcohol use

AUDIT

What are the negatives of anti rejection meds?

Anti rejection meds have high side effects & usually very expensive: -kidney toxicity -high BP -neurotoxicity (tremor, headache, tingling, insomnia) -high BS -diarrhea -nausea -hair loss -high potassium

Which of the following bloo alcohol levels shows marked intoxication? A) 100 B) 300 C) 600 D) 1000

B) 300 *80-200=mild to moderate; 250-400= marked intoxication; >500= respiratory depression & possible death from alcohol intoxication/poisoning

Which of the following orders should the nurse most prioritize calling the provider with for clarification for the patient with liver failure? A) Abdominal girth measurement daily B) Discontinue daily weights C) Continue telemetry D) Endocrine consult E) Hematology consult

B) Discontinue daily weights *don't d/c bc need for ascites; think about fluid; the best objective measurement for fluid

The nurse is completing an admission assessment of a new patient to the unit. The nurse notes a long, thin, fading scar on the patient's abdomen in the right lower quadrant. What is the best explanation for the scar's appearance? A) Optimal functioning of the inflammatory process after an injury B) Fibrous tissue replacing damaged tissue when injury is extensive C) The development of chronic inflammation D) A surgical incision

B) Fibrous tissue replacing damaged tissue when injury is extensive *Scar tissue, or fibrous repair of damaged tissue, occurs when an area is damaged too extensively for the body to replace damaged tissue with identically functioning tissue after removal of injurious agents and pathogens. Optimal functioning of the inflammatory process will result in regeneration of tissue that functions identically to the damaged and replaced tissue. Chronic inflammation can result in fibrous, or scar, tissue, but that scar tissue production is continuous as the inflammation continues. Fibrous tissue production can result from many different kinds of injuries, not just surgical wounds & this occurs in liver dysfunction/cirrhosis.

Which method is most likely to be used in the hospital to administer naloxone for opioid overdose? (Select all that apply) A) intranasal B) IM with syringe & needle C) IM with Evzio auto-administrator D) IV E) PO

B) IM with syringe & needle D) IV *intranasal used by emergency workers & outside hospital; Evzio used outside hospital; & PO not used

Which of the following groups have a higher rate of alcoholism? (Select all that apply) A) nonacculturated latinex B) Native American C) higher soscioeconomic status Americans D) acculturated latinex E) lower soscioeconomic status Americans

B) Native American C) higher soscioeconomic status Americans D) acculturated latinex *high SES Americans more likely to drink BUT more likely without problems; lower SES Americans drink less BUT have more problems; also Icelands has highest amount of AA but consumes less alcohol; Bolivia drink more & its more potent but less problems

-ALK. PHOSPHATASE: 178 H (30-120U/L) -BILIRUBIN - TOTAL: 1.4 H (0.2-1.2MG/DL) -Unconjugated/indirect Bilirubin: 1.2 H (0.2-0.8MG/DL) -Conjugated/ direct Bilirubin: 0.4 H (0.1-0.3MG/DL) -TOTAL PROTEIN: 8.8 H (6.0-8.0G/DL) -ALBUMIN: 6.6 H(3.6-5.0G/DL) -GLUCOSE: 55 L (65-99MG/DL) -AST (SGOT): 107 H (10-40 U/L) -ALT (SGPT): 68 H (2-45 U/L) -SODIUM 143 (135-145 MEQ/L) -POTASSIUM 3.5 (3.5-4.9 MEQ/L) -AMMONIA 105 H (15-45 MCG/DL) -CHLORIDE 96 (96-110 MEQ/L) -LACTATE 3.5 H (0.5-1 Mmol/l) -PLATELETS 120 L (150K-450K /MIC.L) -Anti Nuclear Antibody 20:60 H (1:40 to 1:60 titer) -FIBRINOGEN 100 (150-400 MG/DL) -CRP 1.8 (>3.0 MG/L) -BLOOD ALCOHOL LEVEL/ETHANOL 80 H (.08) -PT 23 H (11.0-13.5 seconds) -INR 2.0 H (0.8-1.1 seconds) The nurse caring for the patient with severe, chronic cirrhosis knows to question which of the following labs? (Or, which of the following labs does NOT fit the clinical picture for chronic, severe cirrhosis?) A) Total and unconjugated bilirubin B) Total protein and albumin C) PT and INR D) AST and ALT E) Ammonia and ANA.

B) Total protein and albumin *Don't forget to absorb Table 58-3 in Iggy, Assessment of Abnormal Laboratory Findings in Liver Disease. These labs are expected to be low in chronic, severe cirrhosis. In comparison with the other labs, and in conjunction with patient assessment, the nurse should compare to past labs and could recommend a lab redraw to reassess based on this critical thinking.

Which of the following are potential complications of alcoholism? (Select all that apply) A) SIADH B) folic acid deficiency C) hypercortisolism D) HTN E) tachycardia F) GERD G) esophageal varices

B) folic acid deficiency C) hypercortisolism D) HTN F) GERD G) esophageal varices *also gastritis, cirrhosis, & liver cancer

Which of the following are potential symptoms of alcohol withdrawal after 12 hrs after last drink? (Select all that apply) A) hallucinations B) low grade fever C) headache D) insomnia E) delirium tremens F) diaphoresis G) palpitations

B) low grade fever C) headache D) insomnia F) diaphoresis G) palpitations *delirium tremens, hallucination, disorientation, tachycardia ,HTN, agitation, &vomiting are severe symptoms seen 24-72 hrs after last drink; other mild symptoms 6-24 hrs after last drink include restlessness, anxiety, tremors, increased BP

The nurse would know to question the student nurse that says: A) women are more likely to become dependent on prescription pain relievers B) women die more from opioid overdose C) white people die from opioid overdose more than any other race D) drug overdose is the leading cause of accidental death in the US

B) women die more from opioid overdose *men die more from opioid overdose

The nurse knows that which of the following are the most Cushinglike symptoms in the liver failure patient? A. Systemic obesity, abdominal striae, bruises B. Central obesity, abdominal striae, irritability C. Central obesity, spider angiomas, increased risk of fractures D. Systemic obesity, bronze skin, low blood pressure

B. Central obesity, abdominal striae, irritability

Which of the following CIWA orders would the nurse questions? (Select all that apply) A. Folic Acid 1 mg orally or IV every day B. Vitamin C 250 mg orally or IV every day ​C. Thiamine 100 mg every day

B. Vitamin C 250 mg orally or IV every day -Normal dose: Folic Acid 1mg PO/IV daily. -Normal dose: Thiamine 100mg PO/IV/IM Q8H/TID during alcohol withdrawal, then reduce 100mg daily -B) Vitamin C is incorrect bc it is not given

What meds are used in alcohol withdrawal? Refer to CIWA scale

Benzos used for control of psychomotor agitation & prevent progression to more severe withdrawal ex: diazepam, lorazepam, chlordiazepoxide

Match the following oncolocic emergencies to the likely cancers: A) Brain CA B) Chest CA C) Breast CA D) Lung CA E) Prostate CA F) Kidney CA G) Leukemia H) Myeloma I) Non Hodgkins J) Skin CA 1. SIADH 2. DIC 3. Sepsis/septic shock 4. Tumor lysis 5. Hypercalcemia 6. Spinal cord compression 7. Superior vena cava syndrome 8. Increased ICP 9. Hyperviscosity 10. Hyperleukocytosis 11. Neutropenia/neutropenia fever 12. Malignant pericardial effusion

Brain CA 8. Increased ICP Chest CA 5. Hypercalcemia 7. Superior vena cava syndrome Breast CA 5. Hypercalcemia 6. Spinal cord compression 7. Superior vena cava syndrome 8. Increased ICP Lung CA 1. SIADH (w/ SCLC) 5. Hypercalcemia 6. Spinal cord compression 7. Superior vena cava syndrome 8. Increased ICP 12. Malignant pericardial effusion Prostate CA 6. Spinal cord compression Kidney CA 5. Hypercalcemia 8. Increased ICP Leukemia 2. DIC 3. Sepsis/septic shock 4. Tumor lysis 9. Hyperviscosity 10. Hyperleukocytosis 11. Neutropenia/neutropenia fever Myeloma 5. Hypercalcemia 6. Spinal cord compression 11. Neutropenia/neutropenia fever Non Hodgkins 4. Tumor lysis 7. Superior vena cava syndrome Skin CA 8. Increased ICP

When are alcohol withdrawal symptoms more severe? A) couple hrs after last drink B) 6-24 hrs after last dirnk C) 24-72 hrs after last drink D) several days after last drink

C) 24-72 hrs after last drink *symptoms like: delirium tremendous, hallucinations, disorientation, tachycardia, HTN, agitation, N/V, & mild symptoms (6-24 hrs): Anxiety, Tremors, Insomnia, Palpitations, high BP, headache, restlessness, low grade fever, diaphoresis

Which of the following best demonstrates that the nurse has most understood the uap scope of practice for the patient with liver failure? A) please check blood with me B) Please help me push this NG tube in C) Please keep pt NPO for now D) Please let me know if you think his BP is getting too high

C) Please keep pt NPO for now (clear directive in SOP) *C) is correct bc is a clear directive in scope of practice of a UAP; A) is incorrect bc 2 nurses are needed to check blood at the bedside; B) is incorrect bc they can't push in, but they can help position the pt & get supplies; D) is incorrect bc that's an assessment if better or worse which is not in their scope of practice

The nurse knows that which of the following shows that the nurse needs more education when speaking to a healthcare colleague when substance abuse is suspected? A. 'You don't seem yourself and I'm concerned. Can we talk about why you're always late?" B. "Can I speak with you about your work? I've noticed some charting errors and I'm concerned" C. " I saw you take that Vicodin. You're so weak that you have to turn to substances to cope. You'll never be a successful nurse" D. "I'd like to help you with this med pass. Mr. Jones seems extra painful and maybe I can help make sure he feels better". E. "I'm worried that I saw you pocketing a pill that looked like Vicodin earlier at the Pxyis. I've called the pharmacy, our manager and security and I wanted to let you know that they will want to talk to you".

C. " I saw you take that Vicodin. You're so weak that you have to turn to substances to cope. You'll never be a successful nurse"

The nurse knows that which of the following are appropriate treatment interventions for opioid misuse? Select all that apply. A. Disulfram B. 12 step program/daily meetings C. Inpatient therapy, possibly long term D. Buprenorphine/Suboxone E. Naltrexone / Vivitrol F. Behaviorial therapy

C. Inpatient therapy, possibly long term D. Buprenorphine/Suboxone E. Naltrexone / Vivitrol F. Behaviorial therapy *Yes, these are all good interventions for opioid misuse. Buprenorphine can treat pain as well as addiction. However, it does have its own dependence issues. The best part is that it can stop things like injections, reusing needles, or risky illegal substance procurement.

Which of the following CIWA orders would the nurse questions? (Select all that apply) A. ​Lorazepam 2 mg IV every 8 hours for CIWA of 17 ​B. Lorazepam 2 mg PO every 8 hours for CIWA of 17 ​C. Lorazepam 10 mg IV every 6 hours for CIWA of 9

C. Lorazepam 10 mg IV every 6 hours for CIWA of 9 *Normal dose: 1-4 mg IVP/PO/NG Q30mins- 4H based on CIWA score, so C) is incorrect bc you would not give 10 mg IV over 6H

What is the treatment of ascites & edema for liver dysfuntion?

Can give albumin IV, but then also should give diuretic as fluid comes back into circulation

What is the disorder of cell proliferation (too many growing cells) & differentiation (to many different/nonspecific cells)?

Cancer "the DNA or genetic materials of a cell can become altered or broken which cause mutations that affect normal division & cell proliferation. The damaged cells continue to divide quickly & begin to accumulate, & change their appearance or mutate. Serving no role in maintaining health, the abnormal cells continue to multiply & grow, sometimes evolving into forming a mass of tissue known as a tumor"

What is the most potent fentanyl analog detected in the US, estimated to be 10,000x more potent than morphine?

Carfentanil

What is defined as a chronic, progressive liver disease & end stage cellular change or dysplasia. Chronic scarring of liver cells results in fibrous bands of connective tissue that become hardened, inflexible, & non functional causing eventual remodeling & restructuring of the liver tissue leading to dysfunction?

Cirrhosis *It is irreversible; usually a response to long term inflammation & necrosis. There's compensated cirrhosis (liver still has some function) & decompensated cirrhosis (liver function is significantly impaired). Cirrhosis can advance to liver cancer over time with continued inflammation

Which of the following CIWA scores require transfer to ICU for immediate treatment? A) 6 B) 10 C) 16 D) 22

D) 20 *no treatment of <=8; treatment begins 8-10 with benzos; standing or as needed order 10-20; transfer ICU >20

Which "feel good" neurochemical is released after consuming alcohol? A) Serotonin B) Oxytocin C) Epinephrine D) Dopamine

D) Dopamine *neuroplasticity rewards body for feeling good making it seek out for it next time (addiction)

WHich of the following best demonstrates that the pt needs more education regarding d/c for liver failure? A) I should monitor my weight B) I should watch for signs of bleeding C) I should eat more protein D) I should drink alcohol moderation E) I should have family call you if i am acting differently

D) I should drink alcohol moderation *D) bc avoid all alcohol bc such irritant; A) is correct bc fluid status; C) monitor levels; don't want to overdue bc hard time metabolizing it; E) good advocate

The nurse assesses the following stool for a patient. Charting this finding accurately in the electronic medical record may include which of the following terminology choices? A) Melena, hematuria, hemorrhage B) Hyperviscosity, hemmorrhage, black, tarry C) Melena, asterixis, hemmorrhage D) Melena, black, tarry, sticky, hematochezia

D) Melena, black, tarry, sticky, hematochezia *This contains the best choices to describe this stool. Tarry and sticky are correct and refer to the consistency, which the nurse can check with a tongue blade. Hematochezia usually describes frank/obvious/ red blood, and can describe stool, although usually is in contrast to the blackness of melena.Stool this color and consistency should be confirmed for blood by sending a specimen to the lab.

Which of the following should nurse least expect as possible complication of liver biopsy or paracentesis? A) Possible drainage at needle entry site B) Possible Pain at procedure site C) Possible Change in BP following procedure D) Possible Cushings signs following procedure E) Possible Infection at procedure site

D) Possible Cushings signs following procedure *not r/t procedure, but can occur for pt with liver dysfunction bc endocrine function affected

When is it more likely that the patient will have more sever opioid withdrawal symptoms? A) couple hrs after last use B) 6 hrs after last use C) 48 hrs after last use D) several days after last use

D) several days after last use *mild symptoms occur 6-12 hrs after ex: muscle cramping, depression, restlessness, anxiety, low grade fever, diaphoresis, sweating, tremors, headache, palpitations, increased BP, insomnia, craving for substance, need substance for 'normal' function; more sever is 72 hrs to 7 days after last use ex: mild symptoms + N/V, diarrhea, stomach cramps, tactile hallucination

The nurse knows that which of the following is the most likely cause of liver cancer (hepatocellular carcinoma)? A. Hepatitis D B. Hepatitis E C. Hepatitis A D. Hepatitis B

D. Hepatitis B *Yes. This serious, viral hepatitis can have long term damage, and long term liver damage can lead to liver cancer. Also hep C

Which of the following concepts does the nurse likely least consider when treating pt with liver disorders? A. problems with nutrition B. problems with blood sugars C. Problems with toxic or low drug levels D. Problems with short term memory E. Problems with potential cushings symptoms

D. Problems with short term memory *D) is incorrect bc yes there is neuro involvement with ammonia not excreted but not memory loss; will look like change in LOC & confusion; nurse will consider A) will have problems with vitamins & protein; C) drugs are not absorbed making low levels or there will e a loss of the "gatekeeper" bc liver impacted causing too high of drug levels; E) will have endocrine imbalance

What are the symptoms & presentation of liver dysfunction?

Depend on different liver functions: -vitamin deficiencies -hormonal changes: facial hair in women, breast development in males -cushings symptoms: round face, buffalo hump, central obesity, stretch marks, abdominal striae -toxic ammonia level: confusion & changes in LOC -toxic drug effects -muscle symptoms bc not metabolism of fats -GI symptoms -jaundice of skin or mucous membranes -spider angiomas or other skin changes -bleeding -clotting factors not produced causing bleeding -weakness, fatigue -RUQ pain or tenderness -ascites & edema in hands, or feet; measure abd girth daily & daily weight -asterixis: tremor in hands, fingers, wrist -no symptoms

What are the symptoms of opioid *MISUSE*?

Depressive symptoms: -miosis; contracted or pinpoint pupils -reduced LOC; lethargy -reduced respiratory function & SpO2 -accumulation of acid in the blood -decrease BP -decrease HR -skeletal & thoracic muscle rigidity -slowing of muscular movement of the stomach with intestinal obstruction from lack of normal muscle function -accumulation of fluid in the lungs -coma -death

Which of the following lab tests is the nurse least likely to recommend to the provider to order and follow for the patient with liver dysfunction? A. ALT B. SGOT C. Protein and albumin D. Aldosterone E. Urine osmolality F. Lipid level

E. Urine osmolality -E) is incorrect bc not with liver dysfunction diagnosis bc it looks at kidneys; now, if the fluid moves to third spacing like abd urine osmolality is affected & would be concentrated, but it's not as obvious & not priority; -A) is a liver lab; B) aka ALT shows liver function; C) shows nutrition, which is affected; D) shows endocrine function; F) is cholesterol, liver, & fat; will also use labs like alkaline phosphatase, & GGT, bilirubin, PT

What is defined as rupture in of small vessels at the bottom of the esophagus where connects to the stomach causing a lot of pain & is hard to correct?

Esophageal varices * complication of alcoholism & liver dysfunction from portal HTN

T or F: substance misuse is a psychological failing not a physiological problem

False! It is a medical condition & a physiological problem NOT psychological

What is the liver disease progression?

Fatty liver (NAFLD) —> Steatohepatitis (NASH) —> cirrhosis —> then either liver failure, portal HTN, & hepatocellular carcinoma (liver cancer)

What is a synthetic opioid given IV/IM/transdermal/lollipops that is similar to morphine but 50-100x stronger

Fentanyl (also made illegally called "illegally manufactured fentanyl of IMF" put on paper, into nasal sprays, or mixed with heroin) *works like heroin where activates reward center of brain releasing dopamine. After taking heroin, fentanyl, & other opioids several times, the brain adapts to the drug diminishing sensitivity

What items/parts do you pass on to the next shift after a paracentesis? What do they need to know?

Fluid removed, how much, dressing, VS, where at, meds/pain

What is the goal when intervening if suspect that colleague has substance misuse?

Goal for the colleague is not punishment, but treatment!

What are the different grades of hepatic encephalopathy?

Grade 0-4; 0= minimal or unimpaired LOC, personality changes, or neuo symtpoms; 4= most impaired, Coma, limp or not repsonsive to pain stimulus

What happens when there is an increase in ammonia levels causing neurotoxic effects & changes in LOC?

Hepatic encephalopathy

What is an illegal & highly addictive drug made from opium/poppy plants that can be inhaled, smoked, or injected?

Heroin *binds to mu-opioid receptors in the reward center of the brain, stimulating release of NT dopamine, causing reinforcement of drug taking behavior

What is the treatment of hepatic encephalopathy?

Lactulose, a non-absorbable disaccharide that lowers the pH of the colon & binds to ammonia & promoting a laxative effect thus reducing blood level of ammonia. Patients with mild HE can drink lactulose & pts with severe HE can be administered by gastric or rectal tube

What are the likely cancers & initial treatment/drug for the oncologic emergency Neutropenia/neutropenia fever?

Leukemia or multiple myeloma; treat with ATB, cooling blanket, & bone marrow stimulation

What are the likely cancers & initial treatment/drug for the oncologic emergency Hyperleukocytosis?

Leukemia; treat with hydration, monitor & watch excretion, & continue chemo

What are the likely cancers & initial treatment/drug for the oncologic emergency Hyperviscosity?

Leukemia; treat with plasmapheresis or blood removal

What is defined as the end stage of cirrhosis where cells have been chronically scarred, become stiffened, & not well perfused? The chronically irritated cells can be poorly differentiated & less specialized

Liver carcinoma (cancer) *from long term cirrhosis

Liver dysfunction can cause an alteration in steroid metabolism. What will the patient's symptoms be?

Liver metabolizes steroids normally keeping them at normal levels, but liver failure causes high levels of steroids. -High testosterone causes unwanted male characteristics like hirsutism(unwanted hair) -high estrogen causes unwanted female characteristics like gynecomastia (male breast development) -high aldosterone causes Cushing's symptoms like round face, central obesity, abdominal striae, stretch marks, buffalo hump -drug detoxification is not happening, causing higher level of all drugs

Liver dysfunction can cause lactation in clotting/bleeding. What will the patient's symptoms be?

Liver normally activates Vitamin K, with liver damage these clotting factors cannot be produced. Patients are more likely to : -bleed with injection/invasive procedures -signs of impaired clotting -chronic bleeding *nurse should look at PT, INR, clotting factors II, VII, IX, X

The extreme version of liver transplantation is rejection. What are these symptoms?

Liver transplantation rejection can happen very rapidly & look like: -tachycardia -HTN -sever abdominal pain -flank pain -decreased urine output/dark urine/Liguria -sepsis *treat with massively increased doses of anti rejection meds & add steroids. Only cure is another transplantation

______ cancer is the leading cause of cancer death

Lung; it crosses every ethnic group; most common is non small cell lung cancer

What is the treatment for liver transplantation rejection?

Massively increased doses of anti rejection meds & add steroids. The only cure is another transplantation

What are the symptoms of opioid *WITHDRAWAL*?

Mild symptoms 6-12 hrs aft last use: -muscle cramping -depression -restlessness -anxiety -low grade fever -diaphoresis, sweating -tremors -headache -palpitations, racing heart -increased BP -insomnia -craving for substance -may need substance just for 'normal' function More severe symptoms 72-7days after last use: Includes mild symptoms, and: -N/V -diarrhea -stomach cramps -tactile hallucinations "my skin is crawling"

What are the different types of alcohol screening Refer to Box 37-2 Giddens

NIAAA: 1. On average, how many days per week do you drink alcohol 2. On a typical day when you drink, how many drinks do you have 3. What is the max number of drinks you had on any given occasion during the last month? CAGE: In the Last 12 months 1. Have you ever felt like you should *CUT* down on your drinking? 2. Have people *ANNOYED* you by criticizing your drinking? 3. Have you ever refit bad or *GUILTY* about your drinking? 4. Have. You ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (*EYE OPENER*) Screen Positive if: 1. positive response on 1 or more Qs from CAGE 2. Consume >14 drinks/week or >4 drinks/occasion for men 3. Consume >7 drinks/week or >3 drinks/occasion for women or over 65 years old

What happens with a liver biopsy to diagnose liver dysfunction/cirrhosis?

Needle aspiration or surgical excision of liver tissue examined under microscope for scarring & possible: tissue changes —>hyperplasia —> dysplasia —> regression & lack of differentiation —> qualities of cancer

What are the likely cancers & initial treatment/drug for the oncologic emergency Tumor lysis?

Non Hodgkins or Leukemia; treat with electrolytes, hormones, hormone blockers, & dialysis

What is the most common form of lung cancer?

Non small cell lung cancer (NSCLC); caused by smoking, radon, occupational exposure, asbestos mesothelioma pesticides, heavy metals, diesel exhaust, air pollution, & family hx (unlink SCLC caused exclusively by smoking)

Liver dysfunction can cause alteration in glucose function called Hepatogluconeogensis. What will the patient's symptoms be?

Norma liver aids in production of new glucose (gluconeogensis), but liver malfunction causes *Cushing's Symptoms* like: -round face -buffalo hump -central obesity -stretch marks -abdominal striae

What are the symptoms of liver cancer?

Often generalized symptoms until progressed to later stage: -change in bowel/bladder -sore that does not heal -unusual bleeding or drainage -lump or thickening -indigestion or GI changes -new cough, hoarseness -new weight loss or gain -new unexplained pain Later stage: -Jaundice -RUQ abdominal pain -Ascites -Abdominal pain -Lump or tenderness in RUQ -Differences in bleeding or bruising -N/V -Weight loss -Neuro changes = encephalopathy -often no symptoms or vague symptoms until cancer has progressed

What is defined as any acute potentially morbid or life-threatening event directly or indirectly related to a patient's tumor or its treatment?

Oncologic emergency

What are the expected outcomes & prognosis for liver cancer? *must know!

Patient will be/have... -free from s/s of liver dysfunction (no N/V, pain, jaundice) -able to verbalize methods to prevent liver damage (diet, no smoking/alcohol) -know what s/s to report to their provider -receive timely diagnosis & treatment regardless of race, ethnicity, etc -maintain adequate liver function -stable labs during & post treatment -receive meds as ordered & will be free from side effects -receive interventions like resection, meds, transplantation, & EOL care

What are expected pt outcomes for cirrhosis?

Patient will have... -stable labs at d/c & follow up appts -free from signs of fluid overload: monitor pt weight & teach pt to report any weight gain greater than 2 lbs in 24 hrs -avoid alcohol permanently -free from s/s of neuro changes; teach family about neuro changes -adequate nutrition & protein intake -verbalize meds schedule & potential side effects -complete all ATB therapy -access to palliative care/hospice/EOL for end stage cirrhosis or liver cancer

What are the causes of liver cancer?

Primary causes: -alcoholism -cirrhosis -hepatitis B and C -diabetes, obesity, hemochromatosis, & some meds -higher in Native American & Eskimo/Inuit population Secondary causes (more common): -lung CA -bowel CA -stomach CA -breast CA

Primary lung cancer starts ______ while secondary lung cancer starts _________

Primary= in the lungs Secondary= elsewhere in the body

How is CIWA scale scored?

Pts with scores: -*Absent or minimal withdrawal*: typically do not require meds for withdrawal <=8 -*Mild to moderate withdrawal*: treatment begins 8-10 with benzos; standing or as needed dosing 10-20 -*Severe withdrawal*: transfer ICU >20

Q1: What should happen after the needle is removed from the paracentesis? Q2: What other bedside procedure would have a site like this?

Q1: -Site care, apply pressure, dressing or bandage depending on if there is still drainage at the site -Reassess: VS, LOC, dressing, & site of puncture Q2: -thoracentesis, wound draining, knee aspiration

Q1: What post procedure orders for the patient do you expect after paracentesis? Q2: What other procedure would have these types of orders?:

Q1: -Pain meds: Tylenol, Motrin, Ice pack -VS/O2 monitoring: procedures VS, assess site Q1 hours, more at first then eventually Q4 -Activity: bed rest d/t procedure for immediate hours after procedure , then up with 1 assist until stable -Diet: clear liquid —> ice—> full liquid —> full diet over next couple of hours hours Q2: cardiac cath

You are caring for a 45-year-old man who arrived at the ED. He reports having abdominal pain for 3 weeks and states that he drinks 3-5 alcoholic drinks daily. He has no known hx of liver disease. He denies fever, chills, nausea and vomiting, or discolored stools. His last drink was last night. Assessment reveals yellowed skin, BP of 100/58, and HR of 102 bpm. His abdomen is distended, and he is having some difficulty breathing; his RR are 34, SpO2 is 87%. The ED provider orders an EKG, chest X-ray, CT scan of abdomen/pelvis, O2 at 2L/NC, and IV access. Q1. What complications is this patient at risk for and why? Q2. In what position will you place the patient and why? What evidence supports your answer? 3. You anticipate that this patient has acute liver failure. What assessment findings support this suspicion? 4. What lab findings do you anticipate that would support the diagnosis of liver failure?

Q1: All pts with liver failure should be screened for esophageal varices by endoscopy to provide early detection before they begin to bleed. Excessive ascitic fluid volume may cause the patient to have respiratory problems. He may develop hepatopulmonary syndrome. Dyspnea develops as a result of increased intra-abdominal pressure, which limits thoracic expansion and diaphragmatic excursion. All patients with ascites have the potential to develop spontaneous bacterial peritonitis (SBP) from bacteria in the collected ascitic fluid. Q2: Dyspnea develops as a result of increased intra-abdominal pressure, which limits thoracic expansion and diaphragmatic excursion. For the patient with hepatopulmonary syndrome, monitor SpO2 with pulse ox. If needed, apply oxygen therapy to ease breathing. Elevate the HOB to at least 30 degrees or higher to improve breathing. This position, with feet elevated to decrease dependent ankle edema, often relieves dyspnea. Q3: Jaundice and abdominal pain support this suspicion. Q4: BUN, hct, and electrolytes help determine fluid and electrolyte status. Abnormal coagulation studies, including PT, PTT, platelet count, and INR, can be an indication of liver failure.

Q1: What will happen if too much fluid is removed after paracentesis? Q2: How much fluid is too much? Q3: Patient presentation? Q4: What other procedures could have this occurrence?

Q1: Electrolytes change, decrease BP, 1st increase HR Q2: Pt dependent >1000 Q3:AO x3, decrease pain, site clean/dry Q4:

Patient prep for paracentesis : Q1: How would you position the patient? Q2: How would you prep the skin? Q3: Sterile or unsterile?

Q1: HOB 30-45 degree angle, supine, not flat on back Q2: Scrub just before; circular prep chlorhexidine (iodine allergy can't use betadine, but used to be used) used in to out circular motion to clean Q3: Sterile!!

Q1: What are possible complications of a paracentesis? Q2: What is the worst case scenario during the procedure?

Q1: Infection, bleeding, pain, couldn't work/not successful procedure, large fluid shift :( Q2: hypovolemic shock and sepsis

Q1: What needs to be done with the fluid that was obtained from paracentesis? Q2: What other procedure would have a specimen collection like this?

Q1: Inspect, label, send to lab, *chart volume* and appearance of liquid Q2: thoracentesis, wound draining, knee aspiration

Q1: It is 8 hours after a paracentesis procedure was performed. What do you need to check back on? Q2: ****What would make this patient deteriorate after the procedure? Q3: What background pieces would make this patient more critical?

Q1: Site, fluid status (VS, urine output, labs), wt Q2: Sepsis, fall, no one assessing them Q3: CHF, AKI, blood thinners, diabetes, change MS

Q1.: Describe a paracentesis procedure in layman's terms. What would you say to the patient? Q2: How long will it take? Q3: Which of the following is the best explanation to patients for paracentesis? Q4: If you do this bedside/ on the unit, what about your other 3 patients?

Q1: Take fluid out of you abdomen with needle tubing Q2: 1-2 hrs Q3: Take fluid to relieve pressure on abd, help try to correct fluid status, take 1-2 hrs Q4: delegate! Inform charge nurse what is going on

Q1: Pre procedure: would this patient get paracentesis? HR of 67 SpO2 94% RA RR 12 BP 92/61 Q2: Post procedure: do you need help with this patient? HR 108 SPO2 93 RR 19 BP 130/71 Q3: Post Procedure med list is there anything you want to hold are start? singular 12mg Lasix 20 mg lisinopril 2.5 mg Xanax 0.25 mg albuterol Advair 50/250 aspirin 81mg

Q1: The HR is a little low, but not a deal breaker. Make sure to cross check with their normals. SpO2 is fine, but grab O2 tubing, BP could be low but check to see if that's their normal. Overall, vitals aren't great but check out the patient and their VS trends then prep the patient Q2: O2 a little low so monitor & give O2; HR little high not deal breaker but coming from 60s is high; possible FE from fluid shift; expect BP decrease from fluid taken off but maybe withheld BP meds and that's why. Q3: Give lisinopril bc missed BP med making BP elevated; resp pt bc albuterol so monitor SpO2; look at coags b4 give aspirin (PT/INR) see how doing. Just removed fluid so hold lasix until further fluid assessment bc don't want to drain one way and drain other way & want to check electrolytes too

Q1: Is cirrhosis acute or chronic, & reversible or irreversible? Q2: What is responsible for causing cirrhosis? Q3: What are the 2 different types of cirrhosis? Q4: What can cirrhosis turn into?

Q1: chronic, progressive liver disease that is irreversible Q2: long term inflammation, infection, & necrosis Q3: compensated cirrhosis (liver still has some function) & decompensated cirrhosis (liver function significantly impaired) Q4: liver cancer over time with continued inflammation

Match the following likely cancers with the oncologic emergencies: A) SIADH B) DIC C) sepsis/septic shock D) Tumor lysis E) Hypercalcemia F) Spinal cord compression G) Superior vena cava syndrome H) Increased ICP I) Hyperviscosity J) Hyperleukocytosis K) Neutropenia/neutropenia fever L) Malignant pericardial effusion 1. Brain CA 2. Chest CA 3. Breast CA 4. Lung CA 5. Prostate CA 6. Kidney CA 7. Leukemia 8. Myeloma 9. Non Hodgkins 10. Skin CA 11. Tx devices

SIADH 4. Lung CA (SCLC) DIC 7. Leukemia Sepsis/septic shock 7. Leukemia 11. Tx devices Tumor lysis 7. Leukemia 9. Non Hodgkins Hypercalcemia 2. Chest CA 3. Breast CA 4. Lung CA 6. Kidney CA 8. Myeloma Spinal cord compression 3. Breast CA 4. Lung CA 5. Prostate CA 8. Myeloma Superior vena cava syndrome 2. Chest CA 3. Breast CA 4. Lung CA 9. Non Hodgkins Increased ICP 1. Brain CA 3. Breast CA 4. Lung CA 6. Kidney CA 10. Skin CA Hyperviscosity 7. Leukemia Hyperleukocytosis 7. Leukemia Neutropenia/neutropenia fever 7. Leukemia 8. Myeloma Malignant pericardial effusion 4. Lung CA

What is the least common type of lung cancer that is cause almost exclusively by smoking? It is the most aggressive form of lung cancer

Small cell lung cancer (SCLC); unlike Non small cell lung cancer (NSCLC) which is most common caused by smoking, smoke, radon, occupational exposure, asbestos heavy metals, diesel exhaust, air pollution

What is all assessed with the CIWA scale? How is it scored?

Symptoms of alcohol withdrawal like: -agitation -visual disturbances -auditory disturbances -N/V -tactile disturbances -paroxysmal sweats -anxiety -tremors -headache/fullness in head -orientation/clouding of sensorium Pts with scores <=8 typically do not require meds for withdrawal; treatment with benzos begins 8-10; standing or as needed dosing 10-20; transfer ICU >20

What is a procedure that may be used to reduce portal HTN & its complication varices where a small wire mesh coil/stent is placed into the liver vein?

TIPS procedure (transjugular intrahepatic portosystemic shunt)

What is the normal dose of magnesium?

Treat IV/PO as needed to reach appropriate serum levels; normal Mg levels 1.2-2 *adjunctive med for alcohol; refer to CIWA

Match each cancer cell picture with its likely definition or explanation. Use each picture and definition only once. *REFER TO IMAGES IN QUIZ 8 ____Disordered architecture, structure and arrangements: likely cancer cells ____Cells all look the same type and size: normal cell structure ____Tumor with smooth border, defined edges, no spreading or extravasation = benign or encapsulated tumor ____Tumor which has extravasated or spread beyond margins/borders = malignant tumor

__1__Disordered architecture, structure and arrangements: likely cancer cells __2__Cells all look the same type and size: normal cell structure __4__Tumor with smooth border, defined edges, no spreading or extravasation = benign or encapsulated tumor __3__Tumor which has extravasated or spread beyond margins/borders = malignant tumor

Put the following pathophysiological conditions in order from least severe to most severe: ____ Cirrhosis ____ Hepatitis ____ Liver cancer ____ NAFLD/FLD

__3__ Cirrhosis __2__ Hepatitis __4__ Liver cancer __1__ NAFLD/FLD 1) Fatty liver condition, either alcoholic or not are common and not life threatening. Fatty liver can also be related to diet and obesity and can be reversed by controlling their cause. They have no symptoms and cannot be detected by labs or physical assessment 2) Hepatitis is an inflammatory condition that irritates the liver. Hepatitis can be caused by food/water/feces (A & E), by a virus ( B, C & D) or can be autoimmune (body turning on itself) can be caused by medications such as minocycline,nitrofurantoin, hydralazine, methyldopa, statins, fenofibrate, alpha and betainterferon, infliximab and etanercept. 3) Cirrhosis is the progressive scarring and fibrosis after chronic irritation. The number one cause of cirrhosis is alcoholism. It is largely irreversible. 4) Liver cancer is the progressive degeneration of the liver cells that lose shape, organization, and function. Such cells, lacking differentiation, tend to go 'rogue' and become cancerous. It is hard to treat. Transplantation may help to restore function.

Put the following in order from progression of cancerous cells ___ anaplasia ___ metaplasia ____ dysplasia

__3__ anaplasia (without differentiation; cells lost original structure) __1__ metaplasia (still differentiated; change in type of cell) __2__ dysplasia (less differentiated; dysfunctional arrangement of cells)

Match these medications used in cirrhosis and alcoholism treatment with their drug classes. ____ Benzodiazepine used during alcoholism detoxification ____ Anticonvulsant: off label use to treat symptoms of alcohol craving ____ Opioid receptor blocker to reduce alcohol craving and use ____ Laxative and ammonia reducer ____ Suboxone: used in both opioid and alcoholism treatment. High risk for dependence: taper off slowly. Do not combine with alcohol. ____ Alcoholism treatment medication that provides an unpleasant reaction when alcohol is ingested (Antabuse) 1.Lactulose 2.Disulfiram 3.Gabapentin 4.Lorazepam 5.Naltrexone 6.Buprenorphine

__4__ Benzodiazepine used during alcoholism detoxification __3__ Anticonvulsant: off label use to treat symptoms of alcohol craving __5__ Opioid receptor blocker to reduce alcohol craving and use __1__ Laxative and ammonia reducer __6__ Suboxone: used in both opioid and alcoholism treatment. High risk for dependence: taper off slowly. Do not combine with alcohol. __2__ Alcoholism treatment medication that provides an unpleasant reaction when alcohol is ingested (Antabuse)

Match the liver malfunction with its assessment finding: ____ Hepatic encephalopathy ____ Medication toxicity ____ Jaundice ____ PT 6, INR 15 ____ Folic acid deficiency ____ Central obesity and round face 1. Hormonal dysregulation 2.Clotting dysfunction 3.Lack of vitamin storage 4.Lack of processing and excreting of ammonia 5.Inability to conjugate/excrete bilirubin 6.Inability to reduce drug levels

__4__ Hepatic encephalopathy __6__ Medication toxicity __5__ Jaundice __2__ PT 6, INR 15 __3__ Folic acid deficiency __1__ Central obesity and round face

Match the oncologic emergency with its most likely preventative assessment and/or intervention. Use each pair only once. ____Assess GFR, BUN, creatinine, and medications that the patient is receiving ____Monitor for muscle innervation, fracture, and parathesias ____Monitor CBC including platelets and for signs/symptoms of bleeding ____Assess for signs of chest pain, difficulty breathing, lightheadedness and cough ____Assess for signs of electrolyte imbalance including high potassium, high phosphate, low calcium and also hyperuricemia, muscle weakness, and renal failure ____Administer calcitonin , hydrate and monitor for neuro changes and muscle weakness 1. Thrombocytopenia 2. Hypercalcemia 3. Spinal cord compression 4. Acute renal failure 5. Tumor lysis syndrome 6. Superior vena cava syndrome

__4__Assess GFR, BUN, creatinine, and medications that the patient is receiving __3__Monitor for muscle innervation, fracture, and parathesias __1__Monitor CBC including platelets and for signs/symptoms of bleeding __6__Assess for signs of chest pain, difficulty breathing, lightheadedness and cough __5__Assess for signs of electrolyte imbalance including high potassium, high phosphate, low calcium and also hyperuricemia, muscle weakness, and renal failure __2__Administer calcitonin , hydrate and monitor for neuro changes and muscle weakness

A patient who is in pain is concerned about becoming addicted to pain medication and asks the nurse, "Can I become addicted to this medication?" What is the nurse's best response? (select all that apply) a) "You may develop a tolerance for the medication and need more of it in order for it to be therapeutic." b) "You will likely experience euphoria from the medication" c) "You will likely become dependent on this medication and require other medications to control your pain." d) "Before stopping the medication, you may need to taper it so you do not suffer from withdrawal." e) "You will not become physically addicted, but you may develop a physiological addiction."

a) "You may develop a tolerance for the medication and need more of it in order for it to be therapeutic." d) "Before stopping the medication, you may need to taper it so you do not suffer from withdrawal." *Tolerance is an increasing need for a substance or a lack of effect when a certain dose is given over time. Withdrawal is a syndrome of symptoms that result from stopping the use of a substance. Dependency and psychological addiction do not usually occur with patients that are in pain, because the pain receptors are not being artificially stimulated.

A patient is being treated for an illicit drug addiction. The nurse understands that the treatment may include which of the following? CORRECT a) A motivational interview b) Observing for stress reaction c) Converting narcotic use from an illicit to a legally controlled drug d) Observing for delirium tremens e) Encouraging involvement in Narcotics Anonymous

a) A motivational interview b) Observing for stress reaction e) Encouraging involvement in Narcotics Anonymous *The motivational interview will help determine the patient's readiness to participate in therapies. Stress reaction is a withdrawal symptom that can occur when detoxification takes place too quickly. Support groups have been shown to be successful for drug addiction. Delirium tremens is usually associated with alcohol withdrawal.

A client who was awaiting liver transplantation is excluded from the procedure after the presence of which condition is discovered? a) Colon cancer with metastasis to the liver b) Hypertension c) Hepatic encephalopathy d) Ascites and shortness of breath

a) Colon cancer with metastasis to the liver *Clients with metastatic cancers are not candidates for liver transplant. Transplantation is performed for hepatitis and primary (not secondary) liver cancers.Hypertension is a controllable factor and would not preclude the client from a liver transplant. Encephalopathy is a consequence of advanced liver disease, consistent with the condition of a client awaiting transplantation. It can be treated with lactulose and nonabsorbable antibiotics. Ascites and resulting shortness of breath are also consequences of advanced liver disease, consistent with the client awaiting transplantation. They can be managed with diuretics and paracentesis.

What are some primary prevention activities a nurse can perform related to substance abuse? CORRECT a) Education to prevent substance abuse b) Focusing on relapse prevention c) Identification of risk factors for abuse d) Medical detoxification e) Referral to a self-help group for stress relief and meditation

a) Education to prevent substance abuse c) Identification of risk factors for abuse e) Referral to a self-help group for stress relief and meditation *Primary prevention actions are those taken in order to prevent a problem from occurring. Primary prevention involves reducing stress to prevent addiction. Secondary prevention includes screening and early detection for prompt treatment. Referral to a support group might be considered secondary prevention if a patient has screened positive for substance abuse and has agreed to start attending a group. Tertiary prevention includes rehabilitative strategies.

When caring for a client with portal hypertension, the nurse assesses for which potential complications? (select all that apply) a) Esophageal varices b) Hematuria c) Fever d) Ascites e) Hemorrhoids f) spontaneous bacterial peritonitis

a) Esophageal varices d) Ascites e) Hemorrhoids f) spontaneous bacterial peritonitis *Potential complications of portal hypertension include esophageal varices, ascites, and hemorrhoids. Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid).Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

When caring for a client with cirrhosis, which of these does the nurse expect to find on assessment? (select all that apply) a) Prolonged partial thromboplastin time b) Icterus of skin c) Swollen abdomen d) Elevated magnesium e) Currant jelly stool f) Elevated amylase level

a) Prolonged partial thromboplastin time b) Icterus of skin c) Swollen abdomen *Clients with cirrhosis have damaged clotting factors, so prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity.Elevated magnesium is not related to cirrhosis. Amylase is typically elevated in pancreatitis. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. It is also consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase.

The nurse is caring for a client who has cirrhosis of the liver. The client has exhibited hand flapping and mental confusion for several weeks. Although the mental confusion is worsening, the client has stopped exhibiting hand flapping movements. How will the nurse interpret these findings? a) The client's symptoms are progressing and getting worse. b) The client's serum ammonia levels are decreasing. c) The client probably has a decrease in serum proteins. s) The client is showing signs of improvement.

a) The client's symptoms are progressing and getting worse. *The nurse interprets these findings as an indication that the client's is getting worse. Clients with cirrhosis who exhibit asterixis or hand flapping, may eventually stop exhibiting this sign as they worsen. The fact that the client's mental confusion is worsening indicates that this is the case.Increased mental confusion is related to elevated, not decreased, ammonia levels, as well as other serum proteins. The client is worsening, not improving.

The nurse is assessing a patient using the CAGE questionnaire. The nurse suspects possible alcoholism when the patient makes which of the following statements? (select all that apply) a) The patient states, "My wife keeps nagging me about my drinking." b) The patient states, "I am going to try to cut down on drinking. I have been partying too much." c) The patient states, "I go to meetings once or twice a week but continue to drink." d) The patient states, "I usually have a Bloody Mary or Mimosa with breakfast." e) The patient says to the nurse, "I am ashamed of how much I have been drinking lately." f) The patient states, "I can quit whenever I want to."

a) The patient states, "My wife keeps nagging me about my drinking." b) The patient states, "I am going to try to cut down on drinking. I have been partying too much." d) The patient states, "I usually have a Bloody Mary or Mimosa with breakfast." e) The patient says to the nurse, "I am ashamed of how much I have been drinking lately." *The patient may need help admitting that there is a problem. The CAGE questionnaire is designed to objectively assist in assessing problems related to alcohol use. A patient who states that he is going to meetings of Alcoholics Anonymous (AA) is admitting he has a problem, even if he still drinks. A patient who feels he can quit whenever he wants to may be in denial of the problem.

When caring for a pt with cirrhosis, the nurse assesses for which potential complications? (select all that apply) a) liver failure b) fatty liver c) portal HTN d) hepatocellular carcinoma e) steatopetatis

a) liver failure c) portal HTN d) hepatocellular carcinoma *fatty liver (NAFLD) & steatopetatits (NASH) can progress & cause/become cirrhosis, not a complication from cirrhosis

A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B? a. A 20-year-old college student who has had several sexual partners b. A 46-year-old woman who takes acetaminophen daily for headaches c. A 63-year-old businessman who travels frequently across the country d. An 82-year-old woman who recently ate raw shellfish for dinner

a. A 20-year-old college student who has had several sexual partners *Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route. A person with multiple sexual partners has more opportunities to contract the infection. Hepatitis B is not transmitted through medications, casual contact with other travelers, or raw shellfish. Although an overdose of acetaminophen can cause liver cirrhosis, this is not associated with hepatitis B. Hepatitis E is found most frequently in international travelers. Hepatitis A is spread through ingestion of contaminated shellfish.

A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.) a. A sore that does not heal b. Changes in menstrual patterns c. Indigestion or trouble swallowing d. Near-daily abdominal pain e. Obvious change in a mole

a. A sore that does not heal b. Changes in menstrual patterns c. Indigestion or trouble swallowing e. Obvious change in a mole *The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning sign.

nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.) a. Apply lotion to the clients dry skin areas. b. Use a basin with warm water to bathe the client. c. For the clients oral care, use a soft toothbrush. d. Provide clippers so the client can trim the fingernails. e. Bathe with antibacterial and water-based soaps.

a. Apply lotion to the clients dry skin areas. c. For the clients oral care, use a soft toothbrush. d. Provide clippers so the client can trim the fingernails. *Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush should be used to prevent gum bleeding, and the clients nails should be trimmed short to prevent the client from scratching himself or herself. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap.

A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important? a. Assess the clients gait and balance. b. Ask the client about the ease of urine flow. c. Document the report completely. d. Inquire about the clients job riskss

a. Assess the clients gait and balance. *This client has manifestations of spinal cord compression, which can be seen with prostate cancer. This may affect both gait and balance and urinary function. For client safety, assessing gait and balance is the priority. Documentation should be complete. The client may or may not have occupational risks for low back pain, but with his history of prostate cancer, this should not be where the nurse starts investigating.

A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important? a. Avoid large crowds and people who are ill. b. Check over-the-counter meds for acetaminophen. c. Take this medicine exactly as prescribed. d. You have a higher risk of developing cancer.

a. Avoid large crowds and people who are ill. *Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor category, such as tacrolimus (Prograf).

Which actions does the nurse teach a client as primary cancer prevention strategies? (Select all that apply.) a. Avoiding sun exposure b. Having a yearly digital rectal examination c. Having genetic testing for specific colon cancer causing genes d. Performing monthly breast self-examinations e. Quitting cigarette smoking f. Having a mole surgically removed

a. Avoiding sun exposure e. Quitting cigarette smoking f. Having a mole surgically removed *Primary prevention strategies are those used to actually prevent cancer development. Such strategies include avoiding known carcinogens (responses A & E), and removal of "at risk" tissue (response F). A yearly digital rectal examination and performing breast self-examination are types of secondary prevention, which is early detection. These actions do not prevent cancer. Having genetic testing assess risk but does not prevent cancer development.

A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, I do not want to take this medication because it causes diarrhea. How should the nurse respond? a. Diarrhea is expected; thats how your body gets rid of ammonia. b. You may take Kaopectate liquid daily for loose stools. c. Do not take any more of the medication until your stools firm up. d. We will need to send a stool specimen to the laboratory.

a. Diarrhea is expected; thats how your body gets rid of ammonia. *The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected and therapeutic effect for him or her to remain compliant. The nurse should not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.

The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? (Select all that apply.) a. Exposure to carcinogens b. Genetic predisposition c. Immune function d. Normal doubling time e. State of euploidy

a. Exposure to carcinogens b. Genetic predisposition c. Immune function *The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function.

A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this laboratory result? (Select all that apply.) a. How frequently do you drink alcohol? b. Have you ever had sex with a man? c. Do you have a family history of cancer? d. Have you ever worked as a plumber? e. Were you previously incarcerated?

a. How frequently do you drink alcohol? b. Have you ever had sex with a man? e. Were you previously incarcerated? *When assessing a client with suspected cirrhosis, the nurse should ask about alcohol consumption, including amount and frequency; sexual history and orientation (specifically men having sex with men); illicit drug use; history of tattoos; and history of military service, incarceration, or work as a firefighter, police officer, or health care provider. A family history of cancer and work as a plumber do not put the client at risk for cirrhosis

An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.) a. Policies related to consistent use of Standard Precautions b. Hepatitis vaccination mandate for workers in high-risk areas c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner

a. Policies related to consistent use of Standard Precautions c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner *Nurses should always use Standard Precautions for client care, and policies should reflect this. Needleless systems and reduction of sharps can help prevent hepatitis. Postexposure prophylaxis should be provided immediately. All health care workers should receive the hepatitis vaccinations that are available.

Which assessment findings in a client who has neutropenia from cancer chemotherapy indicate to the nurse that severe disseminated intravascular coagulation (DIC) is present? (Select all that apply.) a. The client is bleeding from the nose, IV sites, and rectum. b. The client's temperature is 99°F (37.2°C). c. The client's pulse rate is 130 beats per minute. d. The client's respiratory rate is 24 breaths per minute. e. The client's white blood cell count is 3200/mm3 (3.2 × 109/L) f. The client's hourly urine output is 100 mL.

a. The client is bleeding from the nose, IV sites, and rectum. c. The client's pulse rate is 130 beats per minute. d. The client's respiratory rate is 24 breaths per minute. *DIC is a oncologic emergency in which widespread microthrombi form and use all available circulating clotting factors. When these factors are gone, clotting cannot occur and the client bleeds from any site of trauma, no matter how minor the trauma. Spontaneous bleeding can also occur. The elevated pulse rate is consistent with the hypovolemic shock phase of DIC, as is the increased respiratory rate. Both are attempting to maintain oxygenation to vital organs.

A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 18 to 14 breaths/min d. A decrease in the clients weight by 6 kg

a. Urine output via indwelling urinary catheter is 20 mL/hr *Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the clients weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.

When preparing a client to undergo paracentesis, which action is necessary to reduce potential injury as a result of the procedure? a) Encourage the client to take deep breaths and cough b) Ask the client to void prior to the procedure c) Position the client with the head of the bed flat d) Assist the physician to insert a trocar catheter into the abdomen

b) Ask the client to void prior to the procedure *To avoid injury to the bladder during a paracentesis, the client would be asked to void prior to the procedure (Chart 58-1).Taking deep breaths and coughing does not prevent complications or injury as a result of paracentesis. Clients would be positioned with the head of the bed elevated. The trocar catheter is used to drain the ascetic fluid and does not reduce the risk of damage to the bladder.

The RN has just received the change-of-shift report for the medical unit. Which client should the RN see first? a) Client with ascites who had a paracentesis 2 hours ago and is reporting a headache b) Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse c) Client with hepatic cirrhosis and jaundice who has hemoglobin of 10.9 and thrombocytopenia d) Client with hepatitis A who has elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST)

b) Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse *The nurse would first see the client with PSE who is now difficult to arouse. A change in the level of consciousness (LOC) of the client with PSE is the greatest concern. Actions to improve the client's LOC must be rapidly implemented.Although uncomfortable, a headache in the client with ascites is not likely related to liver disease and does not pose an immediate threat or complication. A hemoglobin of 10.9 g/dL (109 mmol/L) and thrombocytopenia are expected findings in a client with cirrhosis and do not pose an immediate threat. Elevated ALT and AST levels are expected for the client with hepatitis A and do not indicate a risk for severe complications.

The nurse is caring for clients in the outclient clinic. Which of these phone calls would the nurse return first? a) Client with hepatitis A reporting severe and ongoing itching b) Client with severe ascites who has a temperature of 101.4°F c) Client with cirrhosis who has had a 3-pound weight gain over 2 days d) Client with esophageal varices and mild right upper quadrant pain

b) Client with severe ascites who has a temperature of 101.4°F *The nurse will first call the client with severe ascites and a temperature of 101.4 (38°C).This client may have spontaneous bacterial peritonitis.Itching is anticipated with jaundice, so this client may be called last. Weight gain with cirrhosis is not uncommon owing to low albumin levels. Cirrhosis may cause mild right upper quadrant pain. This client would be called after the client with severe ascites.

When providing dietary teaching to a client with hepatitis, what practice does the nurse recommend? a) Having a larger meal early in the morning b) Consuming increased carbohydrates and moderate protein c) Restricting fluids to 1500 mL/day d) Limiting alcoholic beverages to once weekly

b) Consuming increased carbohydrates and moderate protein *To repair the liver, the nurse recommends that the client adopt a high-carbohydrate and moderate-protein diet. Fats may cause dyspepsia.The client with hepatitis feels full easily and needs to have four to six small meals daily. Fluids are restricted with ascites caused by cirrhosis. Not all clients with hepatitis progress to cirrhosis. Complete abstention from alcohol is necessary until the liver enzymes return to normal.

When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B? a) Clients who work with shellfish b) Men who engage in sex with men c) Clients traveling to a third-world country d) Clients with elevations of aspartate aminotransferase and alanine aminotransferase

b) Men who engage in sex with men *Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity.Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A. Hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.

When caring for a pt with liver failure, the nurse assesses for which potential complications? (select all that apply) a) hematuria b) jaundice c) coagulopathy d) spontaneuous bacterial peritonitis e) encephalopathy f) hemorrhoids

b) jaundice c) coagulopathy e) encephalopathy

A nurse is interviewing a patient and assessing the patient's readiness to change. Which statements by the patient in the motivational interview reflect this willingness? (select all that apply) a) The patient states, "I don't think my body will recover from the drinking." b) the patient states, "I will watch the game at my friend's house instead of at the bar." c) The patient states, "I now realize that the drinking has affected by family life." d) The patient states, "I am glad that I did not drag others into my drinking." e) The patient states, "I have been attending one meeting a day."

b) the patient states, "I will watch the game at my friend's house instead of at the bar." c) The patient states, "I now realize that the drinking has affected by family life." e) The patient states, "I have been attending one meeting a day." *A patient who realizes that changing his environment will decrease temptation shows that he is motivated and willing to try to change. A patient who is able to see the effect the abuse is having on his life has a key component of motivation. A patient who is attending meetings of Alcoholics Anonymous (AA) is motivated toward recovery.

The client who received combination chemotherapy 7 days ago for breast cancer calls the oncology clinic to report a temperature of 100.5°F (38.06°C) and has no other symptoms of infection. What is the nurse's best response? a. "This is a normal immune-related response to the chemotherapy." b. "Please go to the nearest emergency room for a full workup for infection." c. "You are most likely dehydrated. Come to the clinic now for IV fluids." d. "There is no concern at this time but call if your temperature reaches 101.5°F (38.6°C)."

b. "Please go to the nearest emergency room for a full workup for infection." *Clients with neutropenia, and with this being the 7th day after chemotherapy for breast cancer this client is very likely to be neutropenic, have so few white blood cells that they often do not have the typical symptoms of inflammation and infection. Anti-infective therapy is started when the client's temperature reaches 100°F (37.8°C) to prevent sepsis.

An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a steering wheel mark across the clients chest. Which action should the nurse take? a. Ask the client where in the car he or she was sitting during the crash. b. Assess the client by gently palpating the abdomen for tenderness. c. Notify the laboratory to draw blood for blood type and crossmatch. d. Place the client on the stretcher in reverse Trendelenburg position.

b. Assess the client by gently palpating the abdomen for tenderness. *The liver is often injured by a steering wheel in a motor vehicle crash. Because the clients chest was marked by the steering wheel, the nurse should perform an abdominal assessment. Assessing the clients position in the crash is not needed because of the steering wheel imprint. The client may or may not need a blood transfusion. The client does not need to be in reverse Trendelenburg position.

A nurse cares for a client who is scheduled for a paracentesis. Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)? a. Have the client sign the informed consent form. b. Assist the client to void before the procedure. c. Help the client lie flat in bed on the right side. d. Get the client into a chair after the procedure.

b. Assist the client to void before the procedure. *For safety, the client should void just before a paracentesis. The nurse or the provider should have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table. The client will be on bedrest after the procedure

nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially causing complications of this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)

b. Elevated international normalized ratio (INR) e. Elevated serum ammonia f. Elevated prothrombin time (PT) *Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the clients confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I cannot drink any alcohol at all anymore. b. I need to avoid protein in my diet. c. I should not take over-the-counter medications. d. I should eat small, frequent, balanced meals.

b. I need to avoid protein in my diet. *Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.

The student nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? (Select all that apply.) a. Clotting abnormalities from thrombocythemia b. Increased risk of infection from white blood cell deficits c. Nutritional deficits such as early satiety and cachexia d. Potential for reduced gas exchange e. Various motor and sensory deficits

b. Increased risk of infection from white blood cell deficits c. Nutritional deficits such as early satiety and cachexia d. Potential for reduced gas exchange e. Various motor and sensory deficits *The general consequences of cancer include reduced immunity and blood-producing functions, altered GI structure and function, decreased respiratory function, and motor and sensory deficits. Clotting problems often occur due to thrombocytopenia (not enough platelets), not thrombocythemia (too many platelets).

The nurse is caring for a client who is jaundiced and reports pruritus. Which intervention will the nurse include in the plan of care? a. Monitor the client's vital signs and intake and output. b. Instruct the client to scratch with knuckles instead of nails. c. Assist the client with a hot bath and apply moisturizer. d. Encourage the client to eat a high-protein, high-cholesterol diet.

b. Instruct the client to scratch with knuckles instead of nails. *Pruritus occurs as a result of an accumulation of bile salts under the skin. Scratching with the knuckles instead of the nails preserves the skin's integrity and prevents tearing.

A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance, and the family expresses distress that the client is receiving little dietary protein. How should the nurse respond? a. A low-protein diet will help the liver rest and will restore liver function. b. Less protein in the diet will help prevent confusion associated with liver failure. c. Increasing dietary protein will help the client gain weight and muscle mass. d. Low dietary protein is needed to prevent fluid from leaking into the abdomen.

b. Less protein in the diet will help prevent confusion associated with liver failure. *A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the clients dietary protein will cause complications of liver failure and should not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.

The nurse is caring for a client who has had paracentesis performed. Which nursing intervention is appropriate? (Select all that apply.) a. Keep head of bed flat. b. Measure, describe, and record drainage. c. Ambulate 30 minutes post-procedure. d. Weigh client. e. Label fluid container and send for laboratory analysis.

b. Measure, describe, and record drainage. d. Weigh client. e. Label fluid container and send for laboratory analysis. *Following paracentesis, the nurse should position the patient in bed with the head of the bed elevated; monitor vital signs; measure, describe, and record drainage; maintain bed rest per protocol; weigh the client; and label the fluid container to send for laboratory analysis.

After receiving the hand-off report, which client should the oncology nurse see first? a. Client who is afebrile with a heart rate of 108 beats/min b. Older client on chemotherapy with mental status changes c. Client who is neutropenic and in protective isolation d. Client scheduled for radiation therapy today

b. Older client on chemotherapy with mental status changes *Older clients often do not exhibit classic signs of infection, and often mental status changes are the first observation. Clients on chemotherapy who become neutropenic also often do not exhibit classic signs of infection. The nurse should assess the older client first. The other clients can be seen afterward.

A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the client daily.

b. Provide a low-sodium diet. *A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.

An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.) a. Hypertension b. Tachycardia c. Flushed skin d. Confusion e. Shallow respirations

b. Tachycardia d. Confusion *Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, diaphoresis, cool and clammy skin, and confusion.

A nurse cares for a client with hepatitis C. The clients brother states, I do not want to contract this infection, so I will not go into his hospital room. How should the nurse respond? a. If you wear a gown and gloves, you will not get this virus. b. Viral hepatitis is not spread through casual contact. c. This virus is only transmitted through a fecal specimen. d. I can give you an update on your brothers status from here.

b. Viral hepatitis is not spread through casual contact. *Although family members may be afraid that they will contract hepatitis C, the nurse should educate the clients family about how the virus is spread. Viral hepatitis, or hepatitis C, is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. The nurse would be violating privacy laws by sharing the clients status with the brother.

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, I am experiencing right flank pain and have a temperature of 101 F. How should the nurse respond? a. The anti-rejection drugs you are taking make you susceptible to infection. b. You should go to the hospital immediately to have your new liver checked out. c. You should take an additional dose of cyclosporine today. d. Take acetaminophen (Tylenol) every 4 hours until you feel better.

b. You should go to the hospital immediately to have your new liver checked out. *Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. Anti-rejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse should not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.

When assessing a client for hepatic cancer, the nurse anticipates finding an elevation in which laboratory test result? a) Hemoglobin and hematocrit b) Leukocytes c) Alpha-fetoprotein d) Serum albumin

c) Alpha-fetoprotein *The nurse anticipates finding an elevation in the laboratory test for alpha-fetoprotein. Fetal hemoglobin (alpha-fetoprotein) is normally low in adults, and is a tumor marker indicative of cancers. Other elevated labs include bilirubin, PT, INR, & alkaline phosphatase. Serum albumin levels may be low in liver cancer and in malnutrition. Although anemia may be present, elevated hemoglobin and hematocrit are not diagnostic of hepatic cancer. WBC (leukocytes) are not used to specifically diagnose cancers.

The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN? a) Client who is taking lactulose and has diarrhea b) Client with hepatitis C who requires a dressing change c) Client with end-stage cirrhosis who needs teaching about a low-sodium diet d) Obtunded client with alcoholic encephalopathy who needs a blood draw

c) Client with end-stage cirrhosis who needs teaching about a low-sodium diet *The client with end-stage cirrhosis would be assigned to the RN. The RN is responsible for client teaching.Assisting a client with toileting and recording stool number and amount can be accomplished by nonprofessional staff. The LPN/LVN can provide dressing changes. Ancillary staff can perform venipuncture.

Which activity by the nurse will best relieve symptoms associated with ascites? a) Administering oxygen b) Monitoring serum albumin c) Elevating the head of the bed d) Administering intravenous fluids

c) Elevating the head of the bed *The best action by the nurse caring for a client with ascites is to elevate the head of the bed. The enlarged abdomen of ascites limits respiratory excursion. Fowler's position will increase excursion and reduce shortness of breath.The client may need oxygen, but first the nurse would raise the head of the bed to improve respiratory excursion and oxygenation. Monitoring serum albumin levels will detect anticipated decreased levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

The nurse knows that which of the following is the most likely presentation of Grade II hepatic encepalopathy? a) Tremor and dyscoordination b) Somnolence and/or aggression c) Gross personality changes d) Euphoria or anxiety e) Abnormal changes in neuropsychological tests

c) Gross personality changes *This is a reminder to review the Bager article! In general I want you to know what there are different grades of encephalopathy, and in what direction does 0-4 go. There is a danger with organic cognitive changes that nurses could think their patient is just being a jerk, when actually their body chemistry could be subtly changing. Also read about lactulose use and administration in this article and know what a TIPS procedure is (also detailed in Iggy, use both sources).

What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? a) The client must not consume alcohol. b) Avoid sharing the bathroom with the client c) Members of the household must not share toothbrushes. d) Drink only bottled water and avoid ice.

c) Members of the household must not share toothbrushes. *The nurse teaches the family of a client with Hepatitis C that toothbrushes, razors, towels, and any other items may spread blood and body fluids and must not be shared.The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water needs to be avoided.

A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action does the nurse take first? a) Obtain the charts from the previous admission b) Listen for bowel sounds in all quadrants c) Obtain pulse and blood pressure d) Ask about abdominal pain

c) Obtain pulse and blood pressure. *When caring for a newly admitted client with esophageal varices and vomiting of blood, the nurse would first assess vital signs to detect hypovolemic shock caused by hemorrhage. Assessment for adequate perfusion is the highest priority at this time.Obtaining charts from the previous admission, assessing bowel sounds, and pain assessment can be delayed until the client has stabilized.

Which problem for a client with cirrhosis takes priority? a) Insufficient knowledge related to the prognosis of the disease process b) Discomfort related to the progression of the disease process c) Potential for injury related to hemorrhage d) Inadequate nutrition related to an inability to tolerate usual dietary intake

c) Potential for injury related to hemorrhage *Potential for injury related to hemorrhage is the priority client problem because this complication could be life threatening.Insufficient knowledge of the prognosis of the disease process, discomfort, and inadequate nutrition are not priorities because these issues are not immediately life threatening.

When assessing a client with hepatitis B, a risk factor for cirrhosis, the nurse anticipates which assessment findings? (select all that apply) a) Recent influenza infection b) Brown stool c) Tea-colored urine d) Right upper quadrant tenderness e) Itching

c) Tea-colored urine d) Right upper quadrant tenderness e) Itching *Assessment findings the nurse expects to find in a client with Hepatitis B include brown, tea-, or cola-colored urine, right upper quadrant pain due to inflammation of the liver, and itching, irritating skin caused by deposits of bilirubin on the skin secondary to high bilirubin levels and jaundice.Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored, and not typically brown.

The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose? a) To aid in digestion of dairy product b) To reduce portal pressure c) To promote GI excretion of ammonia d) To reduce the risk of GI bleeding

c) To promote GI excretion of ammonia *In a client with cirrhosis, the administration of lactulose reduces serum ammonia levels by causing the client to excrete ammonia through the GI tract. Lactase, not lactulose, is the enzyme that aids in the digestion of dairy products. The mechanism of action of lactulose is not to reduce portal pressure. Lactulose does not affect bleeding.

What is defined as a need to increase the amount of a substance to achieve the desired effect? It occurs with alcohol abuse/dependence A) abuse B) physical dependence C) tolerance D) withdrawal

c) Tolerance

The nurse is caring for four clients. Which is at the highest risk for Hepatitis B infection? a. 24-year old with abdominal pain who just returned from Central America b. 40-year old who is two days postpartum and is breastfeeding c. 65-year old who reports using street drugs ten years ago when homeless d. 81-year old who donated own blood prior to a surgical procedure

c. 65-year old who reports using street drugs ten years ago when homeless *One mode of Hepatitis B transmission is via sharing needles, syringes, or other drug-injection equipment. The individual who used street drugs is at highest risk for development of hepatitis infection.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of carcinoma of the liver? a. A 22-year-old with a history of blunt liver trauma b. A 48-year-old with a history of diabetes mellitus c. A 66-year-old who has a history of cirrhosis d. An 82-year-old who has chronic malnutrition

c. A 66-year-old who has a history of cirrhosis *The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause. Blunt liver trauma, diabetes mellitus, and chronic malnutrition do not increase a persons risk for developing liver cancer.

A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate? a. Administer a dose of allopurinol (Aloprim). b. Assess the clients serum potassium level. c. Gently inquire about advance directives. d. Prepare the client for emergency surgery. ANS: C

c. Gently inquire about advance directives. *Superior vena cava syndrome is often a late-stage manifestation. After the client is stabilized and comfortable, the nurse should initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of potassium being released into the bloodstream. Surgery is rarely done for superior vena cava syndrome.

A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, All of my family hates me. How should the nurse respond? a. You should make peace with your family. b. This is not unusual. My family hates me too. c. I will help you identify a support system. d. You must attend Alcoholics Anonymous.

c. I will help you identify a support system. *Clients who have chronic cirrhosis may have alienated relatives over the years because of substance abuse. The nurse should assist the client to identify a friend, neighbor, or person in his or her recovery group for support. The nurse should not minimize the clients concerns by brushing off the clients comment. Attending AA may be appropriate, but this response doesnt address the clients concern. Making peace with the clients family may not be possible. This statement is not client-centered.

A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide additional teaching? a. Foods high in vitamin A and vitamin C are important. b. Ill have to cut down on the amount of bacon I eat. c. Im so glad I dont have to give up my juicy steaks. d. Vegetables, fruit, and high-fiber grains are important.

c. Im so glad I dont have to give up my juicy steaks. *To decrease the risk of developing cancer, one should cut down on the consumption of red meats and animal fat. The other statements are correct.

Which client report indicates to the nurse that the oncologic emergency spinal cord compression may be present? a. The client reports having a headache for the past 7 hours. b. The client has reduced breath sounds in the left lung. c. The client has worsening mid-thoracic back pain. d. Pedal edema is now present bilaterally.

c. The client has worsening mid-thoracic back pain. *One of the first symptoms of spinal cord compression in a patient with cancer is new onset or worsening back pain as the disintegrating bones press and compress spinal nerves. Headache is not associated with spinal cord compression.

What common secondary cancers to the liver may have their own oncologic emergencies?

colon, pancreas, & stomach

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? a) "Cirrhosis is a chronic disease that has scarred my liver." b) "The scars on my liver create problems with blood circulation." c) "Because of the scars on my liver, blood clotting and blood pressure are affected." d) "My liver is scarred, but the cells can regenerate themselves and repair the damage."

d) "My liver is scarred, but the cells can regenerate themselves and repair the damage." *The client's statement that, although his liver is scarred, the cells can regenerate and repair the damage indicates that further instruction is needed. Although cells and tissues will attempt to regenerate, destroyed liver cells will result in permanent scarring and irreparable damage.Cirrhosis is a chronic condition that leaves scars on the liver. Permanent scars form in response to attempts by the cells to regenerate and create problems in blood circulation moving through the liver. Liver scarring will create problems with blood clotting, cholesterol levels, and blood pressure, as well as with the metabolism of drugs and toxins.

The nurse asks a client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? a) Positive Babinski's sign b) Hyperreflexia c) Kehr's sign d) Asterixis

d) Asterixis *The nurse documents asterixis when the client's dorsiflexed hands begin to flap upward and downward when outstretched for a few moments. Liver flap or asterixis is related to increased serum ammonia levels.Babinski's sign is positive when, as the sole of the foot is stroked, the great toe points up and the toes fan out. Hyperreflexia refers to deep tendon reflexes that are overactive. Kehr's sign is reflected by increased abdominal pain, exaggerated by deep breathing, and referred to the right shoulder.

It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? a) Right shoulder pain b) Polyuria c) Bone marrow suppression d) Bleeding

d) Bleeding *A potential complication of hepatic artery embolization for hepatic cancer is bleeding. Prompt detection of hemorrhage is the priority.Discomfort such as right shoulder pain may be present, but the priority is to assess for hemorrhage. The nurse must assess for signs of shock, not polyuria. Embolization does not suppress the bone marrow. If chemotherapy or immune modulators are used, the nurse then assesses for bone marrow suppression.

When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? a) Vitamin K-containing products b) Potassium-sparing diuretics c) Nonabsorbable antibiotics d) NSAIDs

d) NSAIDS *The nurse must emphasize avoidance of NSAIDs when providing discharge teaching to a client with cirrhosis. The client with cirrhosis has an increased risk of hemorrhage. Clients who have cirrhosis must not take NSAIDs because they may predispose to bleeding.Products containing vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia levels.

The RN is caring for a client with end-stage liver disease who has ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)? a) Assessing skin integrity and abdominal distention b) Drawing blood from a central venous line for electrolyte studies c) Evaluating laboratory study results for the presence of hypokalemia d) Placing the client in a semi-Fowler's position

d) Placing the client in a semi-Fowler's position *The nurse delegates the client who needs to be placed in a semi-Fowler's position to the UAP. Positioning the client in this position is included within UAP education and scope of practice, although the RN will need to supervise the UAP in providing care and will evaluate the effect of the semi-Fowler's position on the client's comfort and breathing.Assessment of skin integrity and abdominal distention, obtaining blood from a central line, and evaluation of laboratory results must be done by the RN.

How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Evalose)? a) Provides small frequent meals for the client b) Suggests taking daily potassium supplements c) Elevates the head of the bed in high-Fowler's position d) Requests a bedside commode for the client

d) Requests a bedside commode for the client *The home care nurse best modifies the client's home environment to manage side effects of lactulose by making a bedside commode available to the client. Lactulose therapy increases the frequency of stools. A bedside commode is especially necessary if the client has difficulty reaching the toilet.Small frequent meals and elevating the head of the bed will not have any effect on the side effects of lactulose. Although lactulose produces excessive stools and could potentially result in loss of potassium, it is inappropriate for the nurse to suggest that the client take potassium supplements.

Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the health care provider (HCP)? a) The dressing has a 2-cm area of serous drainage b) The client's platelet count is 135,000/mm3 (135 × 109/L) c) The client's albumin level is 2.8 g/dL (28 g/L) d) The client's heart rate is 122 beats/min

d) The client's heart rate is 122 beats/min. *After a paracentesis with 2500 ml of fluid removed, the assessment finding of the client's heart rate is the most important finding to communicate to the HCP. Rapid removal of fluid may cause symptoms of shock, including tachycardia, and are especially associated with hypotension.A small amount of serous fluid may leak, so the dressing would be reinforced. Platelets will be checked before the procedure. These are slightly low, but this is not a cause for concern. An albumin level of 2.8 g/dL (28 g/L) is an expected finding for a client with cirrhosis and is not life threatening.

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first? a. Sedate the client to prevent tube dislodgement. b. Maintain balloon pressure at 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal saline. d. Assess the client for airway patency.

d. Assess the client for airway patency. *Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this treatment. The client should be sedated, balloon pressure should be maintained between 15 and 20 mm Hg, and the lumen can be irrigated with saline or tap water. However, these are not a higher priority than airway patency.

A student nurse asks the nursing instructor what apoptosis means. What response by the instructor is best? a. Growth by cells enlarging b. Having the normal number of chromosomes c. Inhibition of cell growth d. Programmed cell death

d. Programmed cell death *Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having

Which statement about carcinogenesis is accurate? a. An initiated cell will always become clinical cancer. b. Cancer becomes a health problem once it is 1 cm in size. c. Normal hormones and proteins do not promote cancer growth. d. Tumor cells need to develop their own blood supply.

d. Tumor cells need to develop their own blood supply. *Tumors need to develop their own blood supply through a process called angiogenesis. An initiated cell needs a promoter to continue its malignant path. Normal hormones and proteins in the body can act as promoters. A 1-cm tumor is a detectable size, but other events have to occur for it to become a health problem.

Which of the following orders would the nurse questions? (Select all that apply) ​A. Diazepam 2 mg IV every 8 hours for 7 days ​B. Diazepam 10 mg IV every 8 hours for 24 days then continue to taper ​C. Diazepam 100 mg IV every 8 hours for 24 days then continue to taper

​A. Diazepam 2 mg IV every 8 hours for 7 days ​C. Diazepam 100 mg IV every 8 hours for 24 days then continue to taper *Normal dose: Diazepam is Valium 10-20 mg (20 rarely used) IV/PO Q6H, 8H, 12H, daily (each for one day). Note that Benzodiazepines meds will be tapered as symptoms improve ex: diazepam & chlordiazepoxide. A) is incorrect bc 2mg for 7 days. C) is incorrect bc 100mg

Which of the following orders would the nurse questions? (Select all that apply) ​A. Naltrexone 50 mg every day for treatment of alcohol dependence ​B. Naloxone 50 mg every day for treatment of alcohol dependence ​C. Naltrexone 100 mg every other day for treatment of alcohol dependence

​B. Naloxone 50 mg every day for treatment of alcohol dependence -Normal dose: NalTREXone is suboxone for alcohol dependence 50-100mg daily to every other day -Normal dose: NalOXONE is Narcan used for opioid overdose 0.4-0.8 mg IM -B) Naloxone is incorrect bc it is used for opioid overdose NOT alcohol dependence