PREPU: Nursing Management: Patients With Hepatic and Biliary Disorders

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

Loss of 2.2 lb (1 kg) in 24 hours Rationale: Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.

A 67-year-old client is returning for a follow-up appointment to the primary care group where you practice nursing. At his last appointment, he received the diagnosis of portal hypertension and the physician instituted interventions to begin treatment of this condition. What is the primary aim of portal hypertension treatment? Choose all correct options.

Reduce venous pressure Reduce fluid accumulation Rationale: Methods of treating portal hypertension aim to reduce venous pressure and fluid accumulation.

Which of the following terms describes the involuntary flapping movements of the hands associated with metabolic liver dysfunction?

Asterixis Rationale: Asterixis refers to involuntary flapping movements of the hands associated with metabolic liver dysfunction. Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise. Ascites refers to accumulation of serous fluid within the peritoneal cavity. Dialysis refers to a form of filtration to separate crystalloid from colloid substances

When caring for a client with cirrhosis, which of the following should a nurse notify immediately? Choose all correct options.

Signs of GI bleeding Change in mental status Rationale:

Which condition is most likely to have a nursing diagnosis of fluid volume deficit?

Pancreatitis Rationale: Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. Appendicitis, cholecystitis, and gastric ulcer are less likely to exhibit fluid volume deficit.

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

Asterixis Rationale: Hepatic encephalopathy is manifested by numerous central nervous system effects including: disorientation, confusion, personality changes, memory loss, a flapping tremor called asterixis, a positive Babinski reflex, sulfurous breath odor (referred to as fetor hepaticus), and lethargy to deep coma.

A homeless client at the neighborhood clinic has a lengthy history of alcohol addiction and is being seen for jaundice. Which of the following would the appearance of jaundice most likely indicate?

Liver disorder Rationale: Jaundice is a sign of disease, but it is not itself a unique disease. Jaundice accompanies many diseases that directly or indirectly affect the liver and is probably the most common sign of a liver disorder.

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?

Reposition the client every 2 hours. Rationale: Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.

Which of the following would be most appropriate for a client who is experiencing biliary colic?

Ensure that the client rests. Rationale: During an attack of biliary colic, the nurse should ensure that the client rests. The nurse should not give the client a full meal; instead, the nurse should monitor the client's ability to digest a bland liquid diet. The nurse should also administer antispasmodics or analgesics as prescribed to relieve pain and discomfort.

A nurse is responsible for monitoring the diet of a patient with hepatic encephalopathy. The nurse knows that the 185-pound male should have a daily protein intake between __________.

42 and 126 grams Rationale: Daily protein intake should be limited to 0.5 to 1.5 g/kg. Therefore, a person who weighs 185 lbs weighs 84 kg. To calculate protein intake, multiply the 84 kg by the low and high ranges: (84 kg × 0.5 = 42 g; 84 kg × 1.5 = 126 g). This patient would require a daily protein range from 42 to 126 g.

Which of the following is commonly associated with acute episodes of pancreatitis?

Long-term use of alcohol Rationale: Long-term use of alcohol is commonly associated with acute episodes of pancreatitis, but the patient usually has had undiagnosed chronic pancreatitis before the first episode of acute pancreatitis. Less common causes of pancreatitis include bacterial or viral infection.

What is a major concern for the nurse when caring for a patient with chronic pancreatitis?

Weight loss Rationale: Weight loss is a major problem in chronic pancreatitis. More than 80% of patients experience significant weight loss, which is usually caused by decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack (Bope & Kellerman, 2011).

A patient receiving vasopressin for the management of active bleeding due to esophageal varices should be assessed for evidence of the drug's most serious complication. Therefore, the nurse should frequently check the patient's:

Electrocardiogram. Rationale: Vasopressin is administered during an acute esophageal bleed because of its vasoconstrictive properties in the splanchnic, portal, and intrahepatic vessels. This medication also causes coronary artery constriction that may dispose patients with coronary artery disease to cardiac ischemia; therefore, the nurse observes the patient for evidence of chest pain, ECG changes, and vital sign changes.

Which type of deficiency results in macrocytic anemia?

Folic acid Rationale: Folic acid deficiency results in macrocytic anemia. Vitamin C deficiency results in hemorrhagic lesions of scurvy. Vitamin A deficiency results in night blindness and eye and skin changes. Vitamin K deficiency results in hypoprothrombinemia, which is characterized by spontaneous bleeding and ecchymosis.

The most common cause of esophageal varices includes which of the following?

Portal Hypertension Rationale: Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm his diagnosis?

Recent weight loss and temperature elevation Rationale: Assessment findings associated with pancreatitis include recent weight loss and temperature elevation. Inflammation of the pancreas causes a response that elevates temperature and leads to abdominal pain that typically occurs with eating. Nausea and vomiting may occur as a result of pancreatic tissue damage that's caused by the activation of pancreatic enzymes. The client may experience weight loss because of the lost desire to eat. Blood in stools and recent hypertension aren't associated with pancreatitis; fatty diarrhea and hypotension are usually present. Presence of easy bruising and bradycardia aren't found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Adventitious breath sounds and hypertension aren't associated with pancreatitis.

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient?

Respiratory assessment related to increased thoracic pressure Rationale: If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy.

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

The digestion of dietary and blood proteins. Rationale: Circumstances that increase serum ammonia levels tend to aggravate or precipitate hepatic encephalopathy. The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. Ammonia from these sources increases as a result of GI bleeding (ie, bleeding esophageal varices, chronic GI bleeding), a high-protein diet, bacterial infection, or uremia.

A patient is admitted to the hospital with possible cholelithiasis. What diagnostic test of choice will the nurse prepare the patient for?

Ultrasonography Rationale: Ultrasonography has replaced cholecystography (discussed later) as the diagnostic procedure of choice because it is rapid and accurate and can be used in patients with liver dysfunction and jaundice. It does not expose patients to ionizing radiation.

The nurse has admitted a client with suspected cholelithiasis. The nurse knows that the diagnostic procedure of choice for cholelithiasis is

Ultrasonography Rationale: Ultrasonography has replaced cholecystography as the diagnostic procedure of choice because it is rapid and accurate and can be used in clients with liver dysfunction and jaundice. It does not expose clients to ionizing radiation. However, only 15% to 20% of gallstones are calcified sufficiently to be visible on such x-ray studies. Although cholecystography has been replaced by ultrasonography as the test of choice, it is still used if ultrasound equipment is not available or if the ultrasound results are inconclusive.

A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client?

Vasopressin (Pitressin) Rationale: In an actively bleeding client, medications are administered initially because they can be obtained and administered quicker than other therapies. Vasopressin (Pitressin) may be the initial mode of therapy in urgent situations, because it produces constriction of the splanchnic arterial bed and decreases portal pressure. Propranolol (Inderal) and nadolol (Corgard), beta-blocking agents that decrease portal pressure, are the most common medications used both to prevent a first bleeding episode in clients with known varices and to prevent rebleeding. Beta-blockers should not be used in acute variceal hemorrhage, but they are effective prophylaxis against such an episode. Spironolactone (Aldactone), an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. Lactulose (Cephulac) is administered to reduce serum ammonia levels in clients with hepatic encephalopathy.

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

• Measure abdominal girth daily. • Perform daily weights. Rationale: Increased abdominal girth and rapid weight gain are common presenting symptoms of ascites. If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy.

Which of the following the are early manifestations of liver cancer? Select all that apply.

• Pain • Continuous aching in the back Rationale: Early manifestations of liver cancer include pain and continuous dull aching in the right upper quadrant epigastrium or back. Weight loss, anorexia, and anemia may occur. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver. Fever and vomiting are not associated manifestations.

A nurse practitioner treating a patient who is diagnosed with hepatitis A should provide health care information. Which of the following statements are correct for this disorder? Select all that apply.

• There is a 70% chance that jaundice will occur. • Transmission of the virus is possible with oral-anal contact during sex. • Typically there is a spontaneous recovery. Rationale: The incubation period for hepatitis A is 15 to 50 days, with an average of 28 days. The risk of cirrhosis occurs with hepatitis B.

A patient is diagnosed with mild acute pancreatitis. What does the nurse understand is characteristic of this disorder?

Edema and inflammation Rationale: Mild acute pancreatitis is characterized by edema and inflammation confined to the pancreas. Minimal organ dysfunction is present, and return to normal function usually occurs within 6 months.

A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor?

"You must have the second one in 1 month and the third in 6 months." Rationale: Both forms of the hepatitis B vaccine are administered intramuscularly in three doses; the second and third doses are given 1 and 6 months, respectively, after the first dose.

A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood value does the nurse recognize as inadequate to sustain normal brain function?

30 mg/dL Rationale: Hyperinsulinism is caused by overproduction of insulin by the pancreatic islets. Occasionally, tumors of nonpancreatic origin produce an insulinlike material that can cause severe hypoglycemia and may be responsible for seizures coinciding with blood glucose levels that are too low to sustain normal brain function (i.e., lower than 30 mg/dL [1.6 mmol/L]) (Goldman & Schafer, 2012; McPherson & Pincus, 2011).

The nurse reviews the laboratory values for a patient being evaluated for alcoholic cirrhosis. The nurse is aware that a diagnostic indicator present in greater than 70% of cases is which of the following?

AST/ALT ratio >3.0 Rationale: The aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio is helpful in diagnosing liver damage and is present in more than 70% of cases.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client?

Administering morphine I.V. as ordered Rationale: The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

The single modality of pharmacologic therapy for chronic type B viral hepatitis is:

Alpha-interferon Rationale: Alpha-interferon is a biologic response modifier that is highly effective for treatment of hepatitis B. The other antiviral agents are effective but not the preferred single-agent therapy.

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

Asterixis Rationale: Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy.

Which of the following is the imaging modality of choice for assessment of both acute and chronic pancreatitis?

Computed tomography Rationale: Computed tomography is the modality of choice for the assessment of both acute and chronic pancreatitis.

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find?

Elevated urine amylase levels Rationale: Elevated serum and urine amylase, lipase, and liver enzyme levels accompany significant pancreatitis. If the common bile duct is obstructed, the bilirubin level is above normal. Blood glucose levels and white blood cell counts can be elevated. Serum electrolyte levels (calcium, potassium, and magnesium) are low.

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

Fecal-oral Rationale: The mode of transmission of hepatitis A virus (HAV) occurs through fecal-oral route, primarily through person to person contact and/or ingestion of fecal contaminated food or water. Hepatitis B virus (HBV) is transmitted primarily through blood. HBV can be found in blood, saliva, semen, and can be transmitted through mucous membranes and breaks in the skin.

A nurse is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the:

Gallbladder Rationale: The gallbladder functions as a storage depot for bile.

Which type of jaundice seen in adults is the result of increased destruction of red blood cells?

Hemolytic Rationale: Hemolytic jaundice results because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.

A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions?

Hepatic encephalopathy Rationale: Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness, and coma. Portal hypertension is an elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia?

Hypotension Rationale: Signs of potential hypovolemia include cool, clammy skin, tachycardia, decreased blood pressure, and decreased urine output.

Which of the following laboratory test results would the nurse associate with obstructive jaundice?

Increased direct bilirubin Rationale: With obstructive jaundice, direct or conjugated bilirubin levels would be increased. Indirect or unconjugated bilirubin levels would be increased with hemolytic jaundice. Both conjugated and unconjugated bilirubin levels would be elevated with hepatocellular jaundice.

Which of the following aids in digestion of fats?

Lipase Rationale: Lipase is a pancreatic enzyme that aids in the digestion of fats. Amylase aids in the digestion of carbohydrates. Secretin is responsible for stimulating the secretion of pancreatic juice. Trypsin aids in the digestion of protein.

A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?

Liver biopsy Rationale: A liver biopsy which reveals hepatic fibrosis is the most conclusive diagnostic procedure. Coagulation studies provide information about liver function but do not definitively confirm the diagnosis of cirrhosis. Magnetic resonance imaging and radioisotope liver scan help to support the diagnosis but do not confirm it. These tests provide information about the liver's enlarged size, nodular configuration, and distorted blood flow.

Which of the following is the major cause of morbidity and mortality in patients with acute pancreatitis?

Pancreatic necrosis Rationale: Pancreatic necrosis is a major cause of morbidity and mortality in patients with acute pancreatitis. Shock and multiple organ failure may occur with acute pancreatitis. Tetany is not a major cause of morbidity and mortality in patients with acute pancreatitis.

Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit?

Pancreatitis Rationale: Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity. The other conditions are less likely to exhibit fluid volume deficit.

In actively bleeding patients with esophageal varices, the initial drug of therapy is usually:

Pitressin Rationale: In an actively bleeding patient, medications are administered initially because other therapies take longer to initiate. Vasopressin (Pitressin) may be the initial mode of therapy, because it produces constriction of the splanchnic arterial bed and decreases portal pressure. It may be administered by IV infusion.

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

Purpura and petechiae Rationale: A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?

Relieving abdominal pain Rationale: The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can't help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

A patient is diagnosed with gallstones in the bile ducts. What laboratory results should the nurse review?

Serum bilirubin level greater than 1.0 mg/dL Rationale: If the flow of bile is impeded (e.g., by gallstones in the bile ducts), bilirubin does not enter the intestine. As a result, blood levels of bilirubin increase.

Which of the following is the most common complaint(s) of patients with pancreatitis?

Severe, radiating abdominal pain Rationale: The most common complaint of patients with pancreatitis is severe mid- to upper-abdominal pain, radiating to both sides and straight to the back. The patient may describe the stools as being frothy and foul smelling, not black or tarry. The patient's urine may be dark. The patient will not experience increased or painful urination, increased appetite, or weight gain.

A nurse assesses a patient diagnosed with hepatic encephalopathy. She observes a number of clinical signs, including asterixis and fetor hepaticus; the patient's electroencephalogram (EEG) is abnormal. The nurse documents that the patient is exhibiting signs of which stage of hepatic encephalopathy?

Stage 2 Rationale: The signs listed in the question plus disorientation, mood swings, and increased drowsiness are all indicators of stage 2 hepatic encephalopathy.

During chronic pancreatitis, the patient's stool may become frothy and foul-smelling. This would be documented as which of the following?

Steatorrhea Rationale: The stool becomes frequent, frothy, and foul-smelling because of impaired fat digestion, which results in stools with a high fat content.

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

The client's hepatic function is decreasing. Rationale: The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.

A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is boardlike and no bowel sounds are detected. What is the major concern for this patient?

The patient has developed peritonitis. Rationale: Abdominal guarding is present. A rigid or boardlike abdomen may develop and is generally an ominous sign, usually indicating peritonitis.

The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason?

To reduce gastric and pancreatic secretions Rationale: Anticholinergic medications reduce gastric and pancreatic secretion.

Alcohol, which is toxic to the liver, is a common cause of hepatic disorders. As part of health teaching, the nurse advises a group of women that the amount of daily alcohol use should be limited to the equivalent of:

Two 6 oz glasses of wine. Rationale: Intake of 60 g/day for men and 30 g/d for women (10 g of alcohol is equivalent to 1 oz of bourbon, 12 ounces of beer, or 4 ounces of red wine) is sufficient to cause liver injury.

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

Vaccine Rationale: The most effective strategy to prevent hepatitis B infection is through vaccination. Recommendations to prevent transmission of hepatitis B include vaccination of sexual contacts of individuals with chronic hepatitis, use of barrier protection during sexual intercourse, avoidance of sharing toothbrushes, razors with others, and covering open sores or skin lesions.

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client?

Vitamin A Rationale: Problems common to clients with severe chronic liver dysfunction result from inadequate intake of sufficient vitamins. Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency can lead to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Vitamin K deficiency can cause hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:

cirrhosis. Rationale: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:

yellow sclerae. Rationale: Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.