414 Cirrhosis

During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first? A. A 36-yr-old patient recovering from a laparoscopic cholecystectomy who has severe shoulder pain B. A 40-yr-old patient with chronic pancreatitis who has gnawing abdominal pain C. A 58-yr-old patient who has compensated cirrhosis and is complaining of anorexia D. A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C)

Correct Answer: A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) Explanation: This patient's history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.

A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take? A. Administer both drugs B. Administer the spironolactone. C. Withhold both drugs. D. Administer the furosemide

Correct Answer: Administer the spironolactone. Explanation: Spironolactone is a potassium-sparing diuretic and will help increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.

Which focused data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? A. Temperature B. Activity level C. Albumin level D. Hemoglobin

Correct Answer: Albumin level Explanation: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters are not directly associated with the patient's edema.

The autopsy of a 55-year-old revealed an enlarged liver, testicular atrophy, and mild jaundice secondary to cirrhosis. What is the most likely cause of this condition? A. Viral infection B. Drug overdose C. Bacterial infection D. Alcoholic steatohepatitis

Correct Answer: Alcoholic steatohepatitis Explanation: The clinical manifestations of alcoholic steatohepatitis include jaundice, hepatomegaly, and testicular atrophy. These symptoms are not a result of bacterial or viral infection, or a drug overdose.

Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? A. Request that the patient walk with eyes closed. B. Request that the patient stand on one foot C. Ask the patient to perform the Valsalva maneuver. D. Ask the patient to extend both arms forward

Correct Answer: Ask the patient to extend both arms forward Explanation: Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.

Which topic is most important to include in patient teaching for a 41-yr-old patient diagnosed with early alcoholic cirrhosis? A. Avoiding alcohol ingestion B. Taking lactulose C. Using vitamin B supplements D. Maintaining good nutrition

Correct Answer: Avoiding alcohol ingestion Explanation: The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.

A 54-year-old reports vomiting blood. Tests reveal portal hypertension. Which of the following is the most likely cause of this condition? A. Cirrhosis of the liver B. Left ventricular failure C. Renal stenosis D. Thrombosis in the spleen

Correct Answer: Cirrhosis of the liver Explanation: Portal hypertension occurs secondarily to cirrhosis of the liver. Portal hypertension is not associated with thrombosis of the spleen, left ventricular failure, or renal stenosis.

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? A. Improved alertness and orientation B. Increased serum albumin level C. Fewer episodes of bleeding varices D. Decreased indirect bilirubin level

Correct Answer: Fewer episodes of bleeding varices Explanation: TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? A. Monitor the patient for shortness of breath. B. Deflate the gastric balloon if the patient reports nausea. C. Instruct the patient to cough every hour. D. Verify the position of the balloon every 4 hours.

Correct Answer: Monitor the patient for shortness of breath. Explanation: The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. Balloons may be deflated briefly every 8 to 12 hours to avoid tissue necrosis, but if only the gastric balloon is deflated, the esophageal balloon may occlude the airway. Balloons are not deflated for nausea.

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? A. Place the patient on a pressure-relief mattress. B. Restrict daily dietary protein intake. C. Reposition the patient every 4 hours. D. Perform passive range of motion twice daily.

Correct Answer: Place the patient on a pressure-relief mattress. Explanation: The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take the pressure off areas such as the sacrum that are vulnerable to breakdown.

For a patient with cirrhosis, which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)? A. Palpating the abdomen for distention B. Teaching the patient the prescribed diet C. Providing oral hygiene after a meal D. Assessing the patient for jaundice

Correct Answer: Providing oral hygiene after a meal Explanation: Providing oral hygiene is within the scope of UAP. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher level nursing education and scope of practice and would be delegated to licensed practical/vocational nurses (LPNs/LVNs) or RNs.

A patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator to the nurse that the medication has been effective? A. The apical pulse rate is 68 beats/minute. B. The patient reports no chest pain C. Blood pressure is 140/90 mm Hg. D. Stools test negative for occult blood.

Correct Answer: Stools test negative for occult blood. Explanation: Because the purpose of beta-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.

Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices? A. The medication will decrease nausea and improve the appetite. B. The medication will prevent irritation of the enlarged veins. C. The medication will reduce the risk for aspiration D. The medication will inhibit development of gastric ulcers.

Correct Answer: The medication will prevent irritation of the enlarged veins. Explanation: Esophageal varices are dilated submucosal veins. The therapeutic action of H2-receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purposes for H2-receptor blockade in this patient.

The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? A. The patient's hands flap back and forth when the arms are extended. B. The patient has ascites and a 2-kg weight gain from the previous day. C. The patient's abdominal skin has multiple spider-shaped blood vessels. D. The patient complains of right upper-quadrant pain with palpation

Correct Answer: The patient's hands flap back and forth when the arms are extended. Explanation: Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain indicate the need for treatment but not as urgently as the changes in neurologic status.

In alcoholic cirrhosis, hepatocellular damage is caused by: A. acidosis B. fatty infiltrations C. bile toxicity D. acetaldehyde accumulation

Correct Answer: acetaldehyde accumulation Explanation: Alcoholic cirrhosis is caused by the toxic effects of alcohol metabolism on the liver. Alcohol is transformed to acetaldehyde, and excessive amounts significantly alter hepatocyte function and activate hepatic stellate cells, a primary cell involved in liver fibrosis. Bile toxicity does not cause alcoholic cirrhosis. Acidosis does not cause alcoholic cirrhosis. Fatty infiltrations do not cause alcoholic cirrhosis.

To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor A. prothrombin time. B. potassium levels. C. bilirubin levels. D. ammonia levels

Correct Answer: ammonia levels Explanation: The protein in the blood in the gastrointestinal tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode.

To prepare a patient with ascites for paracentesis, the nurse A. positions the patient on the right side. B. places the patient on NPO status. C.assists the patient to lie flat in bed. D. asks the patient to empty the bladder.

Correct Answer: asks the patient to empty the bladder. Explanation: The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.

A 55-year-old is diagnosed with extrahepatic obstructive jaundice that is a result of the obstruction of the: A. gallbladder B. cystic duct C. common bile duct D. intrahepatic bile canaliculi

Correct Answer: common bile duct Explanation: Jaundice is due to obstruction of the common bile duct. This form of jaundice is not due to obstruction of the intrahepatic canaliculi, gallbladder, or the cystic duct.

The most common clinical manifestation of portal hypertension is _______ bleeding. A. intestinal B. esophageal C. rectal D. duodenal

Correct Answer: esophageal Explanation: Vomiting of blood from bleeding esophageal varices is the most common clinical manifestation of portal hypertension. Neither rectal, duodenal, nor intestinal bleeding is a common clinical manifestation of portal hypertension.

The most common disorder associated with upper GI bleeding is: A. esophageal varices B. cancer C. hemorrhoids D. diverticulosis

Correct Answer: esophageal varices Explanation: Esophageal varices is the most common disorder associated with upper GI bleeding. Diverticulosis could lead to bleeding, but it would be lower GI rather than upper. Hemorrhoids can lead to bleeding but they would be lower GI. Cancer could lead to upper GI bleeding, but peptic ulcers and varices are identified as more common.

Manifestations associated with hepatic encephalopathy from chronic liver disease are the result of:

Correct Answer: impaired ammonia metabolism Explanation: Hepatic encephalopathy effect on the liver prevents end products of intestinal protein digestion, particularly ammonia, from being converted to urea by the diseased liver. Impaired ammonia metabolism leads to the symptoms of hepatic encephalopathy. Symptoms are primarily neurologic, not jaundice oriented. Manifestations associated with hepatic encephalopathy are not associated with hyperbilirubinemia and jaundice, fluid, and electrolyte imbalances or decreased cerebral blood flow.

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? A. The patient has at least one stool daily. B. The patient is alert and oriented. C. The patient denies nausea or anorexia. D. The patient's bilirubin level decreases.

Question: Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? Correct Answer: The patient is alert and oriented. Explanation: The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.