Chapter 49: Assessment and Management of Patients With Hepatic Disorders

Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following? a) Calcium b) Alcohol c) Bicarbonate d) Ammonia

Ammonia Lactulose (Cephulac) is administered to reduce serum ammonia levels. Cephulac does not influence calcium, bicarbonate, or alcohol levels.

After undergoing a liver biopsy, a client should be placed in which position? a) Right lateral decubitus position b) Semi-Fowler's position c) Supine position d) Prone position

Right lateral decubitus position After a liver biopsy, the client is placed on the right side (right lateral decubitus position) to exert pressure on the liver and prevent bleeding. Semi-Fowler's position and the supine and prone positions wouldn't achieve this goal.

Which type of deficiency results in macrocytic anemia? a) Vitamin K b) Vitamin C c) Vitamin A d) Folic acid

Folic acid 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.

Which of the following is the most effective strategy to prevent hepatitis B infection? a) Vaccine b) Barrier protection during intercourse c) Covering open sores d) Avoid sharing toothbrushes

Vaccine 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 carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery? a) Vitamin B b) Vitamin K c) Oral bile acids d) Potassium

Vitamin K Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.

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. What is the primary aim of portal hypertension treatment? Select all that apply. a) Reduce fluid output. b) Reduce fluid accumulation. c) Reduce venous pressure. d) Reduce blood coagulation.

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

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report? a) Yellow-green b) Clay-colored or whitish c) Blood tinged d) Black and tarry

Clay-colored or whitish Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.

Which of the following would be the least important assessment in a patient diagnosed with ascites? a) Foul-smelling breath b) Palpation of abdomen for a fluid shift c) Measurement of abdominal girth d) Weight

Foul-smelling breath Foul-smelling breath would not be considered an important assessment for this patient. Measurement of abdominal girth, weight, and palpation of the abdomen for a fluid shift are all important assessment parameters for the patient diagnosed with ascites.

The nurse identifies which of the following types of jaundice in an adult experiencing a transfusion reaction? a) Hepatocellular b) Nonobstructive c) Obstructive d) Hemolytic

Hemolytic Hemolytic jaundice occurs because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. This type of jaundice is encountered in patients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.

A patient with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade therapy is used temporarily to control hemorrhage and stabilize the patient. In planning care, the nurse gives the highest priority to which of the following goals? a) Maintaining the airway b) Relieving the patient's anxiety c) Controlling bleeding d) Maintaining fluid volume

Maintaining the airway Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway is compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider? a) Measure abdominal girth according to a set routine. b) Report the condition to the physician immediately. c) Provide the client with nonprescription laxatives. d) Ask the client about food intake.

Measure abdominal girth according to a set routine. If the abdomen appears enlarged, the nurse measures it according to a set routine. The nurse reports any change in mental status or signs of gastrointestinal bleeding immediately. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis.

A 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: a) peptic ulcer disease. b) appendicitis. c) cholelithiasis. d) cirrhosis.

cirrhosis. 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.

The mode of transmission of hepatitis A virus (HAV) includes which of the following? a) Semen b) Fecal-oral c) Saliva d) Blood

Fecal-oral 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 presentation for a local community group about hepatitis. Which of the following would the nurse include? a) Infection with hepatitis G is similar to hepatitis A. b) Hepatitis B is transmitted primarily by the oral-fecal route. c) Hepatitis C increases a person's risk for liver cancer. d) Hepatitis A is frequently spread by sexual contact.

Hepatitis C increases a person's risk for liver cancer. Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.

Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Bradycardia b) Hypotension c) Polyuria d) Warm moist skin

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

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: a) The digestion of dietary and blood proteins. b) Excess potassium loss subsequent to prolonged use of diuretics. c) Excessive diuresis and dehydration. d) Severe infections and high fevers.

The digestion of dietary and blood proteins. 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.

To reduce risk of injury for a patient with liver disease, what initial measure can the nurse implement? a) Raise all four side rails on the bed b) Prevent visitors, so as not to agitate the patient c) Pad the side rails on the bed d) Apply soft wrist restraints

Pad the side rails on the bed Padding the side rails can reduce injury if the patient becomes agitated or restless. Restraints would not be an initial measure to implement. Four side rails are considered a restraint and this would not be an initial measure to implement. Family and friends most generally assist in calming a patient.

A preoperative client scheduled to have an open cholecystectomy says to the nurse, "The doctor said that after surgery, I will have a tube in my nose that goes into my stomach. Why do I need that?" What most common reason for a client having a nasogastric tube in place after abdominal surgery should the nurse include in a response? a) Lavage b) Gavage c) Instillation d) Decompression

Decompression Negative pressure exerted through a tube inserted in the stomach removes secretions and gaseous substances from the stomach, preventing abdominal distention, nausea, and vomiting. This is not the most common purpose of a nasogastric tube after surgery; instillations in a nasogastric tube after surgery are done when necessary to promote patency. This is contraindicated after abdominal surgery until peristalsis returns. This is not the most common purpose of a nasogastric tube after surgery; lavage after surgery may be done to promote hemostasis in the presence of gastric bleeding.

A patient with hepatic cirrhosis questions the nurse about the possible use of an herbal supplement—milk thistle—to help heal the liver. Which of the following would be the most appropriate response from the nurse? a) Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis.However, you should always notify your primary care provider of any herbal remedies being used so drug interactions can be evaluated. b) You can use milk thistle instead of the medications you have been prescribed. c) Herbal supplements are approved by the FDA, so there should be no problem with their usage if you check with your primary care provider. d) You should not use herbal supplements in conjunction with medical treatment.

Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis.However, you should always notify your primary care provider of any herbal remedies being used so drug interactions can be evaluated. Many patients who have end-stage liver disease (ESLD) with cirrhosis use the herb milk thistle (Silybum marianum) to treat jaundice and other symptoms. This herb has been used for centuries because of its healing and regenerative properties for liver disease. Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis. The natural compound SAM-e (s-adenosylmethionine) may improve outcomes in liver disease by improving liver function, possibly through enhancing antioxidant function. Herbal supplements are used in conjunction with medical treatment and medications. Herbal supplements are not approved by the FDA. Their usage should be discussed with the primary care provider to evaluate their effectiveness and interactions with other treatment regimens.

A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing? a) Vitamin K deficiency b) Riboflavin deficiency c) Vitamin A deficiency d) Folic acid deficiency

Vitamin K deficiency Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency leads to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Pyridoxine deficiency results in skin and mucous membrane lesions and neurologic changes. Vitamin C deficiency results in the hemorrhagic lesions of scurvy. Vitamin K deficiency results in hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses. Folic acid deficiency results in macrocytic anemia.

Which of the following terms is used to describe a chronic liver disease in which scar tissue surrounds the portal areas? a) Postnecrotic cirrhosis b) Compensated cirrhosis c) Alcoholic cirrhosis d) Biliary cirrhosis

Alcoholic cirrhosis This type of cirrhosis is due to chronic alcoholism and is the most common type of cirrhosis. In postnecrotic cirrhosis, there are broad bands of scar tissue, which are a late result of a previous acute viral hepatitis. In biliary cirrhosis, scarring occurs in the liver around the bile ducts. Compensated cirrhosis is a general term given to the state of liver disease in which the liver continues to be able to function effectively.

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice? a) Reduced hematocrit b) Elevated urobilinogen in the urine c) Straw-colored urine d) Clay-colored stools

Clay-colored stools Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen.

Which of the following would be the most important nursing assessment in a patient diagnosed with ascites? a) Assessment of oral cavity for foul-smelling breath b) Daily weight and measurement of abdominal girth c) Palpation of abdomen for a fluid shift d) Auscultation of abdomen

Daily weight and measurement of abdominal girth Daily measurement and recording of abdominal girth and body weight are essential to assess the progression of ascites and its response to treatment.

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct? a) Cholecystectomy b) Endoscopic retrograde cholangiopancreatography (ERCP) c) Colonoscopy d) Abdominal x-ray

Endoscopic retrograde cholangiopancreatography (ERCP) ERCP locates stones that have collected in the common bile duct. A colonoscopy will not locate gallstones but only allows visualization of the large intestine. Abdominal x-ray is not a reliable locator of gallstones. A cholecystectomy is the surgical removal of the gallbladder.

Louisa Collins, a 52-year-old high school science teacher, is your client on the medical-surgical floor at the hospital where you practice nursing. She is undergoing diagnostics to determine what is causing her liver disorder. As you discuss her condition, Louisa asks questions pertaining to liver physiology and cellular function. Which liver cells perform most of the liver's metabolic functions? a) Parenchymal cells b) Canaliculi cells c) Kupffer cells d) Islets of Langerhans

Parenchymal cells

In what location would the nurse palpate for the liver? a) Right upper quadrant b) Left upper quadrant c) Left lower quadrant d) Right lower quadrant

Right upper quadrant The liver may be palpable in the right upper quadrant. A palpable liver presents as a firm, sharp ridge with a smooth surface.

The nurse is concerned about potassium loss when a diuretic is prescribed for a patient with ascites and edema. What diuretic may be ordered that spares potassium and prevents hypokalemia? a) Bumetanide (Bumex) b) Furosemide (Lasix) c) Acetazolamide (Diamox) d) Spironolactone (Aldactone)

Spironolactone (Aldactone) Potassium-sparing diuretic agents such as spironolactone or triamterene (Dyrenium) may be indicated to decrease ascites, if present; these diuretics are preferred because they minimize the fluid and electrolyte changes commonly seen with other agents.

A client is admitted to the hospital with acute hemorrhage from esophageal varices. What medication should the nurse anticipate administering that will reduce pressure in the portal venous system and control esophageal bleeding? a) Vasopressin (Pitressin) b) Vitamin K c) Epinephrine d) Octreotide (Sandostatin)

Octreotide (Sandostatin) Acute hemorrhage from esophageal varices is lifethreatening. Resuscitative measures include administration of IV fluids and blood products. IV octreotide (Sandostatin) is started as soon as possible. Sandostatin is preferred because of fewer side effects. Octreotide reduces pressure in the portal venous system and is preferred to the previously used agents, vasopressin (Pitressin) or terlipressin. Vitamin K promotes blood coagulation in bleeding conditions, resulting from liver disease.

Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following may occur as a result of vitamin C deficiency? a) Hypoprothrombinemia b) Scurvy c) Night blindness d) Beriberi

Scurvy Scurvy may result from a vitamin C deficiency. Night blindness, hypoprothrombinemia, and beriberi do not result from a vitamin C deficiency.

The nurse is caring for a patient with ascites due to cirrhosis of the liver. What position does the nurse understand will activate the renin-angiotensin aldosterone and sympathetic nervous system and decrease responsiveness to diuretic therapy? a) Prone b) Left-lateral Sims' c) Upright d) Supine

Upright In patients with ascites, an upright posture is associated with activation of the renin-angiotensin-aldosterone system and sympathetic nervous system (Porth & Matfin, 2009). This causes reduced renal glomerular filtration and sodium excretion and a decreased response to loop diuretics.

Which type of jaundice is the result of increased destruction of red blood cells? a) Nonobstructive b) Hepatocellular c) Obstructive d) Hemolytic

Hemolytic Hemolytic jaundice is the result of an increased destruction of the red blood cells. Hepatocellular jaundice is caused by the inability of damaged liver cells to clear normal amounts of bilirubin from the blood. Obstructive jaundice resulting from extrahepatic obstruction may be caused by occlusion of the bile duct form a gall stone, inflammatory process, a tumor, or pressure from an enlarged organ. Nonobstructive jaundice occurs with hepatitis.

A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions? a) Asterixis b) Cirrhosis c) Hepatic encephalopathy d) Portal hypertension

Hepatic encephalopathy 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.

The nurse is administering medications to a patient that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent? a) Spironolactone (Aldactone) b) Cholestyramine (Questran) c) Kanamycin (Kantrex) d) Lactulose (Cephulac)

Lactulose (Cephulac) Lactulose (Cephulac) is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients. Potassium-sparing diuretics such as spironolactone (Aldactone) are used to treat ascites. Cholestyramine (Questran) is a bile acid sequestrant and reduces pruritus. Kanamycin (Kantrex) decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.

A 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? a) Magnetic resonance imaging b) Liver biopsy c) Coagulation studies d) Radioisotope liver scan

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

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? a) Blood pH of 7.25 b) Loss of 2.2 lb (1 kg) in 24 hours c) Serum sodium level of 135 mEq/L d) Serum potassium level of 3.5 mEq/L

Loss of 2.2 lb (1 kg) in 24 hours 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 nurse is gathering equipment and preparing to assist with a sterile bedside procedure to withdraw fluid from a patient's abdomen. The procedure tray contains the following equipment: trocar, syringe, needles, and drainage tube. The patient is placed in a high Fowler's position and a BP cuff is secured around the arm in preparation for which of the following procedures? a) Liver biopsy b) Dialysis c) Paracentesis d) Abdominal ultrasound

Paracentesis Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions. Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise.

Louisa Collins, a 52-year-old high school science teacher, is your client on the medical-surgical floor at the hospital where you practice nursing. She is undergoing diagnostics to determine what is causing her liver disorder. As you discuss her condition, Louisa asks questions pertaining to liver physiology and cellular function. Which liver cells perform most of the liver's metabolic functions? a) Parenchymal cells b) Canaliculi cells c) Kupffer cells d) Islets of Langerhans

Parenchymal cells The cellular constituents of the liver include the hepatic parenchymal cells (hepatocytes), which perform most of the liver's metabolic functions. The parenchymal cells perform most of the liver's metabolic functions.

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? a) Gynecomastia and testicular atrophy b) Ascites and orthopnea c) Purpura and petechiae d) Dyspnea and fatigue

Purpura and petechiae 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.

The most common cause of esophageal varices includes which of the following? a) Portal hypertension b) Jaundice c) Ascites d) Asterixis

Portal hypertension 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.

An elderly homeless client with a lengthy history of alcohol addiction is visiting the health clinic where you work. He has worsening jaundice. After diagnostic testing is complete, the physician returns a diagnosis of cirrhosis. The nurse begins client education about this condition. What would the nurse emphasize as the principal goal of cirrhosis therapy? a) Restoring fat-soluble vitamin absorption b) Curing the illness c) Preserving liver function d) Increasing alcohol toleration

Preserving liver function The principal aim of therapy is to prevent further deterioration by abolishing underlying causes and preserving what liver function remains. The principal aim of therapy is to prevent further deterioration.

Which of the following liver function studies is used to show the size of the liver and hepatic blood flow and obstruction? a) Radioisotope liver scan b) Magnetic resonance imaging (MRI) c) Electroencephalogram (EEG) d) Angiography

Radioisotope liver scan A radioisotope liver scan assesses liver size and hepatic blood flow and obstruction. An MRI is used to identify normal structures and abnormalities of the liver and biliary tree. Angiography is used to visualize hepatic circulation and detect the presence and nature of hepatic masses. An EEG is used to detect abnormalities that occur with hepatic coma.

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? a) Urinary output related to increased sodium retention b) Peripheral vascular assessment related to immobility c) Skin assessment related to increase in bile salts d) Respiratory assessment related to increased thoracic pressure

Respiratory assessment related to increased thoracic pressure 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.

Why should total parental nutrition (TPN) be used cautiously in clients with pancreatitis? a) Such clients can digest high-fat foods. b) Such clients are at risk for gallbladder contraction. c) Such clients cannot tolerate high-glucose concentration. d) Such clients are at risk for hepatic encephalopathy.

Such clients cannot tolerate high-glucose concentration. Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.

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? a) The client didn't take his morning dose of lactulose (Cephulac). b) The client's hepatic function is decreasing. c) The client is avoiding the nurse. d) The client is relaxed and not in pain.

The client's hepatic function is decreasing. The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic dysfunction. 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.

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? a) Fetor hepaticus b) Constructional apraxia c) Ataxia d) Asterixis

Asterixis Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy (Fig. 49-13).

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

Hepatic encephalopathy The earliest symptoms of hepatic encephalopathy include minor mental changes and motor disturbances. The client appears slightly confused and unkempt and has alterations in mood and sleep patterns. The client tends to sleep during the day and have restlessness and insomnia at night. As hepatic encephalopathy progresses, the client may become difficult to awaken and completely disoriented with respect to time and place. With further progression, the client lapses into frank coma and may have seizures. Simple tasks, such as handwriting, become difficult.

A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client? a) Spironolactone (Aldactone) b) Propranolol (Inderal) c) Lactulose (Cephulac) d) Vasopressin (Pitressin)

Vasopressin (Pitressin) 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.

Which of the following medications is used to decrease portal pressure, halting bleeding of esophageal varices? a) Vasopressin (Pitressin) b) Spironolactone (Aldactone) c) Cimetidine (Tagamet) d) Nitroglycerin

Vasopressin (Pitressin) Vasopressin may be the initial therapy for esophageal varices, because it constricts the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Aldactone and Tagamet do not decrease portal hypertension.

A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis? a) Platelet count b) A liver biopsy c) A CT scan d) A prothrombin time

A liver biopsy A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding.

A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. Which of the following is an important education topic regarding ingestion of medications? a) The need for more frequently divided doses b) The need for increased drug dosages c) Medications will no longer be effective in clients with liver disease. d) Metabolism of medications

Metabolism of medications Careful evaluation of the client's response to drug therapy is important because the malfunctioning liver cannot metabolize many substances.

Connie, a 60-year-old retired financial planner, is recently diagnosed with carcinoma of the pancreas. She has just met with her surgeon and feels overwhelmed by all the information she was given. She tells you that she is having the head of the pancreas removed; additionally, the surgeon is also removing the duodenum and stomach and redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the middle section of the small intestine. What procedure is Connie having performed? a) Distal pancreatectomy b) Total pancreatectomy c) Cholecystojejunostomy d) Radical pancreatoduodenectomy

Radical pancreatoduodenectomy This surgical procedure involves removing the head of the pancreas, resecting the duodenum and stomach, and redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the jejunum. This surgical procedure is a rerouting of the pancreatic and biliary drainage systems, which may be done to relieve obstructive jaundice. This measure is considered palliative only. A pancreatectomy is the surgical removal of the pancreas. A pancreatectomy may be total, in which case the entire organ is removed, usually along with the spleen, gallbladder, common bile duct, and portions of the small intestine and stomach. A distal pancreatectomy is a surgical procedure to remove the bottom half of the pancreas.

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? a) Cure the cirrhosis. b) Reduce fluid accumulation and venous pressure. c) Treat the esophageal varices. d) Promote optimal neurologic function.

Reduce fluid accumulation and venous pressure. Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.

A patient with bleeding esophageal varices has had pharmacologic therapy with Octreotide (Sandostatin) and endoscopic therapy with esophageal varices banding, but the patient has continued to have bleeding. What procedure that will lower portal pressure does the nurse prepare the patient for? a) Vasopressin (Pitressin) b) Transjugular intrahepatic portosystemic shunting (TIPS) c) Balloon tamponade d) Sclerotherapy

Transjugular intrahepatic portosystemic shunting (TIPS) A TIPS procedure (see Fig. 49-8) is indicated for the treatment of an acute episode of uncontrolled variceal bleeding refractory to pharmacologic or endoscopic therapy. In 10% to 20% of patients for whom urgent band ligation or sclerotherapy and medications are not successful in eradicating bleeding, a TIPS procedure can effectively control acute variceal hemorrhage by rapidly lowering portal pressure.

Which of the following indicates an overdose of lactulose? a) Hypoactive bowel sounds b) Constipation c) Fecal impaction d) Watery diarrhea

Watery diarrhea The patient receiving lactulose is monitored closely for the development of watery diarrheal stool, which indicates a medication overdose.

A patient with end-stage liver disease who is scheduled to undergo a liver transplant tells the nurse, "I am worried that my body will reject the liver." Which of the following statements is the nurse's best response to the patient? a) "You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs." b) "It is easier to get a good tissue match with liver transplants than with other types of transplants." c) "The problem of rejection is not as common in liver transplants as in other organ transplants." d) "You would not be scheduled for a transplant if there was a concern about rejection."

"You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs." Rejection is a primary concern. A transplanted liver is perceived by the immune system as a foreign antigen. This triggers an immune response, leading to the activation of T lymphocytes that attack and destroy the transplanted liver. Immunosuppressive agents are used as long-term therapy to prevent this response and rejection of the transplanted liver. These agents inhibit the activation of immunocompetent T lymphocytes to prevent the production of effector T cells. Although the 1- and 5-year survival rates have increased dramatically with the use of new immunosuppressive therapies, these advances are not without major side effects. The other statements are inaccurate or will not decrease the patient's anxiety.

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? a) Thiamine b) Riboflavin c) Vitamin K d) Vitamin A

Vitamin A 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.