Chapter 49: Assessment and Management of Patients With Hepatic Disorders

Which condition indicates an overdose of lactulose? A. Watery diarrhea B. Constipation C. Hypoactive bowel sounds D. Fecal impaction

A

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. Excessive diuresis and dehydration. C. Severe infections and high fevers. D. Excess potassium loss subsequent to prolonged use of diuretics.

A 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 client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: A. severe abdominal pain radiating to the shoulder. B. anorexia, nausea, and vomiting. C. eructation and constipation. D. abdominal ascites.

B Early hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Abdominal pain may occur but doesn't radiate to the shoulder. Eructation and constipation are common in gallbladder disease, not hepatitis A. Abdominal ascites is a sign of advanced hepatic disease, not an early sign of hepatitis A.

An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is: A. Acetaminophen B. Ibuprofen C. Dextromethorphan D. Benadryl

A Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Other medications commonly associated with liver injury include anesthetic agents, medications used to treat rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsants, and antituberculosis agents.

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. cirrhosis. B. peptic ulcer disease. C. appendicitis. D. cholelithiasis.

A 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.

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

A 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.

Which of the following symptoms would indicate that a client with chronic pancreatitis has developed secondary diabetes? A. Increased appetite and thirst B. Vomiting and diarrhea C. Low blood pressure and pulse D. Decreased urination and constipation

A When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. Vomiting, diarrhea, low blood pressure and pulse, and constipation do not indicate the development of secondary diabetes.

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. Hepatic encephalopathy B. Esophageal varices C. Hepatitis C D. Portal hypertension

A 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.

When caring for a client with cirrhosis, which symptom(s) should the nurse report immediately? A. Fatigue and weight loss B. Change in mental status C. Anorexia and dyspepsia D. Diarrhea or constipation

B When caring for a client with cirrhosis, the nurse should report any change in mental status immediately because they indicate secondary complications. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis.

Which type of jaundice seen in adults is the result of increased destruction of red blood cells? A. Hemolytic B. Hepatocellular C. Obstructive D. Nonobstructive

A Hemolytic jaundice results because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. Obstructive and hepatocellular jaundice are results of liver disease. Nonobstructive jaundice occurs with hepatitis.

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's hepatic function is decreasing. B. The client didn't take his morning dose of lactulose (Cephulac). C. The client is relaxed and not in pain. D. The client is avoiding the nurse.

A 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.

Which is an age-related change of the hepatobiliary system? A. Increased drug clearance capability B. Decreased blood flow C. Enlarged liver D. Decreased prevalence of gallstones

B Age-related changes of the hepatobiliary system include decreased blood flow, decreased drug clearance capability, increased presence of gall stones, and a steady decrease in the size and weight of the liver.

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. Serum potassium level of 3.5 mEq/L B. Loss of 2.2 lb (1 kg) in 24 hours C. Serum sodium level of 135 mEq/L D. Blood pH of 7.25

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

The 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. Furosemide (Lasix) B. Spironolactone (Aldactone) C. Acetazolamide (Diamox) D. Bumetanide (Bumex)

B 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.

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. Constructional apraxia B. Fetor hepaticus C. Ataxia D. Asterixis

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

In what location would the nurse palpate for the liver? A. Left lower quadrant B. Left upper quadrant C. Right lower quadrant D. Right upper quadrant

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

Which of the following would the nurse expect to assess in a client with hepatic encephalopathy? A. Increased motor activity B. Asterixis C. Negative Babinski reflex D. Irritability

B 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 33-year-old male patient with a history of IV heroin and cocaine use has been admitted to the medical unit for the treatment of endocarditis. The nurse should recognize that this patient is also likely to test positive for which of the following hepatitis viruses? A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D

C Transmission of hepatitis C occurs primarily through injection of drugs and through transfusion of blood products prior to 1992. Hepatitis A, B, and D are less likely to result from IV drug use.

Which of the following the are early manifestations of liver cancer? Select all that apply. A. Pain B. Continuous aching in the back C. Increased appetite D. Fever E. Jaundice F. Vomiting

A, B 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 client with cirrhosis is at risk for developing esophageal varices. Which of the following instructions should a nurse provide the client to minimize such risk? A. Abstain from drinking alcohol. B. Use aspirin at least once a day. C. Avoid intake of sodium-rich food. D. Increase intake of potassium-rich food.

A A soft diet and elimination of alcohol, aspirin, and other locally irritating substances minimize the risk for developing esophageal varices. Intake of sodium- or potassium-rich food has no effect on the formation of varices.

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. A liver biopsy B. A CT scan C. A prothrombin time D. Platelet count

A 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.

What is the recommended dietary treatment for a client with chronic cholecystitis? A. low-fat diet B. high-fiber diet C. low-residue diet D. low-protein diet

A The bile secreted from the gallbladder helps the body absorb and break down dietary fats. If the gallbladder is not functioning properly, then it will not secrete enough bile to help digest the dietary fat. This can lead to further complications; therefore, a diet low in fat can be used to prevent complications.

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients: A. cannot tolerate high-glucose concentration. B. are at risk for gallbladder contraction. C. are at risk for hepatic encephalopathy. D. can digest high-fat foods.

A 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.

While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the possibility of liver problems? Select all that apply. A. Jaundice B. Petechiae C. Ecchymoses D. Cyanosis of the lips E. Aphthous stomatitis

A, B, C The skin, mucosa, and sclerae are inspected for jaundice. The nurse observes the skin for petechiae or ecchymotic areas (bruises), spider angiomas, and palmar erythema. Cyanosis of the lips is indicative of a problem with respiratory or cardiovascular dysfunction. Aphthous stomatitis is a term for mouth ulcers and is a gastrointestinal abnormal finding.

The nurse is assisting the physician with a procedure to remove ascitic fluid from a client with cirrhosis. What procedure does the nurse ensure the client understands will be performed? A. Thoracentesis B. Abdominal paracentesis C. Abdominal CT scan D. Upper endoscopy

B Abdominal paracentesis may be performed to remove ascitic fluid. Abdominal fluid is rapidly removed by careful introduction of a needle through the abdominal wall, allowing the fluid to drain. Fluid is removed from the lung via a thoracentesis. Fluid cannot be removed with an abdominal CT scan, but it can assist with placement of the needle. Fluid cannot be removed via an upper endoscopy.

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal? A. Controlling bleeding B. Maintaining the airway C. Maintaining fluid volume D. Relieving the client's anxiety

B 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 can be 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.

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. Dyspnea and fatigue B. Ascites and orthopnea C. Purpura and petechiae D. Gynecomastia and testicular atrophy

C 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 with hepatitis who has not responded to medical treatment is scheduled for a liver transplant. Which of the following most likely would be ordered? A. Chenodiol B. Ursodiol C. Tacrolimus D. Interferon alfa-2b, recombinant

C In preparation for a liver transplant, a client receives immunosuppressants to reduce the risk for organ rejection. Tacrolimus or cyclosporine are two immunosuppresants that may be used. Chenodiol and ursodiol are agents used to dissolve gall stones. Recombinant interferon alfa-2b is used to treat chronic hepatitis B, C, and D to force the virus into remission.

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. Treat the esophageal varices. C. Reduce fluid accumulation and venous pressure. D. Promote optimal neurologic function.

C 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.

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia? A. Polyuria B. Bradycardia C. Hypotension D. Warm moist skin

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

What intervention does the nurse anticipate providing for the patient with ascites that will help correct the decrease in effective arterial blood volume that leads to sodium retention? A. Diuretic therapy B. Therapeutic paracentesis C. Platelet infusions D. Albumin infusion

D Albumin infusions help to correct decreases in effective arterial blood volume that lead to sodium retention. The use of this colloid reduces the incidence of postparacentesis circulatory dysfunction with renal dysfunction, hyponatremia, and rapid reaccumulation of ascites associated with decreased effective arterial volume.

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. instillation B. gavage C. lavage D. decompression

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

The mode of transmission of hepatitis A virus (HAV) includes which of the following? A. Fecal-oral B. Blood C. Semen D. Saliva

A 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 educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. What is an important education topic regarding ingestion of medications? A. need for increased drug dosages B. need for more frequently divided doses C. medications becoming ineffective in clients with liver disease D. metabolism of medications

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

Which symptoms will a nurse observe most commonly in clients with pancreatitis? A. severe, radiating abdominal pain B. black, tarry stools and dark urine C. increased and painful urination D. increased appetite and weight gain

A The most common symptom in clients with pancreatitis is severe midabdominal to upper abdominal pain, radiating to both sides and straight to the back.

When caring for a client with cirrhosis, which symptoms should a nurse report immediately? Select all that apply. A. change in mental status B. signs of GI bleeding C. anorexia and dyspepsia D. diarrhea or constipation

A, B The nurse reports any change in mental status or signs of GI bleeding immediately because they indicate secondary complications.

A nurse is taking health history data from a client. Use of which of the following medications would especially alert the nurse to an increased risk of hepatic dysfunction and disease in this client? Select all that apply. A. Acetaminophen B. Ketoconazole C. Valproic acid D. Diazepam E. Insulin

A, B, C Many medications (including acetaminophen, ketoconazole, and valproic acid) are responsible for hepatic dysfunction and disease. A thorough medication history should address all current and past prescription medications, over-the-counter medications, herbal remedies, and dietary supplements.

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? A. "You must have the second one in 2 weeks and the third in 1 month." B. "You must have the second one in 1 month and the third in 6 months." C. "You must have the second one in 6 months and the third in 1 year." D. "You must have the second one in 1 year and the third the following year."

B 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 client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: A. elevated liver enzymes and low serum protein level. B. subnormal serum glucose and elevated serum ammonia levels. C. subnormal clotting factors and platelet count. D. elevated blood urea nitrogen and creatinine levels and hyperglycemia.

B In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.

A nurse is responsible for monitoring the diet of a client with hepatic encephalopathy. Which daily protein intake should this 185-pound (84-kilogram) male consume? A. 16 to 49 grams B. 50 to 75 grams C. 76 to 99 grams D. 100 to 126 grams

D Daily protein intake should be maintained at 1.2 to 1.5 g/kg per day. To calculate protein intake, multiply the 84 kg by the low and high ranges: (84 kg × 1.2 = 100 g; 84 kg × 1.5 = 126 g). This client would require a daily protein range from 100 to 126 grams.

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct? A. Colonoscopy B. Abdominal x-ray C. Cholecystectomy D. Endoscopic retrograde cholangiopancreatography (ERCP)

D 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.

A client who has just been diagnosed with hepatitis A asks, "How did I get this disease?" What is the nurse's best response? A. "You could have gotten it by using I.V. drugs." B. "You must have received an infected blood transfusion." C. "You probably got it by engaging in unprotected sex." D. "You may have eaten contaminated restaurant food."

D Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn't transmitted by the I.V. route, blood transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex.

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. Potassium B. Vitamin K C. Vitamin B D. Oral bile acids

B 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.

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately? A. Weight loss of 2 pounds in 3 days B. Change in the client's handwriting and/or cognitive performance C. Anorexia for more than 3 days D. Constipation for more than 2 days

B The earliest symptoms of hepatic encephalopathy include mental status changes and motor disturbances. The client will appear confused and unkempt and have altered mood and sleep patterns. Neurologic status should be assessed frequently. Mental status is monitored by the nurse keeping the client's daily record of handwriting and arithmetic performance. The nurse should report any change in mental status immediately. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis.

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices? A. Spironolactone B. Vasopressin C. Nitroglycerin D. Cimetidine

B 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. Spironolactone and cimetidine do not decrease portal hypertension.

Which is the most common cause of esophageal varices? A. Jaundice B. Portal hypertension C. Ascites D. Asterixis

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

Which of the following medications would the nurse expect the physician to order for a client with cirrhosis who develops portal hypertension? A. Spironolactone (Aldactone) B. Kanamycin (Kantrex) C. Lactulose (Cephulac) D. Cyclosporine (Sandimmune)

A For portal hypertension, a diuretic usually an aldosterone antagonist such as spironolactone (Aldactone) is ordered. Kanamycin (Kantrex) would be used to treat hepatic encephalopathy to destroy intestinal microorganisms and decrease ammonia production. Lactulose would be used to reduce serum ammonia concentration in a client with hepatic encephalopathy. Cyclosporine (Sandimmune) would be used to prevent graft rejection after a transplant.

The nurse identifies which type of jaundice in an adult experiencing a transfusion reaction? A. Hemolytic B. Hepatocellular C. Obstructive D. Nonobstructive

A 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 clients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive and hepatocellular jaundice are the result of liver disease. Nonobstructive jaundice occurs with hepatitis.

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition? A. Hepatic encephalopathy B. Portal hypertension C. Asterixis D. Cirrhosis

A Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with an elevated ammonia concentration that produces 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 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. Respiratory assessment related to increased thoracic pressure B. Urinary output related to increased sodium retention C. Peripheral vascular assessment related to immobility D. Skin assessment related to increase in bile salts

A 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.

A client is actively bleeding from esophageal varices. Which medication would the nurse mostexpect to be administered to this client? A. Octreotide B. Spironolactone C. Propranolol D. Lactulose

A In an actively bleeding client, medications are administered initially because they can be obtained and administered quicker than other therapies. Octreotide (Sandostatin) causes selective splanchnic vasoconstriction by inhibiting glucagon release and is used mainly in the management of active hemorrhage. 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.

A client with a lengthy history of alcohol addiction is being seen for jaundice. The appearance of jaundice would most likely indicate: A. liver disorder. B. gallbladder disease. C. bile overproduction. D. glucose underproduction.

A 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 patient is scheduled for a diagnostic paracentesis, but when coagulation studies were reviewed, the nurse observed they were abnormal. How does the nurse anticipate the physician will proceed with the paracentesis? A. The physician will use an ultrasound guided paracentesis B. The physician will not perform the procedure C. The physician will proceed with the paracentesis at the bedside D. The physician will have the nurse administer packed RBCs prior to the paracentesis.

A 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 (Gordon, 2012). Ultrasound guidance may be indicated in some patients who are at high risk for bleeding because of an abnormal coagulation profile and in those who have had previous abdominal surgery and may have adhesions.

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. Vitamin A B. Thiamine C. Riboflavin D. Vitamin K

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.

A client who was recently diagnosed with carcinoma of the pancreas and is having a procedure in which the head of the pancreas is removed. In addition, the surgeon will remove the duodenum and stomach, redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the middle section of the small intestine. What procedure is this client having performed? A. radical pancreatoduodenectomy B. cholecystojejunostomy C. total pancreatectomy D. distal pancreatectomy

A Radical pancreatoduodenectomy 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. Cholecystojejunostomy 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.

Clients with chronic liver dysfunction have problems with insufficient vitamin intake. Which may occur as a result of vitamin C deficiency? A. Night blindness B. Hypoprothrombinemia C. Scurvy D. Beriberi

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

After undergoing a liver biopsy, a client should be placed in which position? A. Semi-Fowler's position B. Right lateral decubitus position C. Supine position D. Prone position

B 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.

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. Report the condition to the physician immediately. B. Measure abdominal girth according to a set routine. C. Provide the client with nonprescription laxatives. D. Ask the client about food intake.

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

A nurse is gathering equipment and preparing to assist with a sterile bedside procedure to withdraw fluid from a client's abdomen. The procedure tray contains the following equipment: trocar, syringe, needles, and drainage tube. The client is placed in he high Fowler position and a blood pressure cuff is secured around the arm in preparation for which procedure? A. Liver biopsy B. Paracentesis C. Abdominal ultrasound D. Dialysis

B 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 accumulated fluid is causing cardiorespiratory compromise. A liver biopsy is removal of tissue from the liver using a scope or surgical instrument. An abdominal ultrasound is a non -invasive procedure using sound waves to produce images. Dialysis is the process of filtering blood as a substitute for normal kidney function.

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

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

The nurse is administering medications to a client 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 B. Cholestyramine C. Lactulose D. Kanamycin

C Lactulose 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 are used to treat ascites. Cholestyramine is a bile acid sequestrant and reduces pruritus. Kanamycin decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.

A client with hepatic cirrhosis questions the nurse about the possible use of an herbal supplement—milk thistle—to help heal the liver. Which is the most appropriate response by the nurse? A. "You should not use herbal supplements in conjunction with medical treatment." B. "Herbal supplements are approved by the FDA, so there should be no problem with their usage if you check with your primary care provider." C. "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." D. "You can use milk thistle instead of the medications you have been prescribed."

C Many clients 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 in 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 of liver disease by improving liver function, possibly by 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 client has a blockage of the passage of bile from a stone in the common bile duct. What type of jaundice does the nurse suspect this client has? A. Hemolytic jaundice B. Hepatocellular jaundice C. Obstructive jaundice D. Cirrhosis of the liver

C Obstructive jaundice is caused by a block in the passage of bile between the liver and intestinal tract. Hemolytic jaundice is caused by excess destruction of red blood cells. Hepatocellular jaundice is caused by liver disease. Cirrhosis of the liver would be an example of hepatocellular jaundice.

The nurse is preparing to interview a client with cirrhosis. Based on an understanding of this disorder, which question would be most important to include? A. "Have you had an infection recently?" B. "Does your work expose you to chemicals?" C. "How often do you drink alcohol?" D. "What type of over-the-counter pain reliever do you use?"

C The most common type of cirrhosis results from chronic alcohol intake and is frequently associated with poor nutrition. Although it can follow chronic poisoning with chemicals or ingestion of hepatotoxic drugs such as acetaminophen, asking about alcohol intake would be most important. Asking about an infection or exposure to hepatotoxins or industrial chemicals would be important if the client had postnecrotic cirrhosis.

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal? A. Creatinine B. Urobilinogen C. Chloride D. Albumin

D Albumin is an abnormal finding in a routine urine specimen. Ascites present in liver failure contain albumin; therefore, if the bladder ruptured, ascites containing albumin would drain from the indwelling urinary catheter because the catheter is no longer contained in the bladder. Creatinine, urobilinogen, and chloride are normally found in urine.

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. Black and tarry C. Blood tinged D. Clay-colored or whitish

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

A 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. Riboflavin deficiency B. Folic acid deficiency C. Vitamin A deficiency D. Vitamin K deficiency

D 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.