DM Ign ch67, Chapter 58 Care of the Patient with Liver Problems final

The nurse administers 6 U of regular insulin and 10 U NPH insulin at 7 AM. At what time is the client most susceptible to hypoglycemia related to the NPH insulin? a. 8 AM b. 4 PM c. 8 PM d. 11 PM

B NPH is an intermediate acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours.

In performing health screening in a local mall, the nurse determines that those with which risk factors are at risk for the development of type 2 diabetes? (Select all that apply.) a. Hypertension b. History of pancreatic trauma c. 30-pound weight gain during pregnancy d. Body mass index greater than 25 kg/m e. Triglyceride levels between 150 and 200 mg/dL f. Delivered baby weighing over 9 pounds

A, D, F Risk factors for type 2 diabetes include habitual inactivity, hypertension, delivery of a baby weighing over 9 pounds, history of vascular disease, body mass index greater than 25 kg/m, and triglyceride levels over 250 mg/dL.

The nurse assesses for which clinical manifestation in a client with uncontrolled diabetes mellitus and ketoacidosis?a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension

A. Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation.

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

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

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

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

11. After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the clients understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for additional teaching? a. I should drink bottled water during my travels. b. I will not eat off anothers plate or share utensils. c. I should eat plenty of fresh fruits and vegetables. d. I will wash my hands frequently and thoroughly.

ANS: C The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by tap water. Drinking bottled water, and not sharing plates, glasses, or eating utensils are good ways to prevent illness, as is careful handwashing.

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

ANS: C The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause. Blunt liver trauma, diabetes mellitus, and chronic malnutrition do not increase a persons risk for developing liver cancer.

A client with a 20-year history of diabetes mellitus and severe burning pain in the feet and hands as a result of peripheral neuropathy asks the nurse why an antidepressant has been prescribed. Which is the nurse's best response? a. "Many people experiencing chronic pain become depressed." b. "The antidepressants may counteract the chemicals causing your pain." c. "You are less likely to become addicted from using antidepressants than you are from using other types of pain killers." d. "The antidepressants also have strong anti-inflammatory properties and can reduce the pain you have from inflammation."

B Much of the pain and discomfort associated with peripheral neuropathy is caused by changes in neurotransmitter release at nerve synapses, especially serotonin. Small doses of antidepressants can inhibit serotonin uptake and provide some degree of analgesia.

The nurse monitors for which clinical manifestations in the diabetic client admitted with DKA (diabetic ketoacidosis)? a. Shallow slow respirations and respiratory alkalosis b. Decreased urine output and hyperkalemia c. Tachycardia and orthostatic hypotension d. Peripheral edema and dependent pulmonary crackles

C DKA is the extreme consequence of severe insulin deficiency. Lack of insulin results in the release of free fatty acids, which leads to ketoacidosis. The lungs attempt to compensate for this acidosis by increasing the depth and rate of respirations. Increased urinary output (polyuria) is severe and may lead to tachycardia and orthostatic hypotension related to fluid volume deficit.

The nurse teaches which intervention to prevent injury in the diabetic client who has numbness and reduced sensation secondary to severe peripheral neuropathy? a. "Examine your feet daily." b. "Rotate your insulin injection sites." c. "Wear white socks instead of colored socks." d. "Use a bath thermometer to test the water temperature."

D Clients with diminished sensory perception can easily experience a burn injury when bath water is too hot. Examining the feet daily does not prevent injury.

A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the client's polyuria? a. Serum sodium: 163 mEq/L b. Serum creatinine: 1.6 mg/dL c. Presence of urine ketone bodies d. Serum osmolarity: 375 mOsm/kg

D Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The client's serum osmolarity is high. The client's sodium would be expected to be high owing to dehydration. Serum creatinine and urine ketone bodies are not related to the polyuria Serum Osmolarity 275-295 mosm/kg

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

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

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

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

16. A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone! Which action should the nurse take? a. Instruct the client to sit in as upright a position as possible. b. Add humidity to the oxygen and encourage the client to wear it. c. Document the clients refusal, and call the health care provider. d. Contact the provider to request an extra dose of the clients diuretic.

ANS: A The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and seeing whether the client will tolerate that. The other two options may be beneficial, but they are not the best choices. If the client is comfortable, his or her agitation will decrease; this will improve respiratory status.

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

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

10. A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this clients discharge education? a. Use a pill organizer to ensure you take this medication as prescribed. b. Transient muscle aching is a common side effect of this medication. c. Follow up with your provider in 1 week to test your blood for toxicity. d. Take your radial pulse for 1 minute prior to taking this medication.

ANS: A Treatment of hepatitis C with ribavirin takes up to 48 weeks, making compliance a serious issue. The nurse should work with the client on a strategy to remain compliant for this length of time. Muscle aching is not a common side effect. The client will be on this medication for many weeks and does not need a blood toxicity examination. There is no need for the client to assess his or her radial pulse prior to taking the medication.

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

ANS: A, B, E When assessing a client with suspected cirrhosis, the nurse should ask about alcohol consumption, including amount and frequency; sexual history and orientation (specifically men having sex with men); illicit drug use; history of tattoos; and history of military service, incarceration, or work as a firefighter, police officer, or health care provider. A family history of cancer and work as a plumber do not put the client at risk for cirrhosis.

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

ANS: A, C, D Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush should be used to prevent gum bleeding, and the clients nails should be trimmed short to prevent the client from scratching himself or herself. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap.

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

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

1. A nurse obtains a clients health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this client? a. I drink two glasses of red wine each week. b. I take a lot of Tylenol for my arthritis pain. c. I have a cousin who died of liver cancer. d. I got a hepatitis vaccine before traveling.

ANS: B Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explore other drug options with the client to manage his or her arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis vaccine do not place the client at risk for a liver disorder, and therefore do not require any health teaching.

The nurse teaches the newly diagnosed client with type 1 diabetes that insulin needs can be decreased through which action? a. Reducing intake of water and other liquids to no more than 2 L/day b. Eating animal organ meats high in insulin c. Taking two 1-hour naps daily d. Walking 1 mile each day

D. Moderate exercise, such as walking, helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for clients with type 1 diabetes.

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

ANS: B Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.

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

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

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

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

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

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

8. After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. Some medications have been known to cause hepatitis A. b. I may have been exposed when we ate shrimp last weekend. c. I was infected with hepatitis A through a recent blood transfusion. d. My infection with Epstein-Barr virus can co-infect me with hepatitis A.

ANS: B The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications, blood transfusions, or Epstein-Barr virus. Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins, but this is not a form of hepatitis A. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A.

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

ANS: B, E, F Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the clients confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.

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

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

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

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

5. A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? a. Nausea and vomiting b. Frontal headache c. Vertigo and syncope d. Mid-sternal chest pain

ANS: D Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea and vomiting, headache, and vertigo and syncope are not side effects of vasopressin.

Which priority intervention does the nurse take for the client having Kussmaul respirations as a result of diabetic ketoacidosis? a. Administration of oxygen by mask or nasal cannula b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin

D. The rapid, deep respiratory efforts of Kussmaul respiration is the body's attempt to reduce the acids produced by using fat rather than glucose for fuel. The client who is in ketoacidosis and who does not also have a respiratory impairment does not need additional oxygen. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat.

The nurse determines that which arterial blood gas values are consistent with ketoacidosis in the client with diabetes? a. pH 7.38, HCO3- 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28, HCO3- 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO3- 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.28, HCO3- 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

B. When the lungs can no longer offset the acidosis, the pH decreases below normal. The arterial blood gases show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels. pH PCO2 HCO3 Range: 7.35-7.45 35-45 mmHg 22-26 mEq/L

Three hours after surgery, the nurse notes that the breath of the client with type 1 diabetes has a "fruity" odor. Which is the nurse's best first action? a. Documenting the finding as the only action b. Increasing the IV fluid flow rate c. Testing the serum for ketone bodies d. Performing oral care

C. The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis.

Which finding in the client with diabetes indicates that exercise should be avoided at this time? a. Ketone bodies in the urine b. Blood sugar level of 155 mg/dL c. Pulse rate of 66 beats/min d. Weight 1 pound higher than the week before

The presence of ketone bodies in the urine is a contraindication to exercise because it indicates that the amount of insulin available is inadequate to promote intracellular glucose transport and uptake. Exercise would lead to further elevations in blood glucose levels.