EAQ Ch 58 Care of Patients with Liver Problems

A client who has liver disease with ascites asks about any necessary dietary changes. What instruction does the nurse include when teaching this client? 1 Avoid using table salt. 2 Consume a high-protein diet. 3 Eat foods high in calcium. 4 Take potassium supplements

Avoid using table salt Because of the fluid accumulation associated with ascites, this client should be on a sodium-restricted diet and should be taught to avoid table salt. High-protein or high-calcium diets are not recommended. Potassium supplements may be prescribed for clients taking certain diuretics, but are not routinely recommended.

The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN? 1 Client who is taking lactulose and has diarrhea 2 Client with hepatitis C who requires a dressing change 3 Client with end-stage cirrhosis who needs teaching about a low-sodium diet 4 Obtunded client with alcoholic encephalopathy who needs a blood draw

Client with end-stage cirrhosis who needs teaching about a low-sodium diet The RN is responsible for client teaching; therefore, the client with end-stage cirrhosis should be assigned to the RN. Assisting a client with toileting and recording stool number and amount can be accomplished by nonprofessional staff. The LPN/LVN can provide dressing changes. Ancillary staff can perform venipuncture.

In caring for a client who has undergone paracentesis, which changes in the client's status should be promptly reported to the provider? 1 Increased blood pressure, increased respiratory rate 2 Decreased blood pressure, increased heart rate 3 Increased respiratory rate, increased apical pulse, pallor 4 Tachypnea, diaphoresis, increased blood pressure

Decreased blood pressure, increased heart rate Decreased blood pressure and increased heart rate are indicative of shock. Increased blood pressure, increased respiratory rate, increased apical pulse, pallor, tachypnea, and diaphoresis are all indicative of anxiety on the client's part.

Which is an important institutional measure that a hospital may take to prevent the transmission of hepatitis B (HBV) to health care workers? 1 Develop a hospital-wide needleless system for delivery of medications. 2 Provide immunoglobulin injections within 14 days of exposure to the virus. 3 Provide information about HBV transmission to at-risk employees. 4 Reinforce Standard Precautions procedures among all hospital employees.

Develop a hospital-wide needleless system for delivery of medications. Needlesticks are the leading cause of HBV exposure among health care workers, so eliminating needles would make a huge impact on preventing transmission of the disease. Providing immunoglobulin injections, providing HBV information, and reinforcing Standard Precautions may all be done as well, but are not as important as the implementation of needleless systems.

The nurse is caring for a client with cirrhosis and profound ascites. Which assessment finding causes the nurse to notify the provider? 1 Anasarca 2 Marked jaundice 3 Multiple ecchymoses 4 Inaudible breath sounds

Inaudible breath sounds Orthopnea and dyspnea can result from ascites, which limit thoracic expansion and diaphragmatic excursion; this is manifested by decreased or absent breath sounds. Anasarca is an expected finding in cirrhosis as the liver is unable to produce plasma proteins which exert colloid osmotic pressure to pull fluid from interstitial tissues. Jaundice, another expected finding, results when the failing liver cannot excrete bilirubin. Ecchymosis is typical when the client with cirrhosis cannot produce prothrombin, which promotes blood clotting.

Which statement about hepatitis A is accurate? 1 It is transmitted by the fecal-oral route. 2 It is resistant to the action of chlorine (bleach). 3 It is more common in affluent countries. 4 It is more severe in children and young adults

It is transmitted by the fecal oral route Hepatitis A virus is spread via the fecal-oral route either by consumption of contaminated water and food, or by person-to-person contact in those who engage in oral-anal sexual activity. The virus is destroyed by chlorine (bleach). It is more common in nonaffluent countries where sanitation is inadequate or lacking. The course of the infection is more severe in those who are older than 40 years.

The nurse is administering spironolactone (Aldactone) to a client with portal hypertension and portal systemic encephalopathy. Which additional medication order does the nurse question? 1 Potassium chloride 2 Lactulose (Cephulac) 3 Neomycin (Mycifradin) 4 Propranolol (Inderal)

Potassium chloride Spironolactone is a potassium-sparing diuretic; additional potassium may result in potassium intoxication. Cephulac and neomycin are used to control hepatic encephalopathy, which is part of the expected treatment plan. Propranolol is used to prevent gastrointestinal hemorrhage secondary to portal hypertension and gastroesophageal varices, which is an expected treatment for portal hypertension.

The nurse is teaching a spouse and client with hepatitis C about preventing the spread of infection. Which instruction does the nurse include in the teaching plan? 1 "Drink only bottled water." 2 "Do not share toothbrushes." 3 "Donate blood only once yearly." 4 "You should use a separate bathroom."

Do not share toothbrushes Household members should not share any personal items with the client infected with hepatitis C such as a toothbrush, razor, drinking glasses, drug paraphernalia, or any item where blood or body fluids could be encountered by others. Bottled water is not necessary as the client is not at risk for contamination from tap water. The client with hepatitis C may become a carrier, so blood should not be donated. There is no need to use a separate bathroom if the client is continent of urine and stool and if the bathroom can be regularly disinfected.

A client with long-standing alcoholic liver disease has a decrease in serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) from previously assessed levels. What does the nurse tell the client about these results? 1 "These results indicate improvement." 2 "These decreases may indicate liver deterioration." 3 "These results indicate depletion of AST and ALT enzymes." 4 "These decreases usually occur when osteoporosis is present.

"These decreases may indicate liver deterioration." AST and ALT are elevated because these enzymes are released into the blood during liver inflammation. As the liver deteriorates, however, the hepatocytes become unable to initiate an inflammatory response and cannot release these enzymes, so the levels decline. In a client with acute liver disease, a decline in these levels may indicate improvement, but not in a client whose disease is long-standing and chronic. The levels drop because they are not produced, not because they are depleted. Osteoporosis causes an increase in alkaline phosphatase.

The nurse is counseling an asymptomatic client who is worried about possible hepatitis C exposure several years ago. What does the nurse tell this client about the risk of this disease? 1 "Unless you have signs of liver disease, you are no longer infected." 2 "You have probably cleared the virus since you have not had symptoms." 3 "You may be a carrier, but will never have serious symptoms of the disease." 4 "You may have serious long-term damage even without symptoms."

"You may have serious long-term damage even without symptoms." Clients exposed to hepatitis C may develop chronic infection even without symptoms until the damage occurs over decades of infection. A client is likely to be asymptomatic for months or years before the virus is detected. A carrier may or may not have serious symptoms of the disease. Individuals with HCV do not clear the virus like those with HBV.

Which instruction is essential for the nurse to include when teaching a client who is undergoing treatment for hepatitis with ribavirin? 1 Never miss a dose. 2 Avoid going out in the sun. 3 Take the medication on an empty stomach. 4 Take the medication at the same time each day

1 Clients being treated with Ribavirin for hepatitis C are instructed to never miss a dose of the drug. The nurse should assist the client in methods to use for reminders such as setting an alarm or alert. Exposure to sun is not contraindicated with ribavirin; this restriction pertains to sulfonamides or antipsychotic medications. This medication is often taken with food.

What type of cirrhosis is caused by hepatitis C? 1 Postnecrotic 2 Laennec's 3 Biliary 4 Cholestatic

1 The hepatitis C virus causes postnecrotic cirrhosis. Laennec's cirrhosis is caused by chronic alcoholism. Biliary cirrhosis is also called cholestatic cirrhosis; it is caused by chronic biliary obstruction or autoimmune disease.

When caring for a client with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? Select all that apply. 1 Prolonged partial thromboplastin time (PTT) 2 Icterus of skin 3 Swollen abdomen 4 Elevated magnesium 5 Currant jelly stool 6 Elevated amylase level

1, 2, 3 The liver produces clotting factors; when it is damaged, prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. Cirrhosis is consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase; amylase is typically elevated in pancreatitis.

The nurse is discussing with a nursing student the care of a client with cirrhosis. Which statement by the student indicates a correct understanding of how to observe for esophageal bleeding in the client? 1 "I should observe for epistaxis." 2 "Hematuria may indicate bleeding varices." 3 "Any melena should be reported immediately." 4 "Prothrombin time should be monitored daily."

3 Melena (tarry stools) may result from bleeding varices; this should be reported. Epistaxis (nosebleed) and hematuria (blood in the urine) may occur with cirrhosis and its resulting prothrombin time (PT) and International Normalized Ratio (INR), but they are not manifestations of esophageal bleeding. PT is prolonged in cirrhosis; however, it is not a specific manifestation of variceal bleeding.

Which diet instruction does the nurse give to a client with active hepatitis? 1 Consume soft, easy-to-chew foods. 2 Follow a low-protein, low-fat diet. 3 Eat a normal diet with fluid restrictions. 4 Eat small meals at frequent intervals

4 Small, frequent meals are often preferable to three standard meals for the client with hepatitis because these clients often experience nausea and vomiting and dietary intolerance. Soft, easy-to-chew foods are used with clients who have problems with dentition/chewing. The diet of the client with hepatitis should be high in carbohydrates and calories with moderate amounts of fat and protein after nausea and anorexia subside; clients with liver disease should limit fat in the diet due to intolerance. Fluid restriction is only recommended in clients with severe ascites and anasarca.

A client who has liver disease with ascites refuses the evening dinner tray and reports moderate abdominal pain. The nurse notifies the provider after assessing a low-grade temperature elevation and rigidity of the abdomen. The provider prepares to perform a paracentesis and orders an antibiotic to be given. When does the nurse expect to administer the antibiotic? 1 After a sample of fluid is sent to the lab for culture 2 After a short-term ascites drain has been placed 3 Before the paracentesis to prevent sepsis from the procedure 4 After the culture and sensitivity results are returned from the lab

After a sample of fluid is sent to the lab for culture This client has symptoms characteristic of spontaneous bacterial peritonitis. The nurse should give the ordered antibiotic after a sample of ascitic fluid has been sent for culture. Since the client is symptomatic, the antibiotic should be given before the culture results are known.

When assessing a client for hepatic cancer, the nurse anticipates finding an elevation in which laboratory test result? 1 Hemoglobin and hematocrit 2 Leukocytes 3 Alpha-fetoprotein 4 Serum albumin

Alpha-fetoprotein Fetal hemoglobin (alpha-fetoprotein) is abnormal in adults; it is a tumor marker indicative of cancers. Although anemia may be present, elevated hemoglobin and hematocrit are not diagnostic of hepatic cancer. White blood cells (leukocytes) are not used to specifically diagnose cancers. Serum albumin levels may be low in liver cancer and in malnutrition.

The nurse asks a client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? 1 Positive Babinski's sign 2 Hyperreflexia 3 Kehr's sign 4 Asterixis

Asterixis Liver flap or asterixis is related to increased serum ammonia levels—the dorsiflexed hands begin to flap upward and downward when outstretched for a few moments. Babinski's sign is positive when the sole of the foot is stroked, the great toe points up, and the toes fan out. Hyperreflexia refers to deep tendon reflexes that are overactive. Kehr's sign is reflected by increased abdominal pain, exaggerated by deep-breathing, and is referred to the right shoulder.

The nurse is assessing diagnostic test results for a client with hepatitis. Which elevated test result does the nurse correlate to the presence of jaundice? 1 Bilirubin 2 Blood urea nitrogen (BUN) 3 Aspartate aminotransferase (AST) 4 Alanine aminotransferase (ALT)

Bilirubin Elevation of the bilirubin level correlates to yellow stain of the skin and sclera secondary to biliary obstruction and inflammation. BUN is a measure of renal function. AST and ALT are enzymes released in response to liver inflammation, but do not correlate to jaundice.

It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? 1 Right shoulder pain 2 Polyuria 3 Bone marrow suppression 4 Bleeding

Bleeding When monitoring a client post-hepatic artery embolization, an arterial approach is taken; therefore, prompt detection of hemorrhage is the priority. Discomfort may be present, but the priority is to assess for hemorrhage. The nurse must assess for signs of shock, not polyuria. Embolization does not suppress the bone marrow; if chemotherapy or immune modulators are used, the nurse then assesses for bone marrow suppression.

A client with liver disease has portal hypertension. Which clinical finding prompts the nurse to notify the provider immediately? 1 Blood pressure of 145/95 mm Hg 2 Blood-tinged emesis 3 Liver distention 4 Urine output of 200 mL/hr

Blood-tinged emesis Clients with portal hypertension are at risk for hemorrhage and should be monitored closely; blood-tinged emesis may indicate bleeding esophageal varices and should be reported immediately. A moderate elevation in blood pressure and liver distention are common, nonemergent findings in clients with liver disease. A urine output of 200 mL/hr does not need to be reported because normal urine output is 1500-2000 mL per day.

The community health nurse is exploring the cause of an outbreak of hepatitis A. Which individual does the nurse suspect may be the source? 1 Individual who recently got a tattoo 2 Clients who were infected after eating at the same restaurant 3 Spouse of an intravenous drug abuser who developed hepatitis 4 Client who had a blood transfusion during cardiac surgery in 1985

Clients who were infected after eating at the same restaurant Hepatitis A is spread by the fecal-oral route either by person-to-person contact, or by consuming contaminated food or water; failure to clean the hands after using the toilet and then preparing food is an example of how hepatitis can be spread by this route. Tattoos, injection drug use, and blood transfusions can spread hepatitis B or C through blood or body fluids.

A client who was awaiting liver transplantation is excluded from the procedure after the presence of which condition is discovered? 1 Colon cancer with metastasis to the liver 2 Hypertension 3 Hepatic encephalopathy 4 Ascites and shortness of breath (SOB)

Colon cancer with metastasis to the liver Transplantation is performed for hepatitis and primary (not secondary) liver cancers. Hypertension is a controllable factor and would not preclude the client from a liver transplant. Encephalopathy is a consequence of advanced liver disease, consistent with the condition of a client awaiting transplantation; it can be treated with lactulose and nonabsorbable antibiotics. Ascites and resulting shortness of breath are also consequences of advanced liver disease, consistent with the client awaiting transplantation; they can be managed with diuretics and paracentesis.

When caring for a client with Laennec's cirrhosis and portal hypertension, which point is essential for the nurse to emphasize to the client and family? 1 Do not consume any alcohol. 2 Reduce the amount of sodium in the diet. 3 Avoid saturated fats in the diet. 4 Adhere to anticoagulant therapy.

Do not consume any alcohol Laennec's cirrhosis is otherwise known as alcoholic cirrhosis; it is caused by chronic alcohol use. Avoiding alcohol is essential to prevent further organ damage. Sodium restriction is recommended for ascites. Fat intolerance may occur with liver disease; however, reduction of alcohol is essential, especially with Laennec's cirrhosis. Anticoagulants are not used to manage cirrhosis as there is a risk of bleeding related to prolonged International Normalized Ratio and prothrombin time.

When teaching a client with viral hepatitis, which instructions does the nurse include in the plan of care? Select all that apply. 1 Do not consume any alcohol. 2 Consume a high-protein diet. 3 Do not drive a car for 1-2 weeks. 4 Monitor blood pressure and pulse daily. 5 Avoid medications containing acetaminophen. 6 Avoid carbonated beverages.

Do not consume any alcohol. Avoid medications containing acetaminophen. The client with hepatitis should avoid all alcohol as well as hepatotoxic medications such as acetaminophen unless instructed otherwise by the provider. The diet should be high in carbohydrates with moderate fat and moderate protein content. The client may drive if he or she feels well. As hepatitis does not directly affect the cardiovascular system, there is no need to monitor vital signs. While carbonated beverages may contribute to a sense of fullness, it is not required that they be absolutely excluded.

A client with refractory ascites has a tunneled ascites drain (PleurX catheter). The community health nurse teaches the client and family which most important aspect of care while this device is in place? 1 Remaining on bedrest 2 Keeping hands and the area clean 3 Observing for diminished urine output 4 Learning to take blood pressure each day

Keeping hands and the area clean Clients with an indwelling device are prone to infection. Clients with ascites may also develop spontaneous bacterial peritonitis. Therefore, hands should always be cleansed before touching the area or using the device. Bedrest is necessary after a procedure such as paracentesis, but is not necessary while the drainage device is in place. Diminished urine output and a lower blood pressure are typically present with hepatic failure and ascites because fluid is third-spaced. Blood pressure may also drop with bleeding varices; however, daily monitoring is not needed with the ascites drainage device.

A client is scheduled to undergo a liver transplantation. Which nursing intervention is most likely to prevent the complications of bile leakage and abscess formation? 1 Preventing hypotension 2 Keeping the T-tube in a dependent position 3 Administering antibiotic vaccinations 4 Administering immune-suppressant drugs

Keeping the T-tube in a dependent position Keeping the T-tube in a dependent position and secured to the client is likely to prevent bile leakage, abscess formation, and hepatic thrombosis. Preventing hypotension will help to prevent the complication of acute kidney injury. Administering antibiotic vaccination will help to prevent infection. Administering immune-suppressant drugs will help to prevent graft rejection.

When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? 1 Kidney failure 2 Refractory ascites 3 Fetor hepaticus 4 Paracentesis scheduled for today

Kidney failure The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and should not be taken by the client with hepatic encephalopathy. Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.

When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? 1 Vitamin K-containing products 2 Potassium-sparing diuretics 3 Nonabsorbable antibiotics 4 Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDS Clients who have cirrhosis should not take NSAIDs because they may predispose to bleeding. The client with cirrhosis is prone to bleeding; vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia levels.

Which individual has the greatest risk for developing hepatitis A? 1 Health care worker 2 Intravenous drug user 3 Client receiving hemodialysis 4 Person who consumes raw oysters

Person who consumes ray oysters Undercooked or raw shellfish from contaminated waters and food handled by those who have not washed their hands thoroughly are at risk for hepatitis A. Intravenous drug users, those undergoing hemodialysis, and health care workers are more at risk for hepatitis B or C, which is spread by blood or body fluids.

The RN is caring for a client with end-stage liver disease that has resulted in ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)? 1 Assessing skin integrity and abdominal distention 2 Drawing blood from a central venous line for electrolyte studies 3 Evaluating laboratory study results for the presence of hypokalemia 4 Placing the client in a semi-Fowler's position

Placing the client in a semi-Fowler's position Positioning the client in a semi-Fowler's position is included within UAP education and scope of practice, although the RN will need to supervise the UAP in providing care and will evaluate the effect of the semi-Fowler's position on client comfort and breathing. Assessment of skin integrity and abdominal distention, obtaining blood from a central line, and evaluation of laboratory results should be done by the RN.

A client with severe cirrhosis of the liver has a urine output of 400 mL for the past 2 days despite adequate intravenous fluid administration. What is the priority nursing action for this client? 1 Contact the provider to discuss obtaining a urine culture. 2 Encourage the client to increase oral fluid intake. 3 Perform a bladder scan to assess for urinary retention. 4 Request an order for blood urea nitrogen (BUN) and serum creatinine levels

Request an order for blood urea nitrogen (BUN) and serum creatinine levels Clients with cirrhosis may develop hepatorenal syndrome (HRS), which is characterized by oliguria less than 500 mL/day and elevated BUN and creatinine levels. The nurse should request these additional tests to help determine this. Decreased urine output is not a sign of urinary tract infection (UTI), so a culture is not indicated. The client has been receiving adequate fluids, so additional intake is not indicated. If BUN and creatinine levels are normal, assessing for retention may then be warranted.

How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Evalose)? 1 Provides small frequent meals for the client 2 Suggests taking daily potassium supplements 3 Elevates the head of the bed in high Fowler's position 4 Requests a bedside commode for the client

Requests a bedside commode for the client Lactulose therapy increases the frequency of stools, so a bedside commode should be made available to the client, especially if he or she has difficulty reaching the toilet. Small frequent meals and elevating the head of the bed will not have any effect on the side effects of lactulose. Although lactulose produces excessive stools and could potentially result in loss of potassium, it is inappropriate for the nurse to suggest that the client take potassium supplements.

Which precaution is most appropriate for the nurse to implement with a client with hepatitis A? 1 Enteric precautions 2 Droplet precautions 3 Protective isolation 4 Standard Precautions

Standard Precautions Standard Precautions are used with all clients to prevent the spread of blood and body fluids, including the client with hepatitis A. Standard Precautions prevent the spread of hepatitis A infection, which is spread by the fecal-oral route. Enteric precautions would be needed for clients with gastrointestinal infection if Standard Precautions were not used. Droplet precautions prevent the inhalation of respiratory droplets that spread infection, such as with meningitis. Protective isolation involves strict handwashing and limiting visitors and plants to protect the immunocompromised client.

A client with cirrhosis is preparing for discharge home. What instruction does the nurse include when teaching this client about dietary supplements? 1 Additional fat-soluble vitamins are usually necessary. 2 An iron supplement should be taken daily. 3 Niacin is an important vitamin when treating cirrhosis. 4 Use only supplements prescribed by the provider

Use only supplements prescribed by the provider The client with cirrhosis should only take vitamin supplements prescribed by the provider. Fat-soluble vitamins, iron, and niacin are toxic to the liver and should be avoided.