EAQ Liver Diseases
The nurse is assessing a client with severe cirrhosis and discovers fetor hepaticus. What did the nurse assess? 1 Urine 2 Stool 3 Hands 4 Breath
Ans: 4 The client's breath has a sweet odor (fetor hepaticus) because the liver is not metabolizing the food, especially proteins. The urine is dark. The stool is clay-colored. The hands develop asterixis or flapping tremors.
A nurse is caring for a client who is admitted to the hospital with ascites and a diagnosis of cirrhosis of the liver. What does the nurse conclude is the probable cause of ascites? 1 Impaired portal venous return 2 Inadequate secretion of bile salts 3 Excess production of serum albumin 4 Decreased interstitial osmotic pressure
Ans: 1 An enlarged liver impairs venous return, leading to an increased portal vein hydrostatic pressure and a fluid shift into the abdominal cavity. Bile plays an important role in digestion of fats, but it is not a major factor in fluid balance. Increased serum albumin causes hypervolemia, not ascites. Ascites is not associated with the interstitial fluid compartment.
A client is diagnosed as having the hepatitis B virus (HBV). The nurse reviews the client's health history for possible situations in which exposure may have occurred. Which event does the nurse determine is most likely the source of this infection? 1 Had a small tattoo on the arm three months ago 2 Assisted in the emergency birth of a baby two weeks ago 3 Worked for a month in an undeveloped area in Mexico four months ago 4 Attended an ecologic conference in a large urban center two months ago
Ans: 1 Any situation in which a needle is inserted under the skin is a potential source of hepatitis; according to the Centers for Disease Control and Prevention, the range for the incubation period is 45 to 180 days; however, the average incubation period is 60 to 90 days. The range for the incubation period is 45 to 180 days. Hepatitis B is not transmitted via inadequate sanitation or a contaminated water supply. Hepatitis B is not transmitted by casual proximity to others.
A nurse is assessing a client with severe liver disease. Which assessment finding will the nurse expect to observe? 1 Icterus 2 Urticaria 3 Uremic frost 4 Hemangioma
Ans: 1 Bile deposits will impart a yellowish tinge (jaundice or icterus) to the skin, often first observed in the sclerae. Urticaria (or hives) generally is characteristic of an allergic response. Uremic frost is characteristic of kidney failure. Hemangioma is a benign lesion composed of blood vessels.
A client has cholelithiasis with possible obstruction of the common bile duct. What should be determined about the client's nutritional status before surgery is scheduled? 1 Is the client deficient in vitamins A, D, and K? 2 Does the client eat adequate amounts of dietary fiber? 3 Does the client consume excessive amounts of protein? 4 Are the client's levels of potassium and folic acid increased?
Ans: 1 Bile promotes the absorption of fat-soluble vitamins; an obstruction of the common bile duct limits the flow of bile to the duodenum, limiting absorption of fat-soluble vitamins A, D, and K. Vitamin K helps with clotting; surgery can be postponed if bleeding problems exist. Knowing if the client eats adequate amounts of dietary fiber is not relevant to the situation. Knowing if the client consumes excessive amounts of protein is unnecessary; however, protein is desirable for wound healing. Increases in potassium and folic acid are not expected with this disease.
A client is admitted to the hospital with a diagnosis of liver disease, and a liver biopsy is prescribed. After the liver biopsy, how often and for how long should the nurse take the client's vital signs? 1 Every 15 minutes for two hours 2 Every 30 minutes for four hours 3 Every hour for 8 hours 4 Every 2 hours for 12 hours
Ans: 1 Every 15 minutes for two hours is an appropriate frequency to take the vital signs after a liver biopsy. The risk of internal bleeding is highest immediately after the biopsy; diseases of the liver result in impaired blood-clotting mechanisms. Every 30 minutes after a liver biopsy is too infrequent; two hours after the procedure the vital signs can be taken every 30 minutes instead of every 15 minutes if they are stable. Every hour for 8 hours is too infrequent and unsafe if hemorrhage is to be detected before shock occurs. Every 2 hours for 12 hours is too infrequent and unsafe if hemorrhage is to be detected before shock occurs.
A nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The nurse concludes that the client understands preventive measures to reduce the risk of spreading the disease when the client makes what statement? 1 "I should wash my hands frequently." 2 "I should launder my clothes separately." 3 "I should put used tissues in the garbage." 4 "I should wear a mask when leaving the house."
Ans: 1 Hepatitis A microorganisms are transmitted via the anal-oral route; handwashing, particularly after toileting, is the most important precaution. The response "Launder my clothes separately" will not deter the spread of the virus; handwashing is necessary. Putting used tissue in the garbage is important, but handwashing is the most important precaution. Hepatitis A microorganisms exit through the rectum, not the respiratory tract.
A client who is about to have a blood transfusion asks the nurse, "Which type of hepatitis is most frequently transmitted thru food?" The nurse should respond, "The type of hepatitis associated with food is hepatitis: 1 A." 2 B." 3 C." 4 D."
Ans: 1 Hepatitis A, also known as infectious hepatitis, is caused by an RNA virus that is transmitted via the fecal-oral route. Hepatitis B is transmitted parenterally, sexually, and by direct contact with infected body secretions. Hepatitis C is caused by an RNA virus that is transmitted parenterally. Hepatitis D is a complication of hepatitis B.
A client is admitted to the ambulatory surgery unit for a liver biopsy. The nurse recalls that which assessment finding will be a cause for the biopsy to be postponed? 1 Signs of bruising 2 Visible hyperactivity 3 Lethargy on the morning of the test 4 Foods high in phytonadione consumed on the day before the test
Ans: 1 If the client has numerous bruises and petechiae, they may indicate deficient thrombocytes or prolonged clotting; both are contraindications for a percutaneous liver biopsy. With both visible hyperactivity and lethargy, the client may need support and the healthcare provider may need assistance, but the test can be done. The client's activity level is unrelated to contraindications for performing a liver biopsy. The amount of foods high in phytonadione consumed the day before the test is unrelated to contraindications for performing a liver biopsy. Although vitamin K is needed for the production of prothrombin, the ingestion of foods high in phytonadione does not guarantee adequate clotting activity.
A nurse is caring for a client who just had a liver biopsy. After the procedure, the nurse should monitor for which common complication associated with the biopsy? 1 Hemorrhage 2 Gastroparesis 3 Pulmonary embolism 4 Tension pneumothorax
Ans: 1 In the impaired liver, blood-clotting mechanisms are disrupted, and hemorrhage may occur from the trauma of this invasive procedure. A liver biopsy will not cause the stomach to empty more slowly. Because clotting mechanisms are prolonged, emboli usually are not a complication. A collapsed lung can occur if the needle is not inserted properly; however, this is not a common occurrence.
A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas? 1 Ammonia level 2 Culture and sensitivity 3 White blood cell count 4 Alanine aminotransferase (ALT) level
Ans: 1 Increased ammonia levels indicate that the liver is unable to detoxify protein by-products. Neomycin reduces the amount of ammonia-forming bacteria in the intestines. Culture and sensitivity testing is unnecessary; cirrhosis is an inflammatory, not infectious, process. Increased white blood cell count may indicate infection; however, this will have no relationship to the need for neomycin enemas. ALT, also called serum glutamic-pyruvic transaminase (SGPT), assesses for liver disease but has no relationship to the need for neomycin enemas.
A client with a long history of alcohol abuse develops cirrhosis of the liver. The client exhibits the presence of ascites. What does the nurse conclude is the most likely cause of this client's ascites? 1 Impaired portal venous return 2 Impaired thoracic lymph channels 3 Excess production of serum albumin 4 Enhanced hepatic deactivation of aldosterone secretion
Ans: 1 The congested liver impairs venous return, leading to increased portal vein hydrostatic pressure and an accumulation of fluid in the abdominal cavity. Although lymph channels in the abdomen become congested, facilitating the leakage of plasma into the peritoneal cavity, it is primarily the increased portal vein hydrostatic pressure that causes the accumulation of fluid in the abdominal cavity. Increased serum albumin causes hypervolemia, not ascites. As fluid is trapped in the peritoneal cavity, circulating blood volume drops and aldosterone secretion increases, not decreases; aldosterone secretion is related to the renin-angiotensin system.
When preparing a client for a liver biopsy, the nurse explains that during the test the client will be placed in what position? 1 In the supine position, with the right arm raised behind the head 2 On the right side, with the left arm stretched up and over the head 3 On the left side, with the right arm extended out in front across the bed 4 In the prone position, with both elbows flexed and the hands resting on the pillow
Ans: 1 The supine position with the right arm raised behind the head exposes the right intercostal space, making the large right lobe of the liver accessible. The right side with the left arm stretched up and over the head will not provide accessibility to the liver; the small left lobe is not anatomically near the left chest wall. On the left side with the right arm extended out in front across the bed, the liver will fall away from the chest wall and be less accessible. The prone position with both elbows flexed and the hands resting on the pillow will not provide accessibility to the liver.
A client with a 20-year history of excessive alcohol use has developed jaundice and ascites and is admitted to the hospital. What is the priority nursing action during the first 48 hours after the client's admission? 1 Monitor vital signs 2 Increase fluid intake 3 Obtain a foam mattress 4 Improve nutritional status
Ans: 1 The vital signs, especially pulse and temperature, will increase before the client demonstrates any of the more severe signs and symptoms of withdrawal from alcohol. Increasing fluid intake is contraindicated initially because it may cause cerebral edema and the client has ascites. Although the client will be more comfortable on a foam mattress, it is not the priority. Improving nutritional status becomes a priority after problems of the withdrawal period have subsided.
A nurse is caring for a client with cholelithiasis and obstructive jaundice. When assessing this client, the nurse should be alert for which findings that are consistent with these conditions? Select all that apply. 1 Ecchymosis 2 Yellow sclera 3 Dark brown stool 4 Straw-colored urine 5 Pain in right upper quadrant
Ans: 1,2,5 Inadequate bile flow interferes with vitamin K absorption, contributing to ecchymosis, hematuria, and other bleeding. Yellow sclera results from failure of bile to enter the intestines, with subsequent backup into the biliary system and diffusion into the blood. The bilirubin is carried to all body regions, including the skin and mucous membranes. Pain in the right upper quadrant occurs especially after eating foods high in fat and is characteristic of acute cholecystitis and biliary colic. With obstructive jaundice the stool is clay colored, not dark brown; the presence of bile causes stool to be brown. When bile levels in the bloodstream are high, as in obstructive jaundice, there is bile in the urine, causing it to have a dark color.
A nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations should the nurse assess in the client? Select all that apply. 1 Ascites 2 Hunger 3 Pruritus 4 Jaundice 5 Headache
Ans: 1,3,4 Ascites is a result of portal hypertension that occurs with cirrhosis. Pruritus is common because bile pigments seep into the skin from the bloodstream. Jaundice occurs because the bile duct becomes obstructed and bile enters the bloodstream. The appetite decreases because of the pressure on the abdominal organs from the ascites and the liver's decreased ability to metabolize food. Headache is not a common manifestation of cirrhosis of the liver.
A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy should the nurse assess this client? Select all that apply. 1 Mental confusion 2 Increased cholesterol 3 Brown-colored stools 4 Flapping hand tremors 5 Musty, sweet breath odor
Ans: 1,4,5 An accumulation of nitrogenous wastes affects the central nervous system, causing mental confusion. An accumulation of nitrogenous wastes in hepatic encephalopathy affects the nervous system. Flapping tremors and generalized twitching occur in the second and third stages, respectively. Fetor hepaticus is the musty, sweet odor of the client's breath. Increased cholesterol levels are not necessarily present. Stool is often clay-colored because of lack of bile caused by biliary obstruction.
A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. Which diet can the nurse expect will be prescribed for this client based upon the assessment? 1 No protein 2 Moderate protein 3 High protein 4 Strict protein restriction
Ans: 2 Because the liver is unable to detoxify ammonia to urea and the client is experiencing impending hepatic encephalopathy coma, protein intake should be moderately restricted. Strict protein and no protein restrictions are not required because clients need protein for healing. High protein is contraindicated in hepatic encephalopathy.
A client with a history of alcoholism and cirrhosis is admitted with severe dyspnea as a result of ascites. Which process that most likely caused the ascites should the nurse consider when planning care? 1 Increased secretion of bile salts 2 Increased pressure in the portal vein 3 Increased interstitial osmotic pressure 4 Increased production of serum albumin
Ans: 2 The enlarged cirrhotic liver impinges on the portal system, causing increased hydrostatic pressure from increased pressure in the portal vein, resulting in ascites. Bile salts are not responsible for fluid shifts; increased serum bile results from biliary obstruction, not increased secretion of bile. Interstitial osmotic pressure is unchanged; decreased intravascular osmotic pressure accounts for fluid movement into interstitial spaces. The liver's production of serum albumin is decreased with cirrhosis of the liver.
A client is admitted to the hospital with Laënnec cirrhosis and chronic pancreatitis. Bile salts (bile acid factor) are prescribed, and the client asks why they are needed. What is the nurse's best response? 1 "They stimulate prothrombin production." 2 "They aid absorption of fat-soluble vitamins." 3 "They promote bilirubin secretion in the urine." 4 "They help the common bile duct contract stronger."
Ans: 2 Bile salts are used to aid digestion of fats and absorption of the fat-soluble vitamins A, D, E, and K. Bile salts are not involved in stimulating prothrombin production, in promoting bilirubin secretion in the urine, or in stimulating contraction of the common bile duct.
A client was admitted to the hospital with blunt trauma as a result of a collision with the steering wheel during a motor vehicle accident. The client was treated for a lacerated liver and abdominal hemorrhage. Which clinical findings should the nurse be alert for when assessing the client for peritonitis during the recovery period? Select all that apply. 1 Jaundice 2 Boardlike abdomen 3 Abdominal tenderness 4 Decreased bowel sounds 5 Rapid decrease in coagulation ability
Ans: 2,3,4 A boardlike abdomen is associated with the inflammatory process in the peritoneum. Abdominal tenderness is caused by the local inflammatory process and resulting bowel distention and irritation of the peritoneum. A decrease or absence of bowel sounds occurs in response to bowel distention caused by gas and shifting of fluid into the bowel. Jaundice is not a sign of peritonitis; it is caused by a disturbance in bilirubin metabolism. A rapid decrease in coagulation ability is associated with acute liver failure, not peritonitis.
A nurse is caring for a client with hepatic encephalopathy and ascites. Which elements are important to include in this client's diet? Select all that apply. 1 High fat 2 Low sodium 3 High vitamins 4 Moderate protein 5 Low carbohydrates
Ans: 2,3,4 A low sodium intake controls fluid retention and edema and, consequently, ascites. Vitamins help to repair long-standing nutritional deficits associated with cirrhosis of the liver. A moderate-protein diet reduces formation of ammonia, which must be degraded by the liver. High fat intake is avoided because of related cardiovascular risks and the demand for bile that the liver may not be capable of meeting. High, not low, carbohydrate intake is necessary to meet energy requirements for tissue regeneration.
A nurse is teaching a client about prophylactic measures that minimize the risk of contracting hepatitis B. Which actions should be included in this teaching plan? Select all that apply. 1 Preventing constipation 2 Screening of blood donors 3 Avoiding shellfish in the diet 4 Limiting hepatotoxic drug therapy 5 Maintaining a monogamous sexual relationship
Ans: 2,5 Contracting hepatitis B through blood transfusions can be prevented by screening donors and testing the blood. Hepatitis B can be transmitted via contaminated body fluids such as semen, saliva, and urine. Having multiple sexual partners increases the risk. A monogamous sexual relationship with an infection-free individual eliminates the risk. Preventing constipation is not related to limiting the risk for contracting hepatitis B. Avoiding shellfish in the diet limits the risk for contracting hepatitis A. Limiting hepatotoxic drug therapy does not prevent transmission of hepatitis B.
A client with esophageal varices has severe hematemesis, and a Sengstaken-Blakemore tube is inserted. What design and purpose does the tube have? 1 Single-lumen; for gastric lavage 2 Double-lumen; for intestinal decompression 3 Triple-lumen; for esophageal compression 4 Multilumen; for gastric and intestinal decompression
Ans: 3 The Sengstaken-Blakemore is a triple-lumen tube; one lumen inflates the esophageal balloon that compresses the esophagus, the second inflates the gastric balloon, and the third is attached to suction to decompress the stomach. The Sengstaken-Blakemore is not a single-lumen tube. The Sengstaken-Blakemore is not a double-lumen tube; the stomach, not the intestine, is decompressed. The intestine is not decompressed with a Sengstaken-Blakemore tube.
A client who has had right upper quadrant pain for several months now experiences clay-colored stools. Laboratory results reveal elevated liver enzymes, and a needle biopsy of the liver is scheduled. What should the nurse include in the client's teaching about the procedure? 1 The procedure is painless because general anesthesia is used. 2 Disfiguring scars are minimal because a small incision is made. 3 Lying on the right side after the procedure is required because it will decrease the risk of hemorrhage. 4 A light meal should be eaten two hours before the procedure because it stimulates gastrointestinal secretions.
Ans: 3 Because of the vascularity of the liver, compression of the needle insertion site limits the risk of hemorrhage; also, it decreases the risk of bile leakage. The procedure is performed under local anesthesia, and some discomfort may be felt during instillation of the anesthetic as well as when the needle enters the liver. There is no scarring because a surgical incision is not necessary for a needle biopsy. The client is kept nothing by mouth for at least six hours before the procedure to prevent nausea and vomiting.
A client with Laënnec cirrhosis has ascites and jaundice and is confused. What is the nursing priority when caring for this client? 1 Correcting nutritional deficiencies 2 Measuring abdominal girth every day 3 Providing for the client's physical safety 4 Placing the client in the high-Fowler position
Ans: 3 Hepatic encephalopathy, related to high ammonia levels, results in central nervous system derangement; physical safety is the priority. Although correcting nutritional deficiencies is important, it is not the priority. Although measuring abdominal girth is important, it is not the priority. The high-Fowler position will be uncomfortable because of the pressure of the distended abdomen against the legs; the semi-Fowler position is more appropriate, and it promotes respiration.
When preparing a client for a liver biopsy, what should the nurse instruct the client to do? 1 Turn onto the left side after the procedure 2 Breathe normally throughout the procedure 3 Hold the breath at the moment of the actual biopsy 4 Bear down during the insertion of the biopsy needle
Ans: 3 Holding the breath at the moment of the actual biopsy ensures that the liver does not move as it normally does with regular respiratory excursions; minimizing movement reduces potential injury to the liver. Lying on the right side after the procedure applies pressure at the insertion site, preventing hemorrhage. Movement or breathing increases the danger of damage to the liver. Bearing down (Valsalva maneuver) during the insertion of the biopsy needle is unnecessary; holding the breath at the moment of the actual biopsy is all that is necessary to help minimize injury to the liver.
When discussing a scheduled liver biopsy with a client, the nurse explains that for several hours after the biopsy the client will have to remain in what position? 1 The left side-lying position with the head of the bed elevated 2 A high-Fowler position with both arms supported on several pillows 3 The right side-lying position with pillows placed under the costal margin 4 Any comfortable recumbent position as long as the client remains immobile
Ans: 3 In the right side-lying position with pillows placed under the costal margin, the liver capsule at the entry site is compressed against the chest wall, and escape of blood or bile is impeded. The left side-lying position with the head of the bed elevated, a high-Fowler position with both arms supported on several pillows, and any comfortable recumbent position as long as the client remains immobile are unsafe because pressure will not be applied to the puncture site and the client can bleed from the insertion site.
A client recovering from hepatitis A asks the nurse about returning to work. Which is the best response by the nurse? 1 "As soon as you're feeling less tired, you may go back to work." 2 "Unfortunately, few people fully recover from hepatitis in less than six months." 3 "Gradually increase your activities because relapses may occur in those who return to full activity too soon." 4 "You cannot return to work for six months because the virus will still be in your stools, and you still are communicable."
Ans: 3 Relapses are common; they occur after too early ambulation and too much physical activity. Fatigue is a cardinal symptom; if the client tires at rest, a return to work must be delayed. The client does not stay contagious for six months.
A healthcare provider schedules a paracentesis for a client with ascites. What should the nurse include in the client's teaching plan? 1 Maintaining a supine position during the procedure 2 Consuming a diet low in fat for three days before the procedure 3 Emptying the bladder immediately before the procedure 4 Staying on a liquid diet for 24 hours after the procedure
Ans: 3 The bladder must be emptied immediately before the procedure to decrease the chance of puncture with the trocar used in a paracentesis. A paracentesis usually is performed with the client in the Fowler position to assist the flow of fluid by gravity. Eating a diet low in fat for three days before the procedure is not necessary for a paracentesis. Staying on a liquid diet is not necessary for a paracentesis.
A client with cirrhosis is scheduled for a liver biopsy. The client asks if there are any risks after the procedure. Which response by the nurse is the best? 1 "There are relatively no risks associated with this procedure." 2 "The major risk is infection at the biopsy site." 3 "The major risk is bleeding postprocedure." 4 "The major risk is liver failure postprocedure."
Ans: 3 The major risk for this client is bleeding postprocedure. In many clients with liver dysfunction, such as cirrhosis, the liver has lost its ability to synthesize proteins, such as clotting factors. The major risk is not infection or liver failure postprocedure, since bleeding is a higher risk. Since there are risks, telling the client there aren't any would be false.
A client in a debilitated state is admitted for palliative treatment of cancer of the liver. Which objective information collected by the nurse is most helpful for future monitoring of the client's condition? 1 Diet history 2 Bowel sounds 3 Present weight 4 Pain description
Ans: 3 Weight is helpful in determining the extent of ascites; 1 L of retained fluid equals approximately 2.2 lb (1 kg). Ascites can develop in late stages of liver cancer, and the effects of cancer and dying cause weight loss. Diet history is subjective information and is not as helpful as weight. Bowel sounds are objective data but do not help monitor the liver. Pain is subjective.
A client reports pain four hours after a liver biopsy. The nurse identifies that there is leakage of a large amount of bile on the dressing over the biopsy site. What should the nurse do first? 1 Tell the client to remain flat on the back. 2 Medicate the client for pain as prescribed. 3 Monitor the client's vital signs every 10 minutes. 4 Notify the primary healthcare provider immediately.
Ans: 4 A small amount of bile-colored spotting is expected, but a large amount is excessive and not expected. The healthcare provider should be notified. The client should be on the right side to compress the liver capsule against the chest wall. Medicating the client treats only the pain and disregards the need for medical evaluation of the complication. Although monitoring vital signs is important, the priority is to notify the healthcare provider.
The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority? 1 Weigh the client daily. 2 Restrict the client's oral fluid intake. 3 Measure the client's urine specific gravity. 4 Observe the client for increasing confusion.
Ans: 4 An increased serum ammonia level impairs the central nervous system, causing an altered level of consciousness. Increasing ammonia levels are not related to weight. An alteration in fluid intake will not affect the serum ammonia level. Measuring the client's urine specific gravity is not the priority; the priority is to monitor the client's neurological status.
A client is diagnosed with hepatitis A. The nurse provides the client with information about untoward signs and symptoms related to hepatitis. The nurse instructs the client to contact the primary healthcare provider if the client develops what symptom? 1 Fatigue 2 Anorexia 3 Yellow urine 4 Clay-colored stools
Ans: 4 Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines. It is unnecessary to call the healthcare provider because fatigue and anorexia are characteristic of hepatitis from the onset of clinical manifestations. Yellow is the expected color of urine
A client has a liver biopsy. Which nursing intervention is appropriate for monitoring or preventing a post-liver biopsy complication? 1 Place the client in a left side-lying position. 2 Keep the client supine on bed rest for six hours. 3 Take the client's pulse and blood pressure every shift. 4 Assess the client for pain in the right upper quadrant.
Ans: 4 If there is bleeding, subcapsular accumulation of blood will occur and cause pressure and pain in the area of the liver. Placing the client in a left side-lying position is to no avail, as the liver is on the right side of the body. A right side-lying or supine position is maintained for one to two hours. Taking the client's pulse and blood pressure every shift is too infrequent. Performing this every 15 minutes for two hours and then every 30 minutes for two hours is more appropriate.
A client with cirrhosis of the liver has a prolonged prothrombin time and a low platelet count. A regular diet is prescribed. What should the nurse instruct the client to do considering the client's condition? 1 Avoid foods high in phytonadione. 2 Check the pulse several times a day. 3 Drink a glass of milk when taking aspirin. 4 Report signs of bleeding no matter how slight.
Ans: 4 One of the many functions of the liver is the manufacture of clotting factors; there is interference in this process with cirrhosis of the liver, resulting in bleeding tendencies. The storage of fat-soluble vitamins (A, D, E, and K), water-soluble vitamins (B1, B2, folic acid, and cobalamin), and minerals (including iron) is compromised in cirrhosis; therefore, these nutrients, including phytonadione, should not be limited. Should the client bleed, the pulse rate may be increased, but it is not necessary for the client to check the pulse rate several times daily. A client whose prothrombin time is prolonged and platelet count is low should not be taking aspirin, even with milk.
A client is a candidate for intubation as a result of bleeding esophageal varices. Which type of tube should the nurse anticipate will most likely be used to meet the needs of this client? 1 Levin 2 Salem sump 3 Miller-Abbott 4 Sengstaken-Blakemore
Ans: 4 Sengstaken-Blakemore includes an esophageal balloon that exerts pressure on inflation, which retards hemorrhage. A Levin tube is used for gastric decompression, gavage, or lavage; it has one lumen. A Salem sump tube is used for gastric decompression; it has two lumens, one for decompression and one for an air vent. A Miller-Abbott tube is used for intestinal decompression.
A client has an adenocarcinoma of the colon. It is suspected that the cancer has metastasized, and a liver computed tomography (CT) scan with contrast medium has been prescribed. What would be appropriate for the nurse to include in the client's instructions? 1 After the procedure, the client will be on bed rest for six hours to prevent complications. 2 During the procedure, the client will experience some discomfort, but an analgesic will be prescribed. 3 During the procedure, the client will receive light sedation, and the client may be able to hear people talking. 4 Before the procedure, the client will be given an intravenous (IV) infusion, and the client must lie as still as possible for a period of time.
Ans: 4 Stating that the client will be given an IV infusion containing a contrast medium before the procedure and must lie as still as possible for a period of time is an accurate explanation of what the client can expect during the CT scan. It is not necessary to rest in bed for six hours. The procedure causes no physical pain, and an analgesic is not necessary. The client will be awake; neither sedation nor anesthesia is used with a CT scan.
A client has a tentative diagnosis of primary biliary cirrhosis. What skin change does the nurse expect to observe when performing a physical assessment? 1 Vitiligo 2 Hirsutism 3 Melanomas 4 Telangiectasia
Ans: 4 Telangiectasia is a vascular lesion associated with cirrhosis; it is thought to be related to increased estrogen levels. Vitiligo refers to patches of depigmentation resulting from destruction of melanocytes. Hirsutism is excessive growth of hair; with cirrhosis, endocrine disturbances result in loss of axillary and pubic hair. Melanomas refer to cancerous skin lesions; they are not associated with biliary cirrhosis.
For which clinical indicator associated with a complication of portal hypertension should the nurse assess the client? 1 Liver abscess 2 Intestinal obstruction 3 Perforation of the duodenum 4 Hemorrhage from esophageal varices
Ans: 4 The increased pressure within the portal circulatory system causes increased pressure in areas of portal systemic collateral circulation (most important, in the distal esophagus and proximal stomach). Hemorrhage is a possible complication. Liver abscesses may occur as a complication of intestinal infections, not portal hypertension. Intestinal obstruction may be caused by manipulation of the bowel during surgery, peritonitis, neurologic disorders, or organic obstruction, not portal hypertension. Perforation of the duodenum usually is caused by peptic ulcers; it is not a direct result of portal hypertension or cirrhosis.
