GI Alterations NCLEX Questions
Which of the following is not a specific element of Hepatitis C? A. Vaccine available B. May be transmitted with sexual contact C. Inflammation of the liver D. Lifetime carrier
A. Vaccine available
A male 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. Anorexia, nausea and vomiting. Rationale: 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.
For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be most important? A. Allowing complete independence of mobility B. Applying pressure to injection sites C. Administering antibiotics as prescribed D. Increasing nutritional intake
B. Applying pressure to injection sites Rationale: The client with cirrhosis who has altered clotting is at high risk for hemorrhage. Prolonged application of pressure to injection or bleeding sites is important. Complete independence may increase the client's potential for injury, because an unsupervised client may injure himself and bleed excessively. Antibiotics and good nutrition are important to promote liver regeneration. However, they are not most important for a client at high risk for hemorrhage.
The physical assessment of a 55 y/o female with end-stage cirrhosis reveals a protuberant abdomen with bulging flanks and dullness to the dependent side while lying on the right. The appropriate terminology for documentation of this assessment is what? A. Fluid overload B. Ascites C. Distension
B. Ascites Rationale: In a person who has cirrhosis, fibrous tissue develops among the parenchymal cells preventing the production of adequate plasma proteins. The consequence of low plasms proteins leads to a decrease in colloid osmotic pressure and generalized edema. When combined with high portal capillary pressures, larga amounts of fluid and protein can form in the abd. cavity, which is called ascities.
When teaching a client about pancreatic function, the nurse understands that pancreatic lipase performs which function? A. Transports fatty acids into the brush border B. Breaks down fat into fatty acids and glycerol C. Triggers cholecystokinin to contract the gallbladder D. Breaks down protein into dipeptides and amino acids
B. Breaks down fat into fatty acids and glycerol Rationale: Lipase hydrolyses or breaks down fat into fatty acids and glycerol. Lipase is not involved with the transport of fatty acids into the brush border. Fat itself triggers cholecystokinin release. Protein breakdown into dipeptides and amino acids is the function of trypsin, not lipase.
For Rico who has chronic pancreatitis, which nursing intervention would be most helpful? A. Allowing liberalized fluid intake B. Counseling to stop alcohol consumption C. Encouraging daily exercise D. Modifying dietary protein
B. Counseling to stop alcohol consumption Rationale: Chronic pancreatitis typically results from repeated episodes of acute pancreatitis. More than half of chronic pancreatitis cases are associated with alcoholism. Counseling to stop alcohol consumption would be the most helpful for the client. Dietary protein modification is not necessary for chronic pancreatitis. Daily exercise and liberalizing fluid intake would be helpful but not the most beneficial intervention.
Tiffany Black is diagnosed with type A hepatitis. What special precautions should the nurse take when caring for this patient? A. Put on a mask and gown before entering the patient's room. B. Wear gloves and a gown when removing the patient's bedpan. C. Prevent the droplet spread of the organism. D. Use caution when bringing food to the patient.
B. Wear gloves and a gown when removing the patient's bedpan. Rationale: The nurse should wear gloves and a gown when removing the patient's bedpan because the type A hepatitis virus occurs in stools. It may also occur in blood, nasotracheal secretions, and urine. Type A hepatitis isn't transmitted through the air by way of droplets. Special precautions aren't needed when feeding the patient, but disposable utensils should be used.
Tony was diagnosed with hepatitis A. The information from the health history that is most likely linked to hepatitis A is: A. Exposed with arsenic compounds at work B. Working as local plumber C. Working at hemodialysis clinic D. Dish washer in restaurants
B. Working as a local plumber Rationale: Hepatitis A is primarily spread via fecal-oral route. Sewage polluted water may harbor the virus.
Nurse Rachel teaches a client who has been recently diagnosed with hepatitis A about untoward signs and symptoms related to Hepatitis that may develop. The one that should be reported immediately to the physician is: A. Restlessness B. Yellow urine C. Nausea D. Clay- colored stools
C. Clay colored stools Rationale: Clay colored stools are indicative of hepatic obstruction.
A patient is admitted with increased ascites associated with cirrhosis. Which nursing diagnosis should receive top priority? A. Fatigue B. Excess fluid volume C. Ineffective breathing pattern D. Imbalanced nutrition: Less than body requirements.
C. Ineffective breathing pattern Rationale: In ascites, the accumulation of large amounts of fluid produces extreme abdominal distension that can put pressure on the diaphragm and interfere with respiration. If uncorrected, this can lead to atelectasis or pneumonia.
A client with chirrhosis may have alterations in what lab values? A. CO2 level B. pH C. prothrombin time (PT) D. WBC
C. prothrombin time (PT) Rationale: Clients with cirrhosis have used their clotting factors, and their liver is unable to provide enough clotting factors. A PT time is an indication of the time needed for blood to clot. If clotting factors are not present, bleeding is more likely.
A 52-year-old man was referred to the clinic due to increased abdominal girth. He is diagnosed with ascites by the presence of a fluid thrill and shifting dullness on percussion. After administering diuretic therapy, which nursing action would be most effective in ensuring safe care? A. Measuring serum potassium for hyperkalemia B. Assessing the client for hypervolemia C. Measuring the client's weight weekly D. Documenting precise intake and output
D. Documenting precise intake and output Rationale: For the client with ascites receiving diuretic therapy, careful intake and output measurement is essential for safe diuretic therapy. Diuretics lead to fluid losses, which if not monitored closely and documented, could place the client at risk for serious fluid and electrolyte imbalances. Hypokalemia, not hyperkalemia, commonly occurs with diuretic therapy. Because urine output increases, a client should be assessed for hypovolemia, not hypervolemia. Weights are also an accurate indicator of fluid balance. However, for this client, weights should be obtained daily, not weekly.
In the United States, nurses performing invasive procedures need to be up-to-date with their immunizations, particularly A. Hepatitis E. B. Hepatitis A. C. Hepatitis C. D. Hepatitis B.
D. Hepatitis B. Rationale: Hepatitis B is transmitted through contact with infected blood or plasma.
Jordin is a client with jaundice who is experiencing pruritus. Which nursing intervention would be included in the care plan for the client? A. Administering vitamin K subcutaneously B. Applying pressure when giving I.M. injections C. Decreasing the client's dietary protein intake D. Keeping the client's fingernails short and smooth
D. Keeping the client's fingernails short and smooth Rationale: The client with pruritus experiences itching, which may lead to skin breakdown and possibly infection from scratching. Keeping his fingernails short and smooth helps prevent skin breakdown and infection from scratching. Applying pressure when giving I.M. injections and administering vitamin K subcutaneously are important if the client develops bleeding problems. Decreasing the client's dietary intake is appropriate if the client's ammonia levels are increased.
Pierre who is diagnosed with acute pancreatitis is under the care of Nurse Bryan. Which intervention should the nurse include in the care plan for the client? A. Administration of vasopressin and insertion of a balloon tamponade B. Preparation for a paracentesis and administration of diuretics C. Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction D. Dietary plan of a low-fat diet and increased fluid intake to 2,000 ml/day
C. Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction Rationale: With acute pancreatitis, the client is kept on nothing-by-mouth status to inhibit pancreatic stimulation and secretion of pancreatic enzymes. NG intubation with low intermittent suction is used to relieve nausea and vomiting, decrease painful abdominal distention, and remove hydrochloric acid. Vasopressin would be appropriate for a client diagnosed with bleeding esophageal varices. Paracentesis and diuretics would be appropriate for a client diagnosed with portal hypertension and ascites. A low-fat diet and increased fluid intake would further aggravate the pancreatitis.
Which of the following considerations is of the highest priority when preparing to administer a medication to a client with cirrhosis? A. Frequency of the medication B. Purpose of the medication C. Necessity of the medication D. Metabolism of the medication
D. Metabolism of the medication Rationale: In cirrhosis, the liver is usually not functioning properly and cannot metabolize medications as well as it normally would if healthy due to the scarring of the tissue. Certain medications are metabolized primarily by the liver, while other medications are metabolized by other organs. Consideration should be made for each med ordered to avoid overburdening the liver.
Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? (Select all that apply.) A. Assessing the client's neurologic status every 2 hours B. Monitoring the client's hemoglobin and hematocrit levels C. Evaluating the client's serum ammonia level D. Monitoring the client's handwriting daily E. Preparing to insert an esophageal tamponade tube F. Making sure the client's fingernails are short
A. Assessing the client's neurologic status every 2 hours C. Evaluating the client's serum ammonia level D. Monitoring the client's handwriting daily Rationale: Hepatic encephalopathy results from an increased ammonia level due to the liver's inability to covert ammonia to urea, which leads to neurologic dysfunction and possible brain damage. The nurse should monitor the client's neurologic status, serum ammonia level, and handwriting. Monitoring the client's hemoglobin and hematocrit levels and insertion of an esophageal tamponade tube address esophageal bleeding. Keeping fingernails short address jaundice.
When doing discharge teaching to a client with chronic cirrhosis, why is it important to put emphasis on bleeding precautions? A. Because of the cirrhosis, the liver is unable to produce clotting factors B. The low protein diet will result in reduced clotting factors C. The increased production of bile decreases clotting factors. D. The required medications reduce clotting factors.
A. Because of the cirrhosis, the liver is unable to produce clotting factors Rationale: When bile productions is reduced, the body has reduced ability to absorb fat-soluble vitamins. W/o adequate Vit K absorption, clotting factors II, VII, IX, and X are not produced in sufficient amounts.
The physical assessment findings of spider angiomas, palmar erythema, peropheral edema, ascities, and change in mental status are consistent with which of the following diagnosis? A. Cirrhosis B. Pancreatitis C. Obstructive Jaundice
A. Cirrhosis Rationale: Portal hypertension and liver failure contribute to the late manifestations of cirrhosis. Pancreatitis presents with pain radiating to the back, mild cardiovascular changes, and hypocalcemia. Obstructive jaundice presents with clay colored stools.
Dr. Smith has determined that the client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D
A. Hepatitis A Rationale: Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.
Which of the following laboratory tests indicates a diagnosis of pancreatitis? A. Lipase 230 IU/L B. Calcium 6.0 mEq/L C. Blood glucose 65 mg/dL D. WBC count 5,000/mm3
A. Lipase 230 IU/L Rationale: For pancreatitis, the lipase, amylase, glucose and WBC are all elevated. The calcium is low for 7-10 days and is a sign of severe pancreatitis.
Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy? A. Passage of two or three soft stools daily B. Evidence of watery diarrhea C. Daily deterioration in the client's handwriting D. Appearance of frothy, foul-smelling stools
A. Passage of two or three soft stools daily Rationale: Lactulose reduces serum ammonia levels by inducing catharsis, subsequently decreasing colonic pH and inhibiting fecal flora from producing ammonia from urea. Ammonia is removed with the stool. Two or three soft stools daily indicate effectiveness of the drug. Watery diarrhea indicates overdose. Daily deterioration in the client's handwriting indicates an increase in the ammonia level and worsening of hepatic encephalopathy. Frothy, foul-smelling stools indicate steatorrhea, caused by impaired fat digestion.
For a client in hepatic coma, which outcome would be the most appropriate? A. The client is oriented to time, place, and person. B. The client exhibits no ecchymotic areas. C. The client increases oral intake to 2,000 calories/day. D. The client exhibits increased serum albumin level.
A. The client is oriented to time, place, and person. Rationale: Hepatic coma is the most advanced stage of hepatic encephalopathy. As hepatic coma resolves, improvement in the client's level of consciousness occurs. The client should be able to express orientation to time, place, and person. Ecchymotic areas are related to decreased synthesis of clotting factors. Although oral intake may be related to level of consciousness, it is more closely related to anorexia. The serum albumin level reflects hepatic synthetic ability, not level of consciousness.
A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis? A. Elevated hemoglobin level B. Elevated serum bilirubin level C. Elevated blood urea nitrogen level D. Decreased erythrocycle sedimentation rate
B. Elevated serum bilirubin level Rationale: Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leukopenia. An elevated blood urea nitrogen level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.
The physican prescribed spironolactone (Aldactone), 50 mg, PO QID, for a client with fluid retention due to cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? A. Serum potassium level of 3.5 mEq/L B. Weight loss of 2 lbs. in 24 hours C. Serum sodium level of 135 mEq/L D. Blood pH of 7.25
B. Weight loss of 2 lbs. in 24 hours Rationale: Daily weight measurement is the most accurate indicator of fluid status. A loss of 2.2 lbs demonstrates the loss of 1 L of fluid. Spironlactone is a diuretic, weight loss is the best indicator of its effectiveness. A blood pH of 7.25 indicates acidosis, a potential adverse reaction to spironolactone.
Which of the following symptoms during the icteric phase of viral hepatitis should the nurse expect the client to exhibit? A. Watery stool B. Yellow sclera C. Tarry stool D. Shortness of breath
B. Yellow sclera Rationale: Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy.
A 45 y/o female hospitalized with acute pancreatitis has orders for meperidine (Demerol) 50 mg IM Q 4 hrs PRN as needed for pain. Demerol has been ordered rather than morphine for this client because it: A. Has a faster onset of action than morphine B. Is less addictive than morphine. C. Causes fewer spasms in the sphincter of Oddi D. Has fewer cognitive side effects
C. Causes fewer spasms in the sphincter of Oddi Rationale: The onset of action for meperidine is 10-15 minutes and the onset of morphine is 20-60 minutes. Both drugs are equal in the potential for addiction. Demerol is less sedating than morphine. The most important difference is that the meperidine causes fewer spasms of the sphincter of Oddi, which contributes to the goal of giving the pancreas a rest.
A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for: A. Malaise B. Stomatitis C. Hand tremors D. Weight loss
C. Hand tremors Rationale: Hepatic encephalopathy results from the accumulation of neurotoxins in the blood, therefore the nurse wants to assess for signs of neurological involvement. Flapping of the hands (asterixis), changes in mentation, agitation, and confusion are common. These clients typically have ascites and edema so experience weight gain. Malaise and stomatitis are not related to neurological involvement.
A female client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response? A. "You may have eaten contaminated restaurant food." B. "You could have gotten it by using I.V. drugs." C. "You must have received an infected blood transfusion." D. "You probably got it by engaging in unprotected sex."
A. "You may have eaten contaminated restaurant food." Rationale: 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.
Which of the following laboratory values will the nurse interpret as confirming a client's diagnosis of pancreatitis? A. Elevated amylase, elevated lipase, elevated serum glucose, and decreased serum calcium levels. B. Elevated amylase, elevated lipase, decreased serum glucose, and decreased serum calcium levels. C. Decreased amylase, decreased lipase, elevated serum glucose, and increased serum calcium levels. D. Decreased amylase, decreased lipase, decreased serum glucose, and increased serum calcium levels.
A. Elevated amylase, elevated lipase, elevated serum glucose and decreased serum calcium levels. Rationale: The elevated amylase and lipase are key lab tests for pancreatitis. The glucose is elevated because of the role of the pancreas controlling glucose values. The calcium is decreased because the calcium is deposited in the fatty necrotic tissue of the pancreas.
For a patient with advanced cirrhosis, which assessment finding best indicates deterioration of liver function? A. fatigue and muscle weakness B. Difficulty in arousal C. Nausea and anorexia D. Weight gain
B. Difficulty in arousal Rationale: Hepatic encephalopathy, which is a major complication of advanced cirrhosis, occurs when the liver can no longer convert ammonia ( a by-product of protein breakdown) into glutamine. It increases the blood level of ammonia-- a CNS toxin-- which decreases the client's level of consciousness.
Which of the following findings would strongly indicate the possibility of cirrhosis? A. Dry skin B. Hepatomegaly C. Peripheral edema D. Pruritus
B. Hepatomegaly (enlarged liver) Rationale: Although option D is correct, it is not a strong indicator of cirrhosis. Pruritus can occur for many reasons. Options A and C are incorrect, fluid accumulation is usually in the form of ascites in the abdomen. The spleen may also be enlarged.
Nurse Farrah is providing care for Kristoff who has jaundice. Which statement indicates that the nurse understands the rationale for instituting skin care measures for the client? A. "Jaundice is associated with pressure ulcer formation." B. "Jaundice impairs urea production, which produces pruritus." C. "Jaundice produces pruritus due to impaired bile acid excretion." D. "Jaundice leads to decreased tissue perfusion and subsequent breakdown."
C. "Jaundice produces pruritus due to impaired bile acid excretion." Rationale: Jaundice is a symptom characterized by increased bilirubin concentration in the blood. Bile acid excretion is impaired, increasing the bile acids in the skin and causing pruritus. Jaundice is not associated with pressure ulcer formation. However, edema and hypoalbuminemia are. Jaundice itself does not impair urea production or lead to decreased tissue perfusion.
The client with pancreatitis may exhibit Cullen's sign on physical examination. Which of the following data best describes Cullen's sign? A. Jaundiced sclera B. Pain that occurs with movement C. Bluish discoloration of the left flank area D. Bluish discoloration of the periumbilical area
D. Bluish discoloration of the periumbilical area Rationale: Bleeding is a complication of pancreatitis and is usually identified through a positive Turner's sign (flank bruising) or Cullen's sign (umbilical bruising).
A female client with hepatitis C develops liver failure and GI hemorrhage. The blood products that would most likely bring about hemostasis in the client are: A. Whole blood and albumin. B. Platelets and packed red blood cells. C. Fresh frozen plasma and whole blood. D. Cryoprecipitate and fresh frozen plasma.
D. Cryoprecipitate and fresh frozen plasma. The liver is vital in the synthesis of clotting factors, so when it's diseased or dysfunctional, as in hepatitis C, bleeding occurs. Treatment consists of administering blood products that aid clotting. These include fresh frozen plasma containing fibrinogen and cryoprecipitate, which have most of the clotting factors. Although administering whole blood, albumin, and packed cells will contribute to hemostasis, those products aren't specifically used to treat hemostasis. Platelets are helpful, but the best answer is cryoprecipitate and fresh frozen plasma.
A client is hospitalized with hepatitis A. Which of the client's regular medications is contraindicated due to the current illness? A. Prilosec (omeprazole) B. Synthroid (levothyroxine) C. Premarin (conjugated estrogens) D. Lipitor (atorvastatin)
D. Lipitor (atorvastatin) Rationale: Lipid-lowering agents are contraindicated in the client with active liver disease. Answers A, B, and C are incorrect because they are not contraindicated in the client with active liver disease.
The nurse is preparing discharge instructions for a client with hepatitis B. The discharge plan should include which of the following instructions for the client? a.) Use a condom during sexual intercourse. b.) Avoid all alcohol consumption for one month. c.) Eat a low protein, high carbohydrate diet. d.) Have all family members vaccinated for hepatitis.
a.) Use a condom during sexual intercourse. Rationale: The hepatitis B virus is spread through contact with infected blood and body fluids and is considered a sexually transmitted disease; therefore it is important to use a condom for sexual relations. The consumption of alcohol should be kept to a minimum but absolute avoidance is not necessary. A well balanced diet is preferable. Vaccination is not necessary for family members.
A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for: a.) hand tremors. b.) weight loss. c.) malaise. d.) stomatitis.
a.) hand tremors Rationale: Hepatic encephalopathy results from the accumulation of neurotoxins in the blood, therefore the nurse wants to assess for signs of neurological involvement. Flapping of the hands (asterixis), changes in mentation, agitation, and confusion are common. These clients typically have ascites and edema so experience weight gain. Malaise and stomatitis are not related to neurological involvement.
Spironolacctone (Aldactone) is prescribed for a client with chronic cirrhosis and ascites. The nurse should monitor the client for which of the following medication-related side effects? a.) Tachycardia b.) Hyperkalemia c.) Constipation d.) Jaundice
b.) Hyperkalemia Rationale: This is a potassium-sparing diuretic so clients should be monitored closely for hyperkalemia. Diarrhea, dizziness, and headaches are other more common side effects. Tachycardia, jaundice, and constipation are not expected side effects of spironolactone (Aldactone).
A client with chronic pancreatitis is being discharged from the hospital. Which of the following statements by the client demonstrates that the client understands how to take prescribed pancreatic enzyme replacements? a.) "I must take capsules three times daily spaced about 8 hours apart." b.) "I must take the medication when I wake up and before bed." c.) "I must take the medication with meals and snacks." d.) "I must take the capsules every 4 hours while awake."
c.) "I must take the medication with meals and snacks." Rationale: Pancreatic enzymes are prescribed to facilitate digestion of protein and fats and must be taken with food. Taking the enzymes at any other time will be ineffective.
Which of the following will the nurse include in the care plan for a client hospitalized with viral hepatitis? a.) Bland diet b.) Administer antibiotics as ordered c.) Increase fluid intake to 3000 ml per day d.) Adequate bed rest
d.) Adequate bed rest Rationale: Treatment of hepatitis consists of bed rest during the acute phase to reduce metabolic demands on the liver, thus increasing blood supply and cell regeneration. Forcing fluids, antibiotics, and bland diets are not part of the treatment plan for viral hepatitis.
