Hinkle Ch 49

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:

cirrhosis. Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating.

A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor?

"You must have the second one in 1 month and the third in 6 months."

The single modality of pharmacologic therapy for chronic type B viral hepatitis is:

Alpha-interferon

The nurse is assessing a client with hepatic cirrhosis for mental deterioration. For what clinical manifestations will the nurse monitor? Select all that apply.

Alterations in mood Agitation Insomnia

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately?

Change in the client's handwriting and/or cognitive performance

A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus (HAV). They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes?

Infection at school Suboptimal sanitary habits Consumption of sewage-contaminated water or shellfish Sexual activity

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?

Measure abdominal girth according to a set routine

A patient who had a recent myocardial infarction was brought to the emergency department with bleeding esophageal varices and is presently receiving fluid resuscitation. What first-line pharmacologic therapy does the nurse anticipate administering to control the bleeding from the varices?

Octreotide Octreotide (Sandostatin), a synthetic analogue of the hormone somatostatin, is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding.

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

Purpura and petechiae A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption.

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?

Reduce fluid accumulation and venous pressure.

A client with hepatitis who has not responded to medical treatment is scheduled for a liver transplant. Which of the following most likely would be ordered?

Tacrolimus In preparation for a liver transplant, a client receives immunosuppressants to reduce the risk for organ rejection. Tacrolimus or cyclosporine are two immunosuppresants that may be used.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?

The client's hepatic function is decreasing.

Which of the following is the most effective strategy to prevent hepatitis B infection?

Vaccine The most effective strategy to prevent hepatitis B infection is through vaccination. Recommendations to prevent transmission of hepatitis B include vaccination of sexual contacts of individuals with chronic hepatitis, use of barrier protection during sexual intercourse, avoidance of sharing toothbrushes, razors with others, and covering open sores or skin lesions.

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?

Vasopressin Vasopressin may be the initial therapy for esophageal varices because it constricts the splanchnic arterial bed and decreases portal hypertension.

Which condition indicates an overdose of lactulose?

Watery diarrhea

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:

anorexia, nausea, and vomiting.

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia?

hypotension

What is the recommended dietary treatment for a client with chronic cholecystitis?

low-fat diet

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is:

subnormal serum glucose and elevated serum ammonia levels.

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition?

Hepatic encephalopathy Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with an elevated ammonia concentration that produces changes in mental status, altered level of consciousness, and coma.

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include?

Hepatitis C increases a person's risk for liver cancer.

The nurse is administering medications to a client that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent?

Lactulose

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?

Loss of 2.2 lb (1 kg) in 24 hours Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness

Which of the following medications would the nurse expect the physician to order for a client with cirrhosis who develops portal hypertension?

Spironolactone (Aldactone)

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

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