N 403 Ch 49
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? - Creatinine - Urobilinogen - Chloride - Albumin
Correct response: Albumin Explanation: 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. Creatinine, urobilinogen, and chloride are normally found in urine.
A client is scheduled to have a laparoscopic cholecystectomy as an outpatient. The client asks the nurse when he will be able to resume normal activities. What information should the nurse provide? - Normal activities may be resumed the day after surgery. - Normal activities may be resumed in 1 week. - Normal activities may be resumed in 2 weeks. - Normal activities may be resumed in 1 month.
Correct response: Normal activities may be resumed in 1 week. Explanation: A prolonged recovery period usually is unnecessary. Most clients resume normal activities within 1 week.
Which type of deficiency results in macrocytic anemia? - Folic acid - Vitamin C - Vitamin A - Vitamin K
Correct response: Folic acid Explanation: Folic acid deficiency results in macrocytic anemia. Vitamin C deficiency results in hemorrhagic lesions of scurvy. Vitamin A deficiency results in night blindness and eye and skin changes. Vitamin K deficiency results in hypoprothrombinemia, which is characterized by spontaneous bleeding and ecchymosis.
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 - Decreased deep tendon reflexes - Report of headache - Insomnia
Correct response: Alterations in mood Agitation Insomnia Explanation: The earliest symptoms of hepatic encephalopathy include both mental status changes and motor disturbances. The client appears confused and unkempt and has alterations in mood and sleep patterns. The client tends to sleep during the day and has restlessness and insomnia at night. To assess for mental deterioration, the nurse will assess general behavior, orientation, and speech as well as cognitive abilities and speech patterns.
What does the nurse recognize as clinical manifestations consistent with ascites? Select all that apply. - increased abdominal girth - rapid weight gain - visible distended veins - stretch marks - foul-smelling breath
Correct response: increased abdominal girth rapid weight gain visible distended veins stretch marks Explanation: The presence and extent of ascites are assessed by percussion of the abdomen. When fluid has accumulated in the peritoneal cavity, the flanks bulge when the patient assumes a supine position. Increased abdominal girth and rapid weight gain are common presenting symptoms of ascites. The patient may be short of breath and uncomfortable from the enlarged abdomen, and striae and distended veins may be visible over the abdominal wall. Foul-smelling breath is not a clinical manifestation of ascites.
A client is seeing the physician for a suspected tumor of the liver. What laboratory study results would indicate that the client may have a primary malignant liver tumor? - Elevated white blood cell count - Elevated alpha-fetoprotein - Decreased AST levels - Decreased alkaline phosphatase levels
Correct response: Elevated alpha-fetoprotein Explanation: Alpha-fetoprotein, a serum protein normally produced during fetal development, is a marker that, if elevated, can induce a primary malignant liver tumor. Total bilirubin and serum enzyme levels may be elevated. White blood cell count elevation would indicate an inflammatory response.
A client has undergone a liver biopsy. After the procedure, the nurse should place the client in which position? - On the left side - Trendelenburg - On the right side - High Fowler
Correct response: On the right side Explanation: Immediately after the biopsy, assist the client to turn on to the right side; place a pillow under the costal margin, and caution the client to remain in this position. In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded. Positioning the client on the left side is not indicated. Positioning the client in the Trendelenburg position may be indicated if the client is in shock, but it is not the position designed for the client after liver biopsy. The high Fowler position is not indicated for the client after liver biopsy.
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? Spironolactone Cholestyramine Lactulose Kanamycin
Correct response: Lactulose Explanation: Lactulose is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients. Potassium-sparing diuretics such as spironolactone are used to treat ascites. Cholestyramine is a bile acid sequestrant and reduces pruritus. Kanamycin decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.
Which of the following is the most effective strategy to prevent hepatitis B infection? - Vaccine - Barrier protection during intercourse - Covering open sores Avoid sharing toothbrushes
Correct response: Vaccine Explanation: 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.
A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice? - Straw-colored urine - Reduced hematocrit - Clay-colored stools - Elevated urobilinogen in the urine
Correct response: Clay-colored stools Explanation: Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen.
A client has developed drug-induced hepatitis from a drug reaction to antidepressants. What treatment does the nurse anticipate the client will receive to treat the reaction? - Paracentesis - Liver transplantation - High-dose corticosteroids - Azathioprine
Correct response: High-dose corticosteroids Explanation: Drug-induced hepatitis occurs when a drug reaction damages the liver. This form of hepatitis can be severe and fatal. High-dose corticosteroids usually administered first to treat the reaction. Liver transplantation may be necessary. Paracentesis would be used to withdrawal fluid for the treatment of ascites. Azathioprine (Imuran) may be used for autoimmune hepatitis.
Which of the following liver function studies is used to show the size of abdominal organs and the presence of masses? - Ultrasonography - Magnetic resonance imaging - Angiography - Electroencephalogram
Correct response: Ultrasonography Explanation: A ultrasonography will show the size of the abdominal organs and the presence of masses. Magnetic resonance imaging is used to detect hepatic neoplasms. An angiography is used to visualize hepatic circulation and detect the presence and nature of hepatic masses. An electroencephalogram is used to detect abnormalities that occur with hepatic coma.
A patient is prescribed Sandostatin for the treatment of esophageal varices. The nurse knows that the purpose of this cyclic octapeptide is to reduce portal pressure by: - Constricting the splanchnic arteries. - Using a beta-adrenergic blocking action. - Selective vasodilation of the portal system. - Reducing blood pressure in the portal.
Correct response: Selective vasodilation of the portal system. Explanation: Sandostatin slows the flow of blood (via vasodilation) from internal organs to the portal system, thus reducing pressure. The other choices are actions of different drugs used for the treatment of esophageal varices. Refer to Table 25-1 in the text.
Which of the following diagnostic studies definitely confirms the presence of ascites? - Ultrasound of liver and abdomen - Abdominal x-ray - Colonoscopy - Computed tomography of abdomen
Correct response: Ultrasound of liver and abdomen Explanation: Ultrasonography of the liver and abdomen will definitively confirm the presence of ascites. An abdominal x-ray, colonoscopy, and computed tomography of the abdomen would not confirm the presence of ascites.
A young client with anorexia, fatigue, and jaundice is diagnosed with hepatitis B and has just been admitted to the hospital. The client asks the nurse how long the stay in the hospital will be. In planning care for the client, the nurse identifies impaired psychosocial issues and assigns the highest priority to which client outcome? - Minimizing social isolation - Establishing a stable home environment - Reducing the spread of the disease - Identifying the source of exposure to hepatitis
Correct response: Minimizing social isolation Explanation: The nurse identifies psychosocial issues and concerns, particularly the effects of separation from family and friends if the client is hospitalized during the acute and infective stages. Convalescence may be prolonged, with complete symptomatic recovery sometimes requiring 3 to 4 months or longer. Even if not hospitalized, the client will be unable to attend school and/or work and must avoid sexual contact. Planning is required to minimize social isolation.
The nurse is teaching a client who was admitted to the hospital with acute hepatic encephalopathy and ascites about an appropriate diet. The nurse determines that the teaching has been effective when the client chooses which food choice from the menu? - Omelet with green peppers, onions, mushrooms, and cheese with milk - Pancakes with butter and honey, and orange juice - Ham and cheese sandwich, baked beans, potatoes, and coffee - Baked chicken with sweet potato french fries, cornbread, and tea
Correct response: Pancakes with butter and honey, and orange juice Explanation: Teach clients to select a diet high in carbohydrates with protein intake consistent with liver function. The client should identify foods high in carbohydrates and within protein requirements (moderate to high protein in cirrhosis and hepatitis, low protein in hepatic failure). The client with acute hepatic encephalopathy is placed on a low-protein diet to decrease ammonia concentration. The other choices are all higher in protein. The client's ascites indicates that a low-sodium diet is needed, and the other choices are all high in sodium.
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? - Vasopressin (Pitressin) - Epinephrine - Octreotide (Sandostatin) - Glucagon
Correct response: Octreotide (Sandostatin) Explanation: 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.
A client is receiving vasopressin for the urgent management of active bleeding due to esophageal varices. What most serious complication should the nurse assess the client for after the administration? - Urinary output changes - Electrocardiogram changes - Electrolytes level changes - Liver enzyme changes
Electrocardiogram changes There is constriction of coronary arteries as well as the splanchnic artery. This could cause cardiac ischemia and result in electrocardiogram changes.
The single modality of pharmacologic therapy for chronic type B viral hepatitis is: - Alpha-interferon - Hepsera - Epivir - Baraclude
Correct response: Alpha-interferon Explanation: Alpha-interferon is a biologic response modifier that is highly effective for treatment of hepatitis B. The other antiviral agents are effective but not the preferred single-agent therapy.
Which of the following the are early manifestations of liver cancer? Select all that apply. - Pain - Continuous aching in the back - Increased appetite - Fever - Jaundice - Vomiting
Correct response: Pain Continuous aching in the back Explanation: Early manifestations of liver cancer include pain and continuous dull aching in the right upper quadrant epigastrium or back. Weight loss, anorexia, and anemia may occur. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver. Fever and vomiting are not associated manifestations.
A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client? - Vitamin A - Thiamine - Riboflavin - Vitamin K
Correct response: Vitamin A Explanation: Problems common to clients with severe chronic liver dysfunction result from inadequate intake of sufficient vitamins. Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency can lead to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Vitamin K deficiency can cause hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses.
A physician has ordered a liver biopsy for a client with cirrhosis whose condition has recently deteriorated. The nurse reviews the client's recent laboratory findings and recognizes that the client is at risk for complications due to: - low platelet count. - low sodium level. - decreased prothrombin time. - low hemoglobin.
Correct response: low platelet count. Explanation: Prolonged prothrombin time (PT) and low platelet count place the client at high risk for hemorrhage. The client may receive intravenous (IV) administration of vitamin K or infusions of platelets before liver biopsy to reduce the risk of bleeding.
The nurse is preparing to interview a client with cirrhosis. Based on an understanding of this disorder, which question would be most important to include? - "Have you had an infection recently?" - "Does your work expose you to chemicals?" - "How often do you drink alcohol?" - "What type of over-the-counter pain reliever do you use?"
Correct response: "How often do you drink alcohol?" Explanation: The most common type of cirrhosis results from chronic alcohol intake and is frequently associated with poor nutrition. Although it can follow chronic poisoning with chemicals or ingestion of hepatotoxic drugs such as acetaminophen, asking about alcohol intake would be most important. Asking about an infection or exposure to hepatotoxins or industrial chemicals would be important if the client had postnecrotic cirrhosis.
A nurse in the surgical ICU just received a client from recovery following a Whipple procedure. Which nursing diagnoses should the nurse consider when caring for this acutely ill client? Select all that apply. - potential for infection - acute pain and discomfort - alterations in respiratory function - fluid volume excess
Correct response: potential for infection acute pain and discomfort alterations in respiratory function Explanation: Monitor for potential for infection related to invasive procedure and poor physical condition. Monitor for pain related to extensive surgical incision. Monitor for alterations in respiratory function related to extensive surgical incisions, immobility, and prolonged anesthesia. Client is at risk for fluid volume deficit related to hemorrhage and loss of fluids.
An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is: - Acetaminophen - Ibuprofen - Dextromethorphan - Benadryl
Correct response: Acetaminophen Explanation: Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Other medications commonly associated with liver injury include anesthetic agents, medications used to treat rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsants, and antituberculosis agents.
A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. A likely cause of these symptoms is: - acute cholecystitis - hepatitis A - hepatitis B - pancreatitis
Correct response: acute cholecystitis Explanation: Gallstones are more frequent in women, particularly women who are middle-aged and obese. With acute cholecystitis, clients usually are very sick with fever, vomiting, tenderness over the liver, and severe pain that may radiate to the back and shoulders. The patient profile and symptoms are suggestive of acute cholecystitis.
The nurse completing a plan of care for a client with cirrhosis who has ascites and 4+ pitting edema of the feet and legs identifies a nursing diagnosis of risk for impaired skin integrity. Which nursing intervention is appropriate for this problem? - Restrict dietary protein intake. - Arrange for a low air loss bed. - Perform passive range-of-motion exercises four times a day. - Reposition the client every 4 hours.
Correct response: Arrange for a low air loss bed. Explanation: Initiating the use of an alternating-pressure mattress or low air loss bed decreases the risk for skin breakdown due to prolonged pressure on bony prominences. The other answers do not apply.
When inspecting the abdomen of a client with cirrhosis, the nurse observes that the veins over the abdomen are dilated. The nurse documents this finding as which of the following? - Gynecomastia - Cutaneous spider angioma - Caput medusae - Palmar erythema
Correct response: Caput medusae Explanation: Caput medusa is a term used to denote the appearance of dilated veins over the client's abdomen. Gynecomastia refers to enlarged breasts in a male, which may occur because the dysfunctional liver is unable to metabolize estrogen. Palmer erythema refers to the bright pink appearance of the palms and cutaneous spider angioma refers to tiny, spider-like blood vessels that may be apparent in a client with cirrhosis due to the liver's inability to inactivate estrogen.
A client with gallstones tells the nurse, "The doctor has to do something. Isn't there something he can give me to dissolve them?" What medication does the nurse know may help dissolve the gallstones? - Pancreatin - Chenodiol - Tacrolimus - Cyclosporine
Correct response: Chenodiol Explanation: Chenodiol suppresses hepatic synthesis of cholesterol and cholic acid to dissolve gallstones. It is administered orally to dissolve gallstones and may require long-term therapy for effectiveness. Pancreatin is a pancreatic enzyme and does not have the properties to dissolve gallstones. Tacrolimus is used to prevent transplant rejection as is cyclosporine.
Which of the following laboratory test results would the nurse associate with obstructive jaundice? - Increased indirect bilirubin - Decreased unconjugated bilirubin - Decreased conjugated bilirubin - Increased direct bilirubin
Correct response: Increased direct bilirubin Explanation: With obstructive jaundice, direct or conjugated bilirubin levels would be increased. Indirect or unconjugated bilirubin levels would be increased with hemolytic jaundice. Both conjugated and unconjugated bilirubin levels would be elevated with hepatocellular jaundice.
A client has ascites. Which of the following interventions would the nurse prepare to assist with implementing to help the client control this condition? Select all that apply. - Instructing the client to remove salty and salted foods from the diet - Administering prescribed spironolactone (Aldactone) - Assisting with placement of a transjugular intrahepatic portosystemic shunt - Mobilizing the client every 2 hours - Taking the client's weight every 3 to 4 days
Correct response: Instructing the client to remove salty and salted foods from the diet Administering prescribed spironolactone (Aldactone) Assisting with placement of a transjugular intrahepatic portosystemic shunt Explanation: The goal of treatment for the client with ascites is a negative sodium balance to reduce fluid retention. Table salt, salty foods, salted butter and margarine, and all ordinary canned and frozen foods that are not specifically prepared for low-sodium diets should be avoided. Spironolactone (Aldactone), an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. Transjugular intrahepatic portosystemic shunt (TIPS) is a method of treating ascites in which a cannula is threaded into the portal vein by the transjugular route. In clients with ascites, an upright posture is associated with activation of the renin-angiotensin-aldosterone system and sympathetic nervous system. This causes reduced renal glomerular filtration and sodium excretion and a decreased response to loop diuretics. Therefore, bed rest may be a useful therapy, especially for clients whose condition is refractory to diuretics. Other measures include assessment and documentation of intake and output, abdominal girth, and daily weight to assess fluid status.
Which liver function study is used to show the size of the liver and hepatic blood flow and obstruction? - Magnetic resonance imaging (MRI) - Angiography - Radioisotope liver scan - Electroencephalography (EEG)
Correct response: Radioisotope liver scan Explanation: A radioisotope liver scan assesses liver size and hepatic blood flow and obstruction. MRI is used to identify normal structures and abnormalities of the liver and biliary tree. Angiography is used to visualize hepatic circulation and detect the presence and nature of hepatic masses. EEG is used to detect abnormalities that occur with hepatic coma.
The nurse is asking the client with acute pancreatitis to describe the pain. What pain symptoms does the client describe related to acute pancreatitis? - Dull pain, points to epigastric area - Sharp, stabbing pain in the left lower quadrant of the abdomen - Severe mid-abdominal to upper abdominal pain radiating to both sides and to the back - Severe abdominal pain that radiates to the right shoulder
Correct response: Severe mid-abdominal to upper abdominal pain radiating to both sides and to the back Explanation: The most common complaint of clients with pancreatitis is severe mid-abdominal to upper abdominal pain, radiating to both sides and straight to the back. The other answers are not pain that is usually associated with acute pancreatitis.
A nurse assesses a patient diagnosed with hepatic encephalopathy. She observes a number of clinical signs, including asterixis and fetor hepaticus; the patient's electroencephalogram (EEG) is abnormal. The nurse documents that the patient is exhibiting signs of which stage of hepatic encephalopathy? - Stage 1 - Stage 2 - Stage 3 - Stage 4
Correct response: Stage 2 Explanation: The signs listed in the question plus disorientation, mood swings, and increased drowsiness are all indicators of stage 2 hepatic encephalopathy. Refer to Table 25-2 in the text.
A nurse is educating a client who has been treated for hepatic encephalopathy about dietary restrictions to prevent ammonia accumulation. What should the nurse include in the dietary teaching? - Decrease the amount of fats in the diet. - Increase the amount of potassium in the diet. - The amount of protein is not restricted in the diet. - Increase the amount of magnesium in the diet.
Correct response: The amount of protein is not restricted in the diet. Explanation: Clients with hepatic encephalopathy and their families are advised that protein intake should not be restricted in hepatic encephalopathy, as was recommended in the past. Protein intake should be maintained at 1.2 to 1.5 g/kg per day. Electrolyte balance may need to be corrected with some clients, but there are no specific recommendations for potassium and magnesium. Fat intake is not limited in clients who have hepatic encephalopathy.
Which medication is used to decrease portal pressure, halting bleeding of esophageal varices? - Spironolactone - Vasopressin - Nitroglycerin - Cimetidine
Correct response: Vasopressin Explanation: Vasopressin may be the initial therapy for esophageal varices because it produces constriction of the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Spironolactone and cimetidine do not decrease portal hypertension.
Which symptoms will a nurse observe most commonly in clients with pancreatitis? - severe, radiating abdominal pain - black, tarry stools and dark urine - increased and painful urination - increased appetite and weight gain
Correct response: severe, radiating abdominal pain Explanation: The most common symptom in clients with pancreatitis is severe midabdominal to upper abdominal pain, radiating to both sides and straight to the back.
A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should: - place the client in a private room. - wear a mask when handling the client's bedpan. - wash her hands after touching the client. - wear a gown when providing personal care for the client.
Correct response: wash her hands after touching the client. Explanation: To maintain enteric precautions, the nurse must wash her hands after touching the client or potentially contaminated articles and before caring for another client. A private room is warranted only if the client has poor hygiene — for instance, if the client is unlikely to wash the hands after touching infective material or is likely to share contaminated articles with other clients. For enteric precautions, the nurse need not wear a mask and must wear a gown only if soiling from fecal matter is likely.