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26 Cards in this Set
- Front
- Back
- 3rd side (hint)
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1. Which statement by the client with cirrhosis indicates that further instruction is needed about the disease? |
* "Cirrhosis is a chronic disease that has scarred my liver." * "The scars on my liver create problems with blood circulation." * "Because of the scars on my liver, blood clotting and blood pressure are affected." * "My liver is scarred, but the cells can regenerate themselves and repair the damage." |
"My liver is scarred, but the cells can regenerate themselves and repair the damage." Correct Correct: Although cells and tissues will attempt to regenerate, this will result in permanent scarring and irreparable damage. |
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2. Which problem for the client with cirrhosis takes priority? |
* Insufficient knowledge related to prognosis of disease process * Discomfort related to progression of disease process * Potential for injury related to hemorrhage * Inadequate nutrition related to inability to tolerate usual dietary intake |
Potential for injury related to hemorrhage Correct Correct: This is the priority client problem because this complication could be life threatening. |
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3. How does the home care nurse best modify the home environment to manage side effects of lactulose ? |
* Provides small frequent meals for the client * Suggests taking daily potassium supplements * Elevates the head of the bed in high Fowler's position * Requests a bedside commode for the client |
Requests a bedside commode for the client Correct Correct: Lactulose therapy increases the frequency of stools; a bedside commode should be made available to the client, especially if he or she has difficulty reaching the toilet. |
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4. In caring for the client who has undergone paracentesis, which changes in the client's status should be promptly reported to the provider? |
* Increased blood pressure, increased respiratory rate * Decreased blood pressure, increased heart rate * Increased respiratory rate, increased apical pulse, pallor * Tachypnea, diaphoresis, increased blood pressure |
Decreased blood pressure, increased heart rate Correct Correct: Decreased blood pressure and increased heart rate are indicative of shock. |
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5. When caring for a client with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? Select all that apply. |
* Prolonged partial thromboplastin time (PTT) * Icterus of skin * Swollen abdomen * Elevated magnesium * Currant jelly stool * Elevated amylase level |
* Prolonged partial thromboplastin time (PTT) Correct * Icterus of skin Correct * Swollen abdomen Correct * Elevated magnesium * Currant jelly stool Incorrect * Elevated amylase level Incorrect Correct Feedback: Correct: The liver produces clotting factors; when damaged, prolonged coagulation times and bleeding may result. Incorrect Feedback: Incorrect: Currant jelly stool is consistent with intussusception, a type of bowel obstruction. |
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6. The nurse administers lactulose (Cephulac) to the client with cirrhosis for which purpose? |
* Provides enzymes necessary to digest dairy productions * Reduces portal pressure * Promotes gastrointestinal excretion of ammonia * Decreases gastrointestinal bleeding |
Promotes gastrointestinal excretion of ammonia Correct Correct: Lactulose reduces serum ammonia levels by excreting ammonia through the GI tract. |
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7. When providing discharge teaching to the client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? |
* Vitamin K-containing products * Potassium-sparing diuretics * Nonabsorbable antibiotics * Nonsteroidal anti-inflammatory drugs |
Nonsteroidal anti-inflammatory drugs Correct Correct: Nonsteroidal anti-inflammatory drugs may predispose to bleeding and are to be avoided. |
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8. When caring for the client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? |
* Kidney failure * Refractory ascites * Fetor hepaticus * Paracentesis scheduled for today |
Kidney failure Correct Correct: The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic. |
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9. Which activity by the nurse will best relieve symptoms associated with ascites? |
* Administering oxygen * Elevating the head of the bed * Monitoring serum albumin levels * Administering intravenous fluids |
Elevating the head of the bed Correct Correct: The enlarged abdomen of ascites limits respiratory excursion; Fowler's position will increase excursion and reduce shortness of breath. |
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10. The nurse is caring for clients in the outpatient clinic. Which of these phone calls should the nurse return first? |
* From the client with hepatitis A reporting severe and ongoing itching * From the client with severe ascites who has a temperature of 101.4° F (38° C) * From the client with cirrhosis who has had a 3-pound weight gain over 2 days * From the client with esophageal varices and mild right upper quadrant pain |
From the client with severe ascites who has a temperature of 101.4° F (38° C) Correct Correct: The client with ascites and an elevated temperature may have spontaneous bacterial peritonitis; the nurse should call this client first. |
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11. A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action should the nurse take first? |
* Obtain the charts from the previous admission. * Listen for bowel sounds in all quadrants. * Obtain pulse and blood pressure. * Ask about abdominal pain. |
Obtain pulse and blood pressure. Correct Correct: The nurse assesses vital signs to detect hypovolemic shock caused by hemorrhage. |
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12. Following paracentesis, during which 2500 mL of fluid has been removed, which assessment finding is most important to communicate to the physician? |
* The dressing has a 2-cm area of serous drainage. * The client's platelet count is 135,000/mm3 . * The client's albumin level is 2.8 mg/dL. * The client's heart rate is 122. |
The client's heart rate is 122. Correct Correct: Rapid removal of fluid may cause symptoms of shock; report tachycardia, especially when associated with hypotension. |
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13. When providing community education, the nurse emphasizes that which group should receive immunization for hepatitis B? |
* Clients who work with shellfish * Men who prefer sex with men * Clients traveling to Third World country * Clients with elevations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) |
Men who prefer sex with men Correct Correct: Men who prefer sex with men are at increased risk for hepatitis B, which is spread by exchange of blood and body fluids during sexual activity. |
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14. When assessing a client with hepatitis B, the nurse anticipates finding which of these? Select all that apply. |
* Recent influenza infection * Brown stool * Tea-colored urine * Right upper quadrant tenderness * Itching |
* Recent influenza infection * Brown stool * Tea-colored urine Correct * Right upper quadrant tenderness Correct * Itching Correct Correct Feedback: Correct: The urine may be brown, tea, or cola colored in clients with hepatitis. Incorrect Feedback: Incorrect: Hepatitis B virus, not the influenza virus, is spread by blood and body fluids. |
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15. When providing dietary teaching to the client with hepatitis, the nurse includes which information? |
* Larger meal early in the morning * Increased carbohydrates and moderate protein * Fluids restricted to 1500 mL per day * Alcoholic beverages limited to once weekly |
Increased carbohydrates and moderate protein Correct Correct: To repair the liver, the client should have a high-carbohydrate and moderate-protein diet; fats may cause dyspepsia. |
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16. The nurse is providing teaching to the client with hepatitis C. Which information is essential to include? |
* Pegylated interferon alpha may cause myalgia. * When ribavirin is taken, contraception must be used. * Immunoglobulin B should be received upon diagnosis. * A diet moderate in protein, fats, and carbohydrates should be consumed. |
When ribavirin is taken, contraception must be used. Correct Correct: Fetal abnormalities are associated with ribavirin; this is essential information. |
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17. When assessing a client for hepatic cancer, the nurse anticipates finding an elevation in which of these? |
* Hemoglobin and hematocrit * Leukocytes * Alpha-fetoprotein * Serum albumin |
Alpha-fetoprotein Correct Correct: Fetal hemoglobin is abnormal in adults; it is a tumor marker indicative of cancers. |
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18. It is essential that the nurse should monitor the client returning from hepatic artery embolization for hepatic cancer for which of these? |
* Right shoulder pain * Polyuria * Bone marrow suppression * Bleeding |
Bleeding Correct Correct: An arterial approach is taken; therefore prompt detection of hemorrhage is the priority. |
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19. When caring for a client awaiting liver transplantation, the nurse recognizes that the client will be excluded from the procedure if which of these is present? |
* Colon cancer with metastasis to the liver * Hypertension * Hepatic encephalopathy * Ascites and shortness of breath (SOB) |
Colon cancer with metastasis to the liver Correct Correct: Transplantation is performed for hepatitis and primary liver cancers. |
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20. The nurse asks the client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? |
* Positive Babinski's sign * Hyperreflexia * Kehr's sign * Asterixis |
Asterixis Correct Correct: Liver flap or asterixis is related to increased serum ammonia levels. The dorsiflexed hands begin to flap upward and downward when outstretched for a few moments. |
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21. Which is important for the nurse to include in the plan of care for a client who is to undergo paracentesis later today? |
* Measure and record drainage. * Monitor aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase. * Obtain informed consent for the procedure. * Have the client void before the procedure is performed. |
Have the client void before the procedure is performed. Correct Correct: Voiding before the procedure prevents bladder injury. |
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22. What teaching does the home care nurse give the client and family to prevent spread of hepatitis C? |
* Do not consume alcohol. * Avoid sharing the bathroom with the client. * Prohibit members of the household from sharing toothbrushes. * Drink only bottled water, and avoid ice. |
Prohibit members of the household from sharing toothbrushes. Correct Correct: Toothbrushes, razors, towels, and items that may spread blood and body fluids are not shared. |
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23. The health care worker believes that he may have been exposed to hepatitis A. Which intervention is the highest priority to prevent him from developing the disease? |
* Requesting vaccination for hepatitis A * Using a needleless system in daily work * Getting the three-part hepatitis B vaccine * Requesting injection of immunoglobulin |
Requesting injection of immunoglobulin Correct Correct: Administration of immunoglobulin, antibodies to hepatitis A, may prevent development of the disease. |
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24. The client is scheduled to undergo a liver transplantation. Which nursing intervention is most likely to prevent the complications of bile leakage and abscess formation? |
* Prevent hypotension. * Keep the T-tube in a dependent position. * Administer antibiotic vaccinations. * Administer immune suppressant drugs. |
Keep the T-tube in a dependent position. Correct Correct: Keeping the T-tube in a dependent position and secured to the client is likely to prevent bile leakage, abscess formation, and hepatic thrombosis. |
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25. The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN? |
* A client who is taking lactulose and has diarrhea * A client with hepatitis C who requires a dressing change * A client with end-stage cirrhosis who needs teaching about a low-sodium diet * An obtunded client with alcoholic encephalopathy for whom a blood draw has been requested |
A client with end-stage cirrhosis who needs teaching about a low-sodium diet Correct Correct: The RN is responsible for client teaching. |
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26. The RN has just received change-of-shift report on a client medical unit. Which client should the RN see first? |
* The client with ascites who had a paracentesis 2 hours ago and is reporting a headache * The client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse * The client with hepatic cirrhosis and jaundice who has hemoglobin of 10.9 g/dL and thrombocytopenia * The client with hepatitis A who has elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST) |
The client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse Correct Correct: A change in the level of consciousness of the client with PSE is the greatest concern; actions to improve the client's level of consciousness should be rapidly implemented. |
