Ignatavicius Chapter 58 (Evolve)

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 does the nurse take first?

A. Obtain the charts from the previous admission.

B. Listen for bowel sounds in all quadrants.

C. Obtain pulse and blood pressure.

D. Ask about abdominal pain.

C. Obtain pulse and blood pressure.

When caring for a newly admitted client with esophageal varices and vomiting of blood, the nurse would first assess vital signs to detect hypovolemic shock caused by hemorrhage. Assessment for adequate perfusion is the highest priority at this time. Obtaining charts from the previous admission, assessing bowel sounds, and pain assessment can be delayed until the client has stabilized.

The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose?

A. To aid in digestion of dairy products

B. To reduce portal pressure

C. To promote gastrointestinal (GI) excretion of ammonia

D. To reduce the risk of GI bleeding

C. To promote gastrointestinal (GI) excretion of ammonia

In a client with cirrhosis, the administration of lactulose reduces serum ammonia levels by causing the client to excrete ammonia through the GI tract. Lactase, not lactulose, is the enzyme that aids in the digestion of dairy products. The mechanism of action of lactulose is not to reduce portal pressure. Lactulose does not affect bleeding.

How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Evalose)?

A. Provides small frequent meals for the client

B. Suggests taking daily potassium supplements

C. Elevates the head of the bed in high-Fowler's position

D. Requests a bedside commode for the client

D. Requests a bedside commode for the client

The home care nurse best modifies the client's home environment to manage side effects of lactulose by making a bedside commode available to the client. Lactulose therapy increases the frequency of stools. A bedside commode is especially necessary if the client has difficulty reaching the toilet. Small frequent meals and elevating the head of the bed will not have any effect on the side effects of lactulose. Although lactulose produces excessive stools and could potentially result in loss of potassium, it is inappropriate for the nurse to suggest that the client take potassium supplements.

Which activity by the nurse will best relieve symptoms associated with ascites?

A. Administering oxygen

B. Elevating the head of the bed

C. Monitoring serum albumin levels

D. Administering intravenous fluids

B. Elevating the head of the bed

The best action by the nurse caring for a client with ascites is to elevate the head of the bed. The enlarged abdomen of ascites limits respiratory excursion. Fowler's position will increase excursion and reduce shortness of breath. The client may need oxygen, but first the nurse would raise the head of the bed to improve respiratory excursion and oxygenation. Monitoring serum albumin levels will detect anticipated decreased levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

When providing dietary teaching to a client with hepatitis, what practice does the nurse recommend?

A. Having a larger meal early in the morning

B. Consuming increased carbohydrates and moderate protein

C. Restricting fluids to 1500 mL/day

D. Limiting alcoholic beverages to once weekly

B. Consuming increased carbohydrates and moderate protein

To repair the liver, the nurse recommends that the client adopt a high-carbohydrate and moderate-protein diet. Fats may cause dyspepsia. The client with hepatitis feels full easily and needs to have four to six small meals daily. Fluids are restricted with ascites caused by cirrhosis. Not all clients with hepatitis progress to cirrhosis. Complete abstention from alcohol is necessary until the liver enzymes return to normal.

Which problem for a client with cirrhosis takes priority?

A. Insufficient knowledge related to the prognosis of the disease process

B. Discomfort related to the progression of the disease process

C. Potential for injury related to hemorrhage

D. Inadequate nutrition related to an inability to tolerate usual dietary intake

C. Potential for injury related to hemorrhage

Potential for injury related to hemorrhage is the priority client problem because this complication could be life threatening. Insufficient knowledge of the prognosis of the disease process, discomfort, and inadequate nutrition are not priorities because these issues are not immediately life threatening.

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease?

A. "Cirrhosis is a chronic disease that has scarred my liver."

B. "The scars on my liver create problems with blood circulation."

C. "Because of the scars on my liver, blood clotting and blood pressure are affected."

D. "My liver is scarred, but the cells can regenerate themselves and repair the damage."

D. "My liver is scarred, but the cells can regenerate themselves and repair the damage."

The client's statement that, although his liver is scarred, the cells can regenerate and repair the damage indicates that further instruction is needed. Although cells and tissues will attempt to regenerate, destroyed liver cells will result in permanent scarring and irreparable damage. Cirrhosis is a chronic condition that leaves scars on the liver. Permanent scars form in response to attempts by the cells to regenerate and create problems in blood circulation moving through the liver. Liver scarring will create problems with blood clotting, cholesterol levels, and blood pressure, as well as with the metabolism of drugs and toxins.

When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)?

A. Kidney failure

B. Refractory ascites

C. Fetor hepaticus

D. Paracentesis scheduled for today

A. Kidney failure

The nurse would question the use of neomycin for a client with kidney failure. Aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and must not be taken by clients with hepatic encephalopathy. Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.

When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B?

A. Clients who work with shellfish

B. Men who engage in sex with men

C. Clients traveling to a third-world country

D. Clients with elevations of aspartate aminotransferase and alanine aminotransferase

B. Men who engage in sex with men

Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity. Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A. Hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.

When preparing a client to undergo paracentesis, which action is necessary to reduce potential injury as a result of the procedure?

A. Encourage the client to take deep breaths and cough

B. Ask the client to void prior to the procedure

C. Position the client with the head of the bed flat

D. Assist the physician to insert a trocar catheter into the abdomen

B. Ask the client to void prior to the procedure

To avoid injury to the bladder during a paracentesis, the client would be asked to void prior to the procedure (Chart 58-1).Taking deep breaths and coughing does not prevent complications or injury as a result of paracentesis. Clients would be positioned with the head of the bed elevated. The trocar catheter is used to drain the ascetic fluid and does not reduce the risk of damage to the bladder.

A 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?

A. Requesting vaccination for hepatitis A

B. Using a needleless system in daily work

C. Getting the three-part hepatitis B vaccine

D. Requesting an injection of immunoglobulin

D. Requesting an injection of immunoglobulin

The highest priority intervention to help prevent the health care worker from developing Hepatitis A after exposure to the disease is requesting the administration of immunoglobulin, antibodies to hepatitis A. The vaccine for hepatitis A will take several weeks to stimulate the development of antibodies. Passive immunity in the form of immunoglobulin is needed. Implementing a needleless system and getting the three-part vaccine may prevent the development of hepatitis B, not hepatitis A.

What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection?

A. The client must not consume alcohol.

B. Avoid sharing the bathroom with the client.

C. Members of the household must not share toothbrushes.

D. Drink only bottled water and avoid ice.

C. Members of the household must not share toothbrushes.

The nurse teaches the family of a client with Hepatitis C that toothbrushes, razors, towels, and any other items may spread blood and body fluids and must not be shared. The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water needs to be avoided.

When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these?

A. Vitamin K-containing products

B. Potassium-sparing diuretics

C. Nonabsorbable antibiotics

D. Nonsteroidal anti-inflammatory drugs (NSAIDs)

D. Nonsteroidal anti-inflammatory drugs (NSAIDs)

The nurse must emphasize avoidance of NSAIDs when providing discharge teaching to a client with cirrhosis. The client with cirrhosis has an increased risk of hemorrhage. Clients who have cirrhosis must not take NSAIDs because they may predispose to bleeding. Products containing vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia levels

The nurse is caring for clients in the outclient clinic. Which of these phone calls would the nurse return first?

A. Client with hepatitis A reporting severe and ongoing itching

B. Client with severe ascites who has a temperature of 101.4°F (38°C)

C. Client with cirrhosis who has had a 3-pound (1.4 kg) weight gain over 2 days

D. Client with esophageal varices and mild right upper quadrant pain

B. Client with severe ascites who has a temperature of 101.4°F (38°C)

The nurse will first call the client with severe ascites and a temperature of 101.4 (38°C).This client may have spontaneous bacterial peritonitis. Itching is anticipated with jaundice, so this client may be called last. Weight gain with cirrhosis is not uncommon owing to low albumin levels. Cirrhosis may cause mild right upper quadrant pain. This client would be called after the client with severe ascites.

The nurse is caring for a client who has cirrhosis of the liver. The client has exhibited hand flapping and mental confusion for several weeks. Although the mental confusion is worsening, the client has stopped exhibiting hand flapping movements. How will the nurse interpret these findings?

A. The client's symptoms are progressing and getting worse.

B. The client's serum ammonia levels are decreasing.

C. The client probably has a decrease in serum proteins.

D. The client is showing signs of improvement.

A. The client's symptoms are progressing and getting worse.

The nurse interprets these findings as an indication that the client's is getting worse. Clients with cirrhosis who exhibit asterixis or hand flapping, may eventually stop exhibiting this sign as they worsen. The fact that the client's mental confusion is worsening indicates that this is the case. Increased mental confusion is related to elevated, not decreased, ammonia levels, as well as other serum proteins. The client is worsening, not improving.

When caring for a client with portal hypertension, the nurse assesses for which potential complications? (select all that apply)

A. Esophageal varices

B. Hematuria

C. Fever

D. Ascites

E. Hemorrhoids

A. Esophageal varices

D. Ascites

E. Hemorrhoids

Potential complications of portal hypertension include esophageal varices, ascites, and hemorrhoids. Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid).Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

The RN is caring for a client with end-stage liver disease who has ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)?

A. Assessing skin integrity and abdominal distention

B. Drawing blood from a central venous line for electrolyte studies

C. Evaluating laboratory study results for the presence of hypokalemia

D. Placing the client in a semi-Fowler's position

D. Placing the client in a semi-Fowler's position

The nurse delegates the client who needs to be placed in a semi-Fowler's position to the UAP. Positioning the client in this position is included within UAP education and scope of practice, although the RN will need to supervise the UAP in providing care and will evaluate the effect of the semi-Fowler's position on the client's comfort and breathing. Assessment of skin integrity and abdominal distention, obtaining blood from a central line, and evaluation of laboratory results must be done by the RN.

Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the health care provider (HCP)?

A. The dressing has a 2-cm area of serous drainage.

B. The client's platelet count is 135,000/mm3 (135 × 109/L).

C. The client's albumin level is 2.8 g/dL (28 g/L).

D. The client's heart rate is 122 beats/min.

D. The client's heart rate is 122 beats/min.

After a paracentesis with 2500 ml of fluid removed, the assessment finding of the client's heart rate is the most important finding to communicate to the HCP. Rapid removal of fluid may cause symptoms of shock, including tachycardia, and are especially associated with hypotension. A small amount of serous fluid may leak, so the dressing would be reinforced. Platelets will be checked before the procedure. These are slightly low, but this is not a cause for concern. An albumin level of 2.8 g/dL (28 g/L) is an expected finding for a client with cirrhosis and is not life threatening.

When assessing a client with hepatitis B, the nurse anticipates which assessment findings? (select all that apply)

A. Recent influenza infection

B. Brown stool

C. Tea-colored urine

D. Right upper quadrant tenderness

E. Itching

C. Tea-colored urine

D. Right upper quadrant tenderness

E. Itching

Assessment findings the nurse expects to find in a client with Hepatitis B include brown, tea-, or cola-colored urine, right upper quadrant pain due to inflammation of the liver, and itching, irritating skin caused by deposits of bilirubin on the skin secondary to high bilirubin levels and jaundice. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored, and not typically brown.