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What assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy?
1. Passage of two or three soft stools daily
2. Evidence of watery diarrhea
3. Daily dterioration in the client's hand-writing
4. Appearance of frothy, foul smelling stools
1. Passageof two or three soft stools daily
- *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 handwriting indicates an increase in ammonia level and worsening of hepatic encephalopathy.
- -Frothy, foul-smelling stools indicate steatorrhea, caused by imapaired fat digestion
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For the client with jaundice, which statement indicates that the nurse understands the rationale for instituting skin care measures?
1. Jaundice is associated with pressure ulcer formation
2. Jaundice impairs urea production
3. Jaundice produces pruritis due to impaired bile acid excretion
4. Jaundice leads to decreased tissue perfusion and subsequent breakdown
3. Jaundice produces pruritis due to impaired bile acid excretion
*Jaundice is a symptom characterized by increased bilirubin concentration in the blood. Bile acid exretion is impaired, increasing the bile acids in the skin and causing pruritis.
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What rationale supports explaining the placement of an esophageal tamponade tube in a client who is hemorrhaging?
1. Obtaining cooperation and reducing fear
2. Beginning teaching for home care
3. Allowing the client to help insert the tube
4. Maintaining the client's level of anxiety and alertness
1. Obtaining cooperation and reducing fear
*An esophageal tamponade tube would be inserted in critical situations. Typically, the client is fearful and highly anxious. The nurse therefore explains about the placement to help obtain the client's cooperation and reduce his fear. This type of tube is used only short term and is not indicated for home use. The tube is large and uncomfortable. The client would not be helping to insert the tube. A client's anxiety should be decreased, not maintained, and depending on the degree of hemorrhage, the client may not be alert.
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Which nursing intervention would be most helpful for a client with chronic pancreatitis?
1. Modifying dietary protein
2. Encouraging daily exercise
3. Allowing liberalized fluid intake
4. Counseling to stop alcohol consumption
4. Counseling to stop alcohol consumption
*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.
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A client is in end-stage liver failure. Which intervention should the nurse implement when addressing hepatic encephalopathy? (select all that apply)
1. Assessing the client's neurologic status every 2 hrs
2. Monitoring the client's hemoglobin and hematocrit levels
3. Evaluating the client's serum ammonia level
4. Monitoring the client's handwriting daily
5. Preparing to insert and esophageal tamponade tube
6. Making sure the client's fingernails are short
- 1. Assessing the client's neurologic status every 2 hrs
- 3. Evaluating the client's serum ammonia level
- 4. Monitoring the client's handwriting daily
*Hepatic encephalopathy results from an increased ammonia level due to the liver's inability to convert 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 addresses jaundice.
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Whih instruction would be included in the teaching plan for the client taking antacids?
1. Take the antacid with 8oz of water
2. Avoid taking other medications within 2 hrs of this one
3. Continue taking antacids even when pain subsides
4. Weigh yourself daily when taking this medication
2. Avoid taking other medications within 2 hrs of this one
- *Antacids neutralize gastric acid and decrease the absorption of other medications.
- -Water dilutes the antacid
- -A histamine receptor antagonist should be taken even when pain subsides
- -Daily weights are indicated for client taking diuretic, not antacid
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Which clinical manifestation would the nurse expect a client diagnosed with acute cholecystitis to exhibit?
1. Nausea, vomiting, and anorexia
2. Ecchymosis, petechiae, and coffee-ground emesis
3. Jaundice, dark urine, and steatorrhea
4. Acute RLQ pain, diarrhea, and dehydration
1. Nausea, vomiting, and anorexia
*Acute cholecystitis is an acute inflammation of the gallbladder commonly manifested by the following: anorexia, nausea, and vomiting; biliary colic; tenderness and rigidity in the RUQ elicited on palpation (Murphy's sign); fever; fat intolerance; and S/S of jaundice.
- -Ecchymosis, petechiae, and coffee-ground emesis are S/S of esophageal bleeding. The coffee-ground appearance indicates old bleeding.
- -Jaundice, dark urine, and steatorrhea are S/S of icteric phase of hepatitis.
- -RLQ pain is commonly present w/appendicitis. Pain of cholecystitis is typically located in the RUQ, not RLQ.
- -Diarrhea and dehydration are not common w/acute cholecystitis.
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Which intervention should the nurse include in the POC for a patient with acute pancreatitis?
1. Administration of vasopressin and insertion of a balloon tamponade
2. Preparation for a paracentesis and administration of diuretics
3. Maintenance of NPO status and insertion of a nasogastric (NG) tube with low intermittent suction
4. Dietary plan of a low-fat diet and increased fluid intake to 2,000 mL/day
3. Maintenance of NPO status and insertion of a nasogastric (NG) tube with low intermittent suction
- *With acute pancreatitis, the client is kept on NPO 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 ABD distention, and remove hydrochloric acid.
- -Vasopressin would be appropriate for a pt diagnosed w/bleeding esophageal varices.
- -Paracentesis and diuretics would be appropriate for a pt diagnosed w/portal hypertension and ascites.
- -A low-fat diet and increased fluid intake would further aggravate the pancreatitis
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When teaching a client about pancreatic function, the nurse understands that pancreatic lipase performs with function?
1. Breaks down fat into fatty acids and glycerol
2. Transports fatty acids into the brush boarder
3. Triggers cholecystokinin to contract the gallbladder
4. Breaks down protein into dipeptides and amino acids
1. Breaks down fat into fatty acids and glycerol
*Lipase hydrolyzes or breaks down fat into fatty acids and glycerol. Lipase is not involved with the transport of fatty acids into the brush boarder. Fat itself trigger cholecystokinin release. Protein breakdown into dipeptides and amino acids is the function of typsin, not lipase.
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After administering diuretic therapy to a client with ascites, which nursing action would be most effective in ensuring safe care?
1. Measuring serum potassium for hyperkalemia
2. Assessing the client for hypervolemia
3. Measuring the client's weight weekly
4. Documenting precise I&O
4. Documenting precise I&O
- *For the client with ascites receiving diuretic therapy, careful I&O 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 pt 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.
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Which outcome would be most appropriate for the client in hepatic coma?
1. The client is oriented to person, place, and time
2. The client exhibits no ecchymotic areas
3. The client increases oral intake to 2,000 kcal/day
4. The client exhibits increased serum albumin level
1. The client is oriented to person, place, and time
- *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 person, place, and time.
- -Ecchymotic areas are r/t decreased synthesis of clotting factors.
- -Although oral intake may be r/t LOC, it is more closely r/t anorexia.
- -The serum albumin level reflects hepatic synthetic ability, not LOC.
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Which nursing intervention would be included in the POC for the client w/jaundice who is experiencing pruritis?
1. Keeping the client's fingernails short and smooth
2. Applying pressure when giving IM injections
3. Decreasing the client's dietary protein intake
4. Administering vitamin K SubQ
1. Keeping the client's fingernails short and smooth
- *The client with pruritis 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 IM injections and administering vitamin K subQ are important if the client develops bleeding problems.
- -Decreasing the client's dietary protein intake is appropriate if the client's ammonia levels are increased.
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Which diet, when selected by the client with cholecystitis, indicates that the nurse's teaching has been successful?
1. Six small meals of low-carbohydrate foods daily
2. High-fat, high-carbohydrate meals
3. Low-fat, high-carbohydrate meals
4. High-fat, low-protein meals
3. Low-fat, high-carbohydrate meals
- *For the client with cholecystitis, fat intake should be reduced. The kcal from fat should be substituted with carbohydrates.
- -Reducing carbohydrate intake would be contraindicated.
- -Any diet high in fat may lead to another attack of cholecystitis.
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Which assessment finding indicates a complication after percutaneous transhepatic cholangiography?
1. Fever and chills
2. Hypertension
3. Bradycardia
4. Nausea and diarrhea
1. Fever and chills
- *Septicemia is a common complication after a percutaneous transhepatic cholangiography. Evidence of fever and chills, possibly indicative of septicemia, is important.
- -Hypotension, not hypertension, is associated with septicemia.
- -Tachycardia, not bradycardia, is most likely to occur.
- -Nausea and diarrhea may occur but are not classic signs of sepsis.
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When planning home care for a client with hepatitis A, which preventive measure should be emphasized to protect the client's family?
1. Keeping the client in complete isolation
2. Using good sanitation with dishes and shared bathrooms
3. Avoiding contact with blood-soiled clothing or dressings
4. Forbidding the sharing of needles or syringes
2. Using good sanitation with dishes and shared bathrooms
- *Hepatitis A is transmitted through the fecal-oral route or from contaminated water or food. Measures to protect the family include good handwashing, personal hygiene and sanitation, and use of standard precautions.
- -Complete isolation is not required.
- -Avoiding contact w/blood-soiled clothing/dressings or avoiding sharing of needles or syringes are precautions needed to prevent transmission of hepatitis B.
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Which intervention would be most important for the client with hepatic cirrhosis who has altered clotting mechanisms?
1. Allowing complete independence of mobility
2. Applying pressure to injection sites
3. Administering antibiotics as prescribed
4. Increasing nutritional intake
2. Applying pressure to injection sites
- *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.
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