(61) When caring for a client with advanced cirrhosis, what laboratory assessment findings will the nurse expect? Select all that apply.
A. Increased serum albumin
B. Decreased bilirubin in the urine
C. Increased alanine aminotransferase
D. Increased alkaline phosphatase
E. Decreased bilirubin in the stool
F. Increased platelets
C, D, E
Rationale: Serum levels of alanine aminotransferase (ALT) may be elevated because these enzymes are released into the blood during hepatic inflammation.
Alkaline phosphatase is also increased.
Fecal urobilinogen concentration is decreased in clients with biliary tract obstruction; these clients have light- or clay-colored stools.
Total serum albumin levels are decreased in clients with severe or chronic liver disease as a result of decreased synthesis by the liver.
Bilirubin in the urine would be increased—when liver function is impaired or when biliary drainage is blocked, conjugated bilirubin leaks out of the hepatocytes and appears in the urine, turning the urine dark amber.
Platelets would be decreased—splenomegaly often occurs with cirrhosis and results from the backup of blood into the spleen. The enlarged spleen destroys platelets, causing thrombocytopenia (low serum platelet count) and an increased risk for bleeding.
(61) A 27-year-old secretary is preparing to fly home to visit her mother. Her best friend, who is a nurse, notices that the woman has yellowish skin and icterus. He asks if she has noticed any changes in her urine and bowel movements. She responds that she has noticed that her urine is dark and her stool has been much lighter for the past week. He tells her that she may have hepatitis or some other liver problem and takes her to the emergency department, where she is diagnosed with hepatitis A. She is very dehydrated and weak and is admitted for overnight hydration, additional testing, and observation. You have been assigned to take care of her this AM.
1. What transmission precautions will you provide for this patient and why? Should her friend who is a nurse be treated in any way? Why or why not?
Use Standard Precautions to prevent the transmission of disease between patients or between patients and health care staff. If the friend believes he has been exposed to the virus via the oral-fecal route, he should seek medical attention immediately for immunoglobulin (Ig) administration. Furthermore, the friend should consider getting the hepatitis A and B vaccines or the combination vaccinations if he has not done so. If the friend has not been exposed, there is no need for any special treatment.
2. The patient is very upset that she is not able to fly home and see her mother, who is ill. She asks you when she will be able to take the trip. What is your best response to her concerns?
The nurse should explain that she will need to wait until she is feeling stronger. Furthermore, she should not expose her ill mother to hepatitis A because her mother would be more susceptible to contracting it if the daughter stays with her during the visit.
3. How will you determine when the patient is adequately rehydrated?
Normalization of the patient’s sodium levels and BUN value indicates rehydration. Normal skin turgor, near-equal intake and output values, and a light-yellow urine color are also indications. Assessing daily weight is another method to determine fluid volume status.
4. What health teaching will you provide before she goes home?
Teaching should include self-care measures, such as:
· Avoiding all medications (including OTC drugs) unless prescribed
· Avoiding all alcohol
· Resting frequently throughout the day, and getting adequate sleep at night
· Eating small, frequent meals with a high-carbohydrate, moderate-fat, and moderate-protein content
· Avoiding transmission by refraining from sexual intercourse, maintaining adequate sanitation and personal hygiene, washing hands before eating and after toileting, drinking purified water, covering cuts or sores with bandages, and not sharing linens, eating utensils, razors, nail clippers, or drinking glasses with others.
(61) When caring for a client with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? Select all that apply.
A. Prolonged partial thromboplastin time (PTT)
B. Icterus of skin
C. Swollen abdomen
D. Elevated magnesium
E. Currant jelly stool
F. Elevated amylase level
A, B, C
Incorrect: Currant jelly stool is consistent with intussusception, a type of bowel obstruction.
Incorrect: Cirrhosis is consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase; amylase is typically elevated in pancreatitis.
(61) The nurse administers lactulose (Cephulac) to the client with cirrhosis for which purpose?
A. Promotes gastrointestinal excretion of ammonia
(61) When providing discharge teaching to the client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these?
A. Nonsteroidal anti-inflammatory drugs
Incorrect: The client with cirrhosis is prone to bleeding; vitamin K can decrease bleeding; it is not necessary to restrict this in the diet.
Incorrect: Potassium-sparing diuretics are used to reduce ascites.
Incorrect: Nonabsorbable antibiotics are used to decrease ammonia levels.
Correct: Nonsteroidal anti-inflammatory drugs may predispose to bleeding and are to be avoided.
(61) When caring for the client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)?
B. Kidney failure
Correct: The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic.
Incorrect: Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known.
Incorrect: Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels.
Incorrect: 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.
(61) The nurse is caring for clients in the outpatient clinic. Which of these phone calls should the nurse return first?
D. From the client with severe ascites who has a temperature of 101.4° F (38° C)
Incorrect: Itching is anticipated with jaundice, this client may be called last.
Correct: The client with ascites and an elevated temperature may have spontaneous bacterial peritonitis; the nurse should call this client first.
Incorrect: Weight gain is not uncommon owing to low albumin levels.
Incorrect: Cirrhosis may cause mild right upper quadrant; phone this client after Client B.
(61) 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?
D. Obtain pulse and blood pressure.
Hypovolemic shock is the first concern
(61) When providing community education, the nurse emphasizes that which group should receive immunization for hepatitis B?
B. Men who prefer sex with men
Incorrect: Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B.
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.
Incorrect: 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.
Incorrect: Clients who have liver disease should receive the vaccine, but the clients in option B are at higher risk for contracting hepatitis B.
(61) When assessing a client with hepatitis B, the nurse anticipates finding which of these? Select all that apply.
A. Recent influenza infection
B. Brown stool
C. Tea-colored urine
D. Right upper quadrant tenderness
C, D, E
Correct: The urine may be brown, tea, or cola colored in clients with hepatitis.
Correct: Inflammation of the liver may cause right upper quadrant pain.
Correct: Deposits of bilirubin on the skin, secondary to high bilirubin levels, and jaundice irritate the skin and cause itching.
Incorrect: Hepatitis B virus, not the influenza virus, is spread by blood and body fluids.
Incorrect: The stool in hepatitis may be tan or clay colored.
(61) When providing dietary teaching to the client with hepatitis, the nurse includes which information?
C. Increased carbohydrates and moderate protein
Incorrect: The client feels full easily and should have four to six small meals daily.
Correct: To repair the liver, the client should have a high-carbohydrate and moderate-protein diet; fats may cause dyspepsia.
Incorrect: Fluids are restricted with ascites caused by cirrhosis; not all clients with hepatitis progress to cirrhosis.
Incorrect: Abstention from alcohol is necessary until the liver enzymes return to normal.
(61) The nurse is providing teaching to the client with hepatitis C. Which information is essential to include?
C. When ribavirin is taken, contraception must be used.
Incorrect: Pegylated interferon alpha may cause myalgia; however, it is not as important as mot getting PG.
Correct: Fetal abnormalities are associated with ribavirin; this is essential information.
Incorrect: Immunoglobulin B confers passive immunity to hepatitis B, not hepatitis C.
Incorrect: Diet teaching is not as essential as avoiding pregnancy; diet should be high in carbohydrates and moderate in proteins; fats may cause dyspepsia.
(61) When assessing a client for hepatic cancer, the nurse anticipates finding an elevation in which of these?
Incorrect: Although anemia may be present, it is not diagnostic of hepatic cancer.
Incorrect: White blood cells are not used to specifically diagnose cancers.
Correct: Fetal hemoglobin is abnormal in adults; it is a tumor marker indicative of cancers.
Incorrect: Serum albumin levels may be low in liver cancer and in malnutrition.
(61) It is essential that the nurse should monitor the client returning from hepatic artery embolization for hepatic cancer for which of these?
Incorrect: Discomfort may be present; however, an arterial approach is taken. Therefore prompt detection of hemorrhage is the priority.
Incorrect: The nurse must assess for signs of shock, not polyuria.
Incorrect: Embolization does not suppress the bone marrow; if chemotherapy or immune modulators are used, the nurse then assesses for bone marrow suppression.
Correct: An arterial approach is taken; therefore prompt detection of hemorrhage is the priority.
(61) 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?
A. Colon cancer with metastasis to the liver
Correct: Transplantation is performed for hepatitis and primary liver cancers.
Incorrect: Hypertension is a controllable factor.
Incorrect: Encephalopathy is a consequence of advanced liver disease, consistent with the condition of a client awaiting transplantation; it can be treated with lactulose and nonabsorbable antibiotics.
Incorrect: Ascites and resulting shortness of breath are consequences of advanced liver disease, consistent with the client awaiting transplantation. They can be managed with diuretics and paracentesis.
(61) 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?
Incorrect: Babinski's sign is positive when the sole of the foot is stroked, the great toe points up, and the toes fan out.
Incorrect: This term refers to deep tendon reflexes that are overactive.
Incorrect: Kehr's sign is reflected by increased abdominal pain, exaggerated by deep breathing, and referred to the right shoulder
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.
(61) Decompensated Cirrhosis Manifestations
Ascites and esophageal varices
JaundicePortal-systemic encephalopathy (PSE) with hepatic coma
Spontaneous bacterial peritonitis
(61) Which is important for the nurse to include in the plan of care for a client who is to undergo paracentesis later today?
D. Have the client void before the procedure is performed.
Incorrect: The drainage color and amount will be recorded after the procedure.
Incorrect: Liver enzymes are expected to be elevated; this is the purpose of the procedure.
Incorrect: The physician performing the procedure should discuss the intervention and potential complications.
Correct: Voiding before the procedure prevents bladder injury.
(61) What teaching does the home care nurse give the client and family to prevent spread of hepatitis C?
A. Prohibit members of the household from sharing toothbrushes.
Incorrect: The client may share a bathroom if he is continent. Toothbrushes, razors, towels, and items that may spread blood and body fluids are not shared.
Correct: Toothbrushes, razors, towels, and items that may spread blood and body fluids are not shared.
Incorrect: To prevent hepatitis A when traveling to foreign countries, bottled water should be used; ice made from tap water should be avoided.
(61) 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?
C. Requesting injection of immunoglobulin
Incorrect: The vaccine for hepatitis A will take several weeks to stimulate the development of antibodies; passive immunity in the form of an immunoglobulin is needed.
Incorrect: Implementing a needleless system may prevent the development of hepatitis B.
Incorrect: The three-part vaccine will prevent the development of hepatitis B, not hepatitis A.
Correct: Administration of immunoglobulin, antibodies to hepatitis A, may prevent development of the disease.
(61) 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?
A. Keep the T-tube in a dependent position.
Incorrect: Preventing hypotension is likely to prevent the complication of acute kidney injury.
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.
Incorrect: Administering antibiotic vaccination is likely to prevent infection.
Incorrect: Administering immune suppressant drugs is likely to prevent graft rejection.
(61) The RN has just received change-of-shift report on a client medical unit. Which client should the RN see first?
A. The client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse
Incorrect: Although uncomfortable, the headache is not likely related to liver disease and does not pose an immediate threat or complication.
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.
Incorrect: These are expected findings in a client with cirrhosis and do not pose an immediate threat.
Incorrect: Assessment data are expected for this client and do not indicate a risk for the severe complication of hepatitis.