AND VERIFIED ANSWERS

NCLEX Exam 4 Cirrhosis | 2023 QUESTIONS

AND VERIFIED ANSWERS

• The nurse is reviewing the record of a client with a dx of cirrhosis and notes

that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

a.Dorsiflex the foot b.Measure abdominal girth c.Ask pt to extend the arms

d.Instruct pt to lean forward:

• Ask the pt to extend the arms

Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread.It is the most common and reliable sign that hepati encephalopathy is developing.

• The nurse is reviewing the lab results for a pt with cirrhosis and notes

that the ammonia level is elevated. Which diet does the nurse anticipate to be presribed for this pt?

a.Low- protein b.High- protein c.Moderate- fat

High-carb:

• Low-protein diet

Protein provided by the diet is transported to the liver via the portal vein. The liver breaks down protein, which results in the formation of ammonia.

• During assessment of a pt with obstructive jaundice, the nurse would expect

to find:

a.clay colored stools b.dark urine and stool

• pyrexia and

pruritis

d.elevated urinary urobilinogen:

• clay colored stool

• A pt has been told she has NAFLD. The nursing teaching plan should include

• having genetic testing done
• recommend a heart healthy diet
• the necessity to reduce weight rapidly

d. avoiding alcohol until liver enzymes return to normal:

B

NAFLD can progress to cirrhosis. NO definitive treatment; therapy directed at reduc- ing risk like diabetes, body weight, and harmful medications.

• The pt with advanced cirrhosis asks why his abdomen is so swollen. The

nurse's best response is based on the knowledge that

• a lack of clotting factors promotes the collection of blood in the abdominal

cavity

• portal hypertension and hypoalbuminemia cause fluid shift into the peri-

toneal space.

• decreased peristalsis in the GI tract contributes to gas formation and

distention of the bowel

• bile salts in the blood irritate the peritoneal membranes, causing edema and

pocketing of fluid.: B

Ascites is accumulation of serious fluid in peritoneal cavity. With portal hypertension, protein shifts from the blood into the lymph. When the lymph system is unable to carry excess, it leaks thru the liver into the peritoneal cavity. osmotic pressure of the proteins pulls additional fluid into cavity. Second mechanism of ascites if hypoalbuminemia from the liver unable to synthesize albumin, resulting in decreased colloidal oncotic pressure.

• The health care provider orders lactulose for a patient with hepatic en-

cephalopathy. The nurse will monitor for effectiveness of this medication for this pt by assessing what?

• relief of constipation
• relief of ab pain
• decreased liver enzymes

d. decreased ammonia levels:

D

hepatic encephalopathy is associated with elevated ammonia levels. Lactulose traps ammonia in the intestinal tract. It's laxative effect then expels ammonia from the colon, resulting in decreased ammonia levels, correcting hepatic encephalopathy.

• When planning care for a pt with cirrhosis, the nurse will give highest

priority to which nursing diagnosis?

• impaired skin integrity related to edema, ascites, and pruritis

b. imbalanced nutrition: less than body requirements related to anorexia

• excess fluid volume related to portal hypertension and hyperaldosteronism
• ineffective breathing pattern related to pressure on diaphragm and reduced

lung volume:

D

airway and breathing are always highest priority.

• When caring for a pt with liver disease, the nurse recognizes the need to

prevent bleeding resulting from altered clotting factors and rupture of varices.Which nursing interventions would be appropriate to achieve this outcome?Select all that apply.

• use smallest gauge needle possible when giving injections or drawing

blood.

• teach pt to avoid straining at stool, vigorous blowing of nose, and coughing
• advise pt to use soft-bristle toothbrush and avoid ingestion of irritating

food.

• apply gentle pressure for the shortest possible time period after performing

venipuncture

• instruct pt to avoid aspirin and NSAIDs to prevent hemorrhage when varices

are present.:

A, B, C, E

• small gauge minimize risk of bleeding into tissues.
• avoiding strain reduces hemorrhage
• soft bristle reduce injury to highly vascular mucous membranes
• apply gentle but prolonged pressure to venipuncture
• aspirin and NSAIDs should not be used in pt with liver disease b/c they interfere

w/ platelet aggregation, increasing bleeding risk

• A pt with type 2 diabetes and cirrhosis asks if it would be okay to take

silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge?

• milk thistle may affect liver enzymes and thus alter drug metabolism
• milk thistle is generally safe in recommended doses for up to 10 yrs
• there is unclear scientific evidence for the use of milk thistle in treating

cirrhosis

• milk thislte may elevate the serum glucose level and is thus contraindicated

in diabetes.:

A

There is evidence that there is no real benefit from using milk thistle to protect liver enzyme from toxic damage. Milk thistle does affect liver enzyme and could alter drug metabolism. Pt will need to be monitored for drug interactions. It is dafe for up to 6 yrs not 10, and it may lower, not elevate, blood glucose levels.

• The condition of the pt who has cirrhosis of the liver has deteriorated.

Which diagnostic study would help determine if the pt has developed liver cancer?

• serum a-fetoprotein level
• ventilation/perfusion scan
• hepatic structure ultrasound

d. abdominal girth measurement: C

• The pt with cirrhosis has increased ab girth from ascites. The nurse should

know that this fluid gathers in the ad for which reasons? Select all that apply.

• there is decreased colloid oncotic pressure from the liver's inability to

synthesize albumin.

• hyperaldosteronsim related to damaged hepatocytes increases sodium and

fluid retention