cirrhosis testbank - marinaamalak Save A nurse is performing an a...

cirrhosis testbank ScienceMedicineNursing marinaamalak Save A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis.What technique should the nurse use to palpate the patients liver?

• Place hand under the right lower abdominal quadrant and press down lightly with the

other hand.

• Place the left hand over the abdomen and behind the left side at the 11th rib.
• Place hand under right lower rib cage and press down lightly with the other hand.
• Hold hand 90 degrees to right side of the abdomen and push down firmly.

Ans: C

Feedback:

To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant.

A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem?

• Assessment of blood pressure and assessment for headaches and visual changes
• Assessments for signs and symptoms of venous thromboembolism
• Daily weights and abdominal girth measurement
• Blood glucose monitoring q4h

Ans: C

Feedback:

Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths.Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.

A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patients presentation?

• How many alcoholic drinks do you typically consume in a week?
• To the best of your knowledge, are your immunizations up to date?
• Have you ever worked in an occupation where you might have been exposed to toxins?
• Has anyone in your family ever experienced symptoms similar to yours?

Ans: A

Feedback:

Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use.Immunization status, occupational risks, and family history are also relevant considerations, but alcohol use is a more common etiologic factor in liver disease.

A nurse is participating in the emergency care of a patient who has just developed variceal bleeding.What intervention should the nurse anticipate?

• Infusion of intravenous heparin
• IV administration of albumin
• STAT administration of vitamin K by the intramuscular route
• IV administration of octreotide (Sandostatin)

Ans: D

Feedback:

Octreotide (Sandostatin)a synthetic analog of the hormone somatostatinis effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin.Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not administered and heparin would exacerbate, not alleviate, bleeding.