Exam 4- Cirrhosis NCLEX questions and

Exam 4- Cirrhosis NCLEX questions and answers well illustrated.

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?

Dorsiflex the foot Measure abdominal girth Ask pt to extend the arms Instruct pt to lean forward - correct answers.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?

Low-protein High-protein Moderate-fat High-carb - correct answers.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:

clay colored stools dark urine and stool 1 / 2

pyrexia and pruritis elevated urinary urobilinogen - correct answers.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
• avoiding alcohol until liver enzymes return to normal - correct answers.B

NAFLD can progress to cirrhosis. NO definitive treatment; therapy directed at reducing 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 peritoneal 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. - correct answers.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 encephalopathy. 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
• decreased ammonia levels - correct answers.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 -

correct answers.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.

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