GI Alterations NCLEX Questions

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NCLEX Practice Questions: Liver, Bili...

20 terms JLT84Preview Diabete 24 terms stud A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis?

• Elevated hemoglobin level
• Elevated serum bilirubin level
• Elevated blood urea nitrogen level
• Decreased erythrocycle sedimentation rate
• Elevated serum bilirubin level

Rationale:

Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leukopenia.An elevated blood urea nitrogen level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.A client with advanced cirrhosis has been diagnosed with

hepatic encephalopathy. The nurse expects to assess for:

a.) hand tremors.b.) weight loss.c.) malaise.d.) stomatitis.a.) hand tremors

Rationale:

Hepatic encephalopathy results from the accumulation of neurotoxins in the blood, therefore the nurse wants to assess for signs of neurological involvement.Flapping of the hands (asterixis), changes in mentation, agitation, and confusion are common. These clients typically have ascites and edema so experience weight gain. Malaise and stomatitis are not related to neurological involvement.

A client with chronic pancreatitis is being discharged from the hospital. Which of the following statements by the client demonstrates that the client understands how to take prescribed pancreatic enzyme replacements?a.) "I must take capsules three times daily spaced about 8 hours apart." b.) "I must take the medication when I wake up and before bed." c.) "I must take the medication with meals and snacks." d.) "I must take the capsules every 4 hours while awake." c.) "I must take the medication with meals and snacks."

Rationale:

Pancreatic enzymes are prescribed to facilitate digestion of protein and fats and must be taken with food. Taking the enzymes at any other time will be ineffective.Which of the following will the nurse include in the care plan for a client hospitalized with viral hepatitis?a.) Bland diet b.) Administer antibiotics as ordered c.) Increase fluid intake to 3000 ml per day d.) Adequate bed rest d.) Adequate bed rest

Rationale:

Treatment of hepatitis consists of bed rest during the acute phase to reduce metabolic demands on the liver, thus increasing blood supply and cell regeneration. Forcing fluids, antibiotics, and bland diets are not part of the treatment plan for viral hepatitis.Spironolacctone (Aldactone) is prescribed for a client with chronic cirrhosis and ascites. The nurse should monitor the client for which of the following medication- related side effects?a.) Tachycardia b.) Hyperkalemia c.) Constipation d.) Jaundice b.) Hyperkalemia

Rationale:

This is a potassium-sparing diuretic so clients should be monitored closely for hyperkalemia. Diarrhea, dizziness, and headaches are other more common side effects. Tachycardia, jaundice, and constipation are not expected side effects of spironolactone (Aldactone).For a client in hepatic coma, which outcome would be the most appropriate?

• The client is oriented to time, place, and person.
• The client exhibits no ecchymotic areas.
• The client increases oral intake to 2,000 calories/day.
• The client exhibits increased serum albumin level.
• The client is oriented to time, place, and person.

Rationale:

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 time, place, and person.Ecchymotic areas are related to decreased synthesis of clotting factors. Although oral intake may be related to level of consciousness, it is more closely related to anorexia. The serum albumin level reflects hepatic synthetic ability, not level of consciousness.Jordin is a client with jaundice who is experiencing pruritus. Which nursing intervention would be included in the care plan for the client?

• Administering vitamin K subcutaneously
• Applying pressure when giving I.M. injections
• Decreasing the client's dietary protein intake
• Keeping the client's fingernails short and smooth
• Keeping the client's fingernails short and smooth

Rationale:

The client with pruritus 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 I.M. injections and administering vitamin K subcutaneously are important if the client develops bleeding problems. Decreasing the client's dietary intake is appropriate if the client's ammonia levels are increased.

Pierre who is diagnosed with acute pancreatitis is under the care of Nurse Bryan. Which intervention should the nurse include in the care plan for the client?

• Administration of vasopressin and insertion of a

balloon tamponade

• Preparation for a paracentesis and administration of

diuretics

• Maintenance of nothing-by-mouth status and insertion

of nasogastric (NG) tube with low intermittent suction

• Dietary plan of a low-fat diet and increased fluid intake

to 2,000 ml/day

• Maintenance of nothing-by-mouth status and insertion of nasogastric (NG)

tube with low intermittent suction

Rationale:

With acute pancreatitis, the client is kept on nothing-by-mouth 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 abdominal distention, and remove hydrochloric acid. Vasopressin would be appropriate for a client diagnosed with bleeding esophageal varices. Paracentesis and diuretics would be appropriate for a client diagnosed with portal hypertension and ascites. A low-fat diet and increased fluid intake would further aggravate the pancreatitis.When teaching a client about pancreatic function, the nurse understands that pancreatic lipase performs which function?

• Transports fatty acids into the brush border
• Breaks down fat into fatty acids and glycerol
• Triggers cholecystokinin to contract the gallbladder
• Breaks down protein into dipeptides and amino acids
• Breaks down fat into fatty acids and glycerol

Rationale:

Lipase hydrolyses or breaks down fat into fatty acids and glycerol. Lipase is not involved with the transport of fatty acids into the brush border. Fat itself triggers cholecystokinin release. Protein breakdown into dipeptides and amino acids is the function of trypsin, not lipase.A 52-year-old man was referred to the clinic due to increased abdominal girth. He is diagnosed with ascites by the presence of a fluid thrill and shifting dullness on percussion. After administering diuretic therapy, which nursing action would be most effective in ensuring safe care?

• Measuring serum potassium for hyperkalemia
• Assessing the client for hypervolemia
• Measuring the client's weight weekly
• Documenting precise intake and output
• Documenting precise intake and output

Rationale:

For the client with ascites receiving diuretic therapy, careful intake and output 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 client 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.Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy?

• Passage of two or three soft stools daily
• Evidence of watery diarrhea
• Daily deterioration in the client's handwriting
• Appearance of frothy, foul-smelling stools
• Passage of two or three soft stools daily

Rationale:

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 the client's handwriting indicates an increase in the ammonia level and worsening of hepatic encephalopathy. Frothy, foul-smelling stools indicate steatorrhea, caused by impaired fat digestion.

Nurse Farrah is providing care for Kristoff who has jaundice. Which statement indicates that the nurse understands the rationale for instituting skin care measures for the client?

• "Jaundice is associated with pressure ulcer formation."
• "Jaundice impairs urea production, which produces

pruritus."

• "Jaundice produces pruritus due to impaired bile acid

excretion."

• "Jaundice leads to decreased tissue perfusion and

subsequent breakdown."

• "Jaundice produces pruritus due to impaired bile acid excretion."

Rationale:

Jaundice is a symptom characterized by increased bilirubin concentration in the blood. Bile acid excretion is impaired, increasing the bile acids in the skin and causing pruritus. Jaundice is not associated with pressure ulcer formation.However, edema and hypoalbuminemia are. Jaundice itself does not impair urea production or lead to decreased tissue perfusion.Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? (Select all that apply.)

• Assessing the client's neurologic status every 2 hours
• Monitoring the client's hemoglobin and hematocrit

levels

• Evaluating the client's serum ammonia level
• Monitoring the client's handwriting daily
• Preparing to insert an esophageal tamponade tube
• Making sure the client's fingernails are short
• Assessing the client's neurologic status every 2 hours
• Evaluating the client's serum ammonia level
• Monitoring the client's handwriting daily

Rationale:

Hepatic encephalopathy results from an increased ammonia level due to the liver's inability to covert 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 address jaundice.For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be most important?

• Allowing complete independence of mobility
• Applying pressure to injection sites
• Administering antibiotics as prescribed
• Increasing nutritional intake
• Applying pressure to injection sites

Rationale:

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.A client with advanced cirrhosis has been diagnosed with

hepatic encephalopathy. The nurse expects to assess for:

• Malaise
• Stomatitis
• Hand tremors
• Weight loss
• Hand tremors

Rationale:

Hepatic encephalopathy results from the accumulation of neurotoxins in the blood, therefore the nurse wants to assess for signs of neurological involvement.Flapping of the hands (asterixis), changes in mentation, agitation, and confusion are common. These clients typically have ascites and edema so experience weight gain. Malaise and stomatitis are not related to neurological involvement.