NCLEX Questions - Care of Patients ...

Cirrhosis ScienceMedicineHepatology morganbustamante Save NCLEX Questions - Care of Patients ...15 terms beth_lewis_moore Preview Exam 4- Cirrhosis NCLEX Teacher 26 terms RegisteredNurse22 Preview Pancreatitis, NCLEX 59 terms melissa-knight Preview Nursing 14 terms che Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis?

• "How many years have you been drinking alcohol?"
• "Have you completed an advance directive?"
• "When did you have your last alcoholic drink?"
• "What foods did you eat at your last meal?"

ANS: 3

• The nurse must know when the client

had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol.The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy?

• Gastrointestinal bleeding.
• Hypoalbuminemia.
• Splenomegaly.
• Hyperaldosteronism.

ANS: 1

• Blood in the intestinal tract is digested

as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy.

A patient with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to order for this patient?

• Packed red blood cells (PRBCs)
• Vitamin K
• Oral anticoagulants
• Heparin infusion

Ans: A

Patients with liver dysfunction may have life-threatening hemorrhage from peptic ulcers or esophageal varices. In these cases, replacement with fresh frozen plasma, PRBCs, and platelets is usually required. Vitamin K may be ordered once the bleeding is stopped, but that is not what is needed to stop the bleeding of the varices. Anticoagulants would exacerbate the patients bleeding.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

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 has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patients current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

• Two to 3 soft bowel movements daily
• Significant increase in appetite and food intake
• Absence of nausea and vomiting
• Absence of blood or mucus in stool

ANS: A

Lactulose (Cephulac) is administered to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the patients appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.

A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patients plan of care?

• Measurement of abdominal girth and body weight
• Assessment for variceal bleeding
• Assessment for signs and symptoms of jaundice
• Monitoring of results of liver function testing

ANS: B

Esophageal varices are a major cause of mortality in patients with uncompensated cirrhosis. Consequently, this should be a focus of the nurses assessments and should be prioritized over the other listed assessments, even though each should be performed.A patient with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the patients treatment?

• Decisional Conflict
• Deficient Knowledge
• Death Anxiety
• Disturbed Thought Processes

ANS: C

The sudden hemorrhage that accompanies variceal bleeding is intensely anxiety-provoking. The nurse must address the patients likely fear of death, which is a realistic possibility. For most patients, anxiety is likely to be a more acute concern than lack of knowledge or decisional conflict. The patient may or may not experience disturbances in thought processes.A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurses most recent assessment reveals subtle changes in the patients cognition and behavior. What is the nurses most appropriate response?

• Ensure that the patients sodium intake does not exceed recommended levels.
• Report this finding to the primary care provider due to the possibility of hepatic encephalopathy.
• Inform the primary care provider that the patient should be assessed for alcoholic hepatitis.
• Implement interventions aimed at ensuring a calm and therapeutic care environment.

Ans: B

Feedback:

Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patients mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the patients physiologic deterioration

The serum ammonia level of a client with cirrhosis is elevated. As a priority, a nurse should plan to:

• monitor the client's temperature every 4 hours.
• observe for increasing confusion.
• measure the urine specific gravity.
• restrict the client's oral fluid intake.

ANS: 2

Elevated serum ammonia levels may cause neurological changes, such as confusion. The client's temperature or urine specific gravity will not be affected. Oral fluid intake should be encouraged if tolerated by the client.A client is hospitalized for conservative treatment of cirrhosis. As part of the collaborative plan of care, a nurse would anticipate:

• monitoring the client's blood sugar.
• maintaining NPO (nothing by mouth) status.
• administering antibiotics.
• encouraging frequent ambulation.

ANSWER: 1

Clients with cirrhosis may develop insulin resistance. Impaired glucose tolerance is common, and about 20% to 40% of clients with cirrhosis also have diabetes. For some clients with cirrhosis, however, hypoglycemia may occur during fasting because of decreased hepatic glycogen reserves and decreased gluconeogenesis. Clients with cirrhosis should receive a high-protein diet unless hepatic encephalopathy is present. Antibiotics are not part of the treatment plan of cirrhosis because it is not caused by microorganisms. The client with cirrhosis requires rest, thus activity should not be encouraged.A client diagnosed with cirrhosis is scheduled for a transjugular intrahepatic portosystemic shunt (TIPS) placement. A nurse realizes the client does not understand

the procedure when the client says:

• "I hope my abdominal incision heals better

after this procedure then it did when I had my appendix out."

• "This procedure should decrease the risk that I

might have another episode of bleeding from my esophagus."

• "I know the shunt they are placing could become

occluded in the future."

• "This procedure should keep me from getting so

much fluid buildup in my abdomen."

ANS: 1

The TIPS is placed through the jugular vein and threaded down to the hepatic vein. There is no need for an abdominal incision. The procedure will decrease pressure in the portal vein and thus decrease the risk of bleeding from esophageal varices. There is a risk that the stent that is placed will become occluded. The shunt will decrease ascites formation.