Chapter 47: Management of Clients with Hepatic Disorders Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 47: Management of Clients with Hepatic Disorders

MULTIPLE CHOICE

1. The nurse caring for a client with jaundice would assess for other findings frequently associated with this condition, such as

a.

a change in the texture of the hair.

b.

clay-colored stools.

c.

excess pigmentation to the hands.

d.

friable, ridged nails.

ANS: C

Manifestations of jaundice include yellow sclerae, yellowish orange skin, clay-colored feces, tea-colored urine, pruritus, fatigue, and anorexia.

DIF: Application/Applying REF: p. 1136 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

2. The nurse notes on a clients chart a report revealing unconjugated hyperbilirubinemia. The nurse explains the presence of unconjugated bilirubin indicates

a.

a decreased amount of red cells are being destroyed.

b.

biliary obstruction is preventing blood flow through the liver.

c.

conjugated bilirubin must be converted to unconjugated bilirubin in the liver.

d.

the kidneys are not converting unconjugated to conjugated bilirubin.

ANS: B

Unconjugated (indirect) bilirubin is perfused by blood flow through the liver, where it is converted to conjugated (direct) bilirubin, which is water soluble. The unconjugated bilirubin is not water soluble and remains in the circulating volume, indicating a biliary obstruction.

DIF: Comprehension/Understanding REF: p. 1135 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

3. A 15-year-old client admitted with severe jaundice is having diagnostic testing. The nursing diagnosis that would have priority is

a.

Activity Intolerance related to fatigue

b.

Deficient Knowledge related to diet modification

c.

Disturbed Body Image related to yellowing of skin and sclera

d.

Impaired Skin Integrity related to jaundice

ANS: D

Skin care is high priority when the client with jaundice is already symptomatic, and early intervention is essential to preserve the skin. The other diagnoses are important, but the skin interventions can begin immediately.

DIF: Application/Applying REF: p. 1137 OBJ: Diagnosis

MSC: Physiological Integrity Physiological Adaptation-Illness Management

4. Preparing for travel to an area of Africa where hepatitis A is endemic, a client receives immune serum. The nurse would remind the client that this prophylaxis is effective for up to

a.

2 weeks.

b.

1 month.

c.

3 months.

d.

6 months.

ANS: C

Clients who live in or visit high-risk areas can be protected for up to 3 months by immune globulin.

DIF: Knowledge/Remembering REF: p. 1139 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Immunizations

5. The factor in a clients history that the nurse would recognize as placing the client at risk for developing hepatitis A is

a.

donating blood frequently.

b.

eating fish caught in the pond on the clients farm.

c.

working as a nursing assistant in a nursing home.

d.

having multiple colorful tattoos.

ANS: C

Persons who work in day care centers, nursing homes, and hospital laundries have a vocational opportunity to be exposed to feces that may be infected with hepatitis A. Eating shellfish from contaminated water is also a risk.

DIF: Comprehension/Understanding REF: p. 1138 OBJ: Assessment

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

6. The nurse assesses asterixis while monitoring the blood pressure of a client with viral hepatitis. The nurse would interpret this finding as an indication of

a.

fluid volume deficit.

b.

hepatic encephalopathy.

c.

impending seizure.

d.

increased bleeding tendency.

ANS: B

Asterixis, also called flapping tremor or liver flap, is a manifestation of hepatic encephalopathy.

DIF: Analysis/Analyzing REF: p. 1167 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

7. A nurse explains to a client who recently ate in a fast-food restaurant where several people have developed hepatitis that the incubation period for this type of hepatitis is

a.

1 to 10 days.

b.

15 to 30 days.

c.

1 to 6 months.

d.

up to 1 year.

ANS: B

The most likely type of hepatitis contracted from a restaurant is hepatitis A. The incubation period for hepatitis A is 15-45 days, with a mean of 30 days.

DIF: Comprehension/Understanding REF: p. 1138 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

8. A client has been admitted for suspected hepatic carcinoma. The client and family are anxious and agitated. Which intervention by the nurse would best support them?

a.

Bring the client and family coffee and food from the cafeteria.

b.

Educate the client and family about upcoming procedures and tests.

c.

Plan care so the family has uninterrupted time with the client.

d.

Have the medical social worker stop by and discuss advance directives.

ANS: B

Giving the client and family the needed information to understand procedures will best help them cope with the uncertainty and fear. Certainly offering food and beverages is a comfort measure too. Planning care to allow the family uninterrupted time with the client is fine as long as the time is not too lengthy between when the client sees the nurse; otherwise, the client will feel abandoned. The medical social worker can discuss advance directives, but it might be better to wait until the client and family are not so anxious.

DIF: Application/Applying REF: p. 1172 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Coping Mechanisms

9. The nurse is working in an area experiencing an outbreak of hepatitis. The manifestations that the nurse would identify as early manifestations of the disease are

a.

clay-colored stools and dark urine.

b.

epigastric pain and flu-like manifestations.

c.

jaundice and severe pruritus.

d.

petechiae and purpura.

ANS: B

Epigastric pain and flu-like manifestations with nausea and vomiting are common initial manifestations of hepatitis. Other early manifestations include jaundice, lethargy, irritability, myalgia, arthralgia, anorexia, abdominal pain, fever, and diarrhea or constipation. Anicteric hepatitis may or may not precede jaundice.

DIF: Application/Applying REF: p. 1140 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

10. The nurse preparing to discharge a client with acute hepatitis B instructs the client to avoid

a.

acetaminophen and aspirin.

b.

laxatives and stool softeners.

c.

nicotine and caffeine.

d.

oral decongestants.

ANS: A

The nurse should advise the client to avoid alcohol and medications such as aspirin, acetaminophen, and sedatives because of their hepatotoxicity.

DIF: Application/Applying REF: p. 1143 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

11. In caring for a client admitted to the hospital for treatment of cirrhosis, the nurse would know that priority interventions revolve around the clients

a.

hypoglycemia related to pancreatitis.

b.

infection related to neutropenia.

c.

nerve impairment related to encephalopathy.

d.

risk for hemorrhage related to bleeding tendencies.

ANS: D

Because of the increased risk of bleeding in the client with cirrhosis, the nursing diagnosis Ineffective Tissue Perfusion related to bleeding tendencies and varices that may hemorrhage is common and so takes priority in this situation. If the pancreas were involved, the client would probably manifest hyperglycemia because of loss of endocrine function. Encephalopathy is a possible consequence of cirrhosis but may or may not be present. Infection is another possible complication.

DIF: Application/Applying REF: p. 1153 OBJ: Assessment

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

12. A nurse is serving food trays. From the tray of a client with hepatic encephalopathy, the nurse would remove

a.

eggs.

b.

fresh fruit.

c.

pasta.

d.

spinach.

ANS: A

The usual protein restriction is 20 to 40 grams per day.

DIF: Analysis/Analyzing REF: p. 1168 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

13. The client with esophageal varices has a Sengstaken-Blakemore tube in place for esophageal tamponade. As a measure to prevent aspiration of saliva, the nurse would

a.

assist the client to cough and spit saliva into an emesis basin.

b.

completely deflate the esophageal balloon every 30 minutes.

c.

remove saliva through the fourth lumen.

d.

suction saliva accumulation with a nasogastric tube.

ANS: D

Because the Sengstaken-Blakemore tube does not have a fourth lumen, the saliva should be suctioned via a nasogastric tube from the top of the esophageal balloon.

DIF: Application/Applying REF: pp. 1156, 1157

OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment

14. In caring for a client who has an esophageal tamponade, the nurse would be alerted that the tamponade is inadequate with the assessment of

a.

diarrhea.

b.

increased abdominal girth.

c.

increasing jaundice.

d.

rising ammonia level.

ANS: D

A rising ammonia level indicates that the colon is still metabolizing blood as protein; therefore the bleeding is still continuing and the protein metabolism will increase the ammonia level.

DIF: Analysis/Analyzing REF: p. 1155 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Therapeutic Procedures

15. The nursing intervention that takes priority for the nursing diagnosis High Risk for Injury related to presence of Sengstaken-Blakemore tube is

a.

massaging bony prominences frequently.

b.

offering fluids frequently.

c.

placing a pair of scissors at the bedside.

d.

restraining the clients hands.

ANS: C

It is important to ensure that the gastric balloon is inflated to prevent migration of the tube. Scissors should be available at the bedside to remove the tube in an emergency. Complications of balloon tamponade, which include aspiration pneumonitis and esophageal rupture, may occur in 15% or more of clients.

DIF: Application/Applying REF: pp. 1156, 1157

OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment

16. To best facilitate an effective breathing pattern, the nurse would place a client with massive ascites in the

a.

high-Fowler position.

b.

lithotomy position.

c.

recumbent position.

d.

side-lying position.

ANS: A

The nurse should position the client in high-Fowler position to facilitate breathing and should monitor the clients respiratory status for development of atelectasis or pneumonia.

DIF: Application/Applying REF: p. 1161 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

17. A client experiencing hepatic encephalopathy is receiving lactulose. An irate family member asks, Why in the world would the doctor give my husband something that gives him diarrhea when he is already so sick? The nurses response would include that the purpose of the lactulose is to

a.

change ammonia to urea.

b.

eliminate ascites.

c.

empty the bowel of protein.

d.

reduce fluid retention.

ANS: C

Lactulose will empty the bowel of protein content, which is metabolized into ammonia, and will reduce the encephalopathy.

DIF: Analysis/Analyzing REF: pp. 1167, 1168

OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Expected Effects/Outcomes

18. In caring for a client with severe hepatic abscess, the nurse would assess carefully for the common complication of

a.

frequent diarrhea.

b.

increasing jaundice.

c.

increasing pruritus.

d.

pleural effusion.

ANS: D

Because of the proximity of the liver to the right pleural space, an inflammatory process can start in the pleura. The other three options are not clinical manifestations.

DIF: Comprehension/Understanding REF: p. 1174 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

19. The nurse would counsel a client that the portosystemic shunt will

a.

eliminate the danger of hepatic failure.

b.

reduce ascites.

c.

reduce portal hypertension only.

d.

reverse effects of cirrhosis.

ANS: C

The portosystemic shunt is a last resort when other remedies have not been effective. The surgery reduces the portal hypertension and then reduces the varices only. The surgery does nothing for cirrhosis or ascites. The hope is that enough blood flow to the liver will remain present to stave off hepatic failure, but this is considered a palliative therapy.

DIF: Comprehension/Understanding REF: p. 1158 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Therapeutic Procedures

20. The nurse counseling a client who has used oral contraceptives (OCs) since age 17 would make the client aware that the use of OCs has increased the incidence of

a.

adenomas of the liver.

b.

gallbladder disease.

c.

gastric ulcerations.

d.

pancreatitis.

ANS: A

Hepatic adenomas are benign tumors of the liver occurring more often in women in their 20s and 30s. Almost 90% of cases are associated with OC use.

DIF: Knowledge/Understanding REF: p. 1170 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

21. The nurse would be aware that the condition present in a client that is a predisposing factor in development of liver abscess is

a.

acute diabetes insipidus.

b.

alcoholic hepatitis of several months.

c.

bile duct obstruction with a stone.

d.

pancreatitis of long-standing duration.

ANS: C

Liver abscesses usually develop after one of three conditions: (a) bacterial cholangitis, which results from obstruction of the bile ducts by stone or stricture; (b) portal vein bacteremia, which may develop after bowel inflammation or organ perforation; and (c) amebiasis. Other predisposing factors are diabetes mellitus, infected hepatic cysts, metastatic liver tumors with secondary infection, and diverticulitis.

DIF: Comprehension/Understanding REF: p. 1174 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

22. The nurse would explain to a client that to combat the rising rate of primary hepatocellular cancer in the United States public health measures need to be directed towards decreasing the

a.

incidence of HIV infection and AIDS.

b.

increasing prevalence of hepatitis C.

c.

level of alcoholism in America.

d.

long-term use of NSAIDs.

ANS: B

The increasing incidence of hepatitis C is responsible for the rising rate of primary hepatocellular cancer.

DIF: Comprehension/Understanding REF: p. 1170 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

23. The nurse is preparing to immunize a client who has had sexual contact with a known carrier of hepatitis B. The nurse would know that the medication providing the best immediate protection against hepatitis B is

a.

hepatitis B immune globulin.

b.

hepatitis B surface antigen.

c.

hepatitis B vaccine.

d.

standard immune globulin.

ANS: A

Although standard immune globulin may contain antibodies against hepatitis B, hepatitis B immune globulin contains much higher levels of antibody.

DIF: Comprehension/Understanding REF: p. 1139 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

24. A client with jaundice is experiencing uncomfortable itching of the skin. The nurse would anticipate an order to administer

a.

acetaminophen (Tylenol).

b.

diphenhydramine (Benadryl).

c.

oral cholestyramine (Questran).

d.

phenobarbital (Luminal).

ANS: C

Oral cholestyramine resin provides some relief by binding bile salts in the intestine so that they can be excreted. Antihistamines and phenobarbital (which enhances bile flow) may also relieve itching. Remember that acetaminophen is hepatotoxic.

DIF: Application/Applying REF: p. 1137 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Expected Effects/Outcomes

25. A client with cirrhosis is on the transplant list and is now admitted for end-stage liver failure. The spouse breaks down crying, stating I just cant cope any more. I already have to do every thing at home and for the kids, now if he/she dies, I just dont know what I will do! The best response by the nurse is

a.

I see you are upset. I will come back in 10 minutes and we can talk.

b.

Im sure they will find a donor before it is too late.

c.

We do a lot of transplants here and our outcomes are very good.

d.

What has helped you handle all the family responsibilities so far?

ANS: D

Because this client has been admitted for end-stage liver failure, without a transplant, he/she will die. The spouse needs support to deal with this crisis. Providing support and knowledge are two key responsibilities pre-transplant. The best response by the nurse is to try to help the spouse utilize support systems he/she may already have in place but is too upset to recall. Options b and c offer false hope and are dismissive of the spouses feelings. Option a is a great response when a client is acting out and you need to set some limits on behavior, but is not appropriate here.

DIF: Application/Applying REF: pp. 1173-1174

OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Support Systems

26. The nurse providing information about the hepatitis B vaccine would include the information that the inoculation

a.

consists of a single injection but is extremely uncomfortable.

b.

is given by three separate injections over 6 months.

c.

is recommended only for adults and those at risk.

d.

works best when it is given in the gluteal muscle.

ANS: B

This injection is best given in the deltoid muscle. Hepatitis B vaccine is given in three doses, with the first and second doses separated by at least 1 month; the third dose is administered at least 4 months after the initial dose. Hepatitis B vaccine is now included in the routine vaccination schedule for children.

DIF: Comprehension/Understanding REF: p. 1139 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Immunizations

27. A client has been admitted with a diagnosis of fatty liver. The nurse is aware that manifestations of this condition are

a.

likely to worsen even after the cause is eliminated.

b.

related to the degree of fat infiltration.

c.

severe even in mild cases of the condition.

d.

vague and nonspecific.

ANS: B

Manifestations are directly related to the degree of fat infiltration. Recovery can begin after the causative factor is eliminated unless there is permanent residual damage. Clients can be asymptomatic even with moderate or severe disease. Specific manifestations are anorexia, abdominal pain, sometimes jaundice, and elevated serum alkaline phosphatase and bilirubin levels.

DIF: Comprehension/Understanding REF: p. 1169 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

28. A client admitted with a diagnosis of Lannecs cirrhosis would be questioned by the nurse about the etiologic factor of

a.

alcohol ingestion.

b.

food-borne illness.

c.

gallstones.

d.

heart failure.

ANS: A

Lannecs cirrhosis is associated with alcohol abuse.

DIF: Comprehension/Understanding REF: p. 1147 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

29. A client has ascites and the nursing diagnosis Excess Fluid Volume. The nurse has orders to administer albumin and furosemide (Lasix). Which action by the nurse regarding this order is correct?

a.

Call the physician to clarify the order.

b.

Give the albumin first and then give the furosemide.

c.

Give the furosemide first and then give the albumin.

d.

Have the pharmacy mix both drugs in the same IV bag.

ANS: B

The nurse should give the albumin first to pull fluid back into the vascular space, and then follow it with the diuretic so the client excretes the excess fluid.

DIF: Analysis REF: p. 1161 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Expected Effects/Outcomes

30. The nurse would explain to a client that the persistent presence of hepatitis B surface antigen (HBsAg) without overt manifestations strongly suggests that the client is

a.

a carrier of hepatitis B.

b.

immune to hepatitis B.

c.

not contagious for hepatitis B.

d.

pre-morbid for hepatitis B.

ANS: A

The persistent presence of HBsAg in a client without manifestations of hepatitis is indicative of a carrier state in which the carrier is asymptomatic but still contagious.

DIF: Comprehension/Understanding REF: p. 1146 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Laboratory Values

31. In a client with esophageal varices who is receiving vasopressin, the nurse would closely monitor for

a.

chest pain.

b.

dramatic onset of hypotension.

c.

perforated esophagus.

d.

pulmonary effusion.

ANS: A

Vasopressin is a very strong vasoconstrictor that increases blood pressure and can cause myocardial infarction and cerebrovascular accident.

DIF: Analysis/Analyzing REF: p. 1156 OBJ: Assessment

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Adverse Effects/Contraindications

32. A client with massive ascites had a paracentesis. The site continues to leak through several layers of dressings, despite the nurse holding pressure. Which intervention should the nurse do first?

a.

Call the physician and request the puncture site be sutured.

b.

Have the client lie on the side with the puncture site.

c.

Obtain a urostomy pouch and apply it at the puncture site.

d.

Use a roll of Kerlex to hold the dressing in place.

ANS: C

Sometimes a pouch can be used to collect fluid draining from the paracentesis site if it is excessive. This allows the nurse to objectively measure the output and helps preserve the clients skin. This is an independent nursing action. In extreme cases, the physician can suture the puncture wound shut.

DIF: Application/Applying REF: p. 1161 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Therapeutic Procedures

33. A client with ascites has the nursing diagnosis Activity Intolerance. An appropriate goal for this client would be: the client will

a.

not experience complications of bed rest.

b.

learn to balance activity with rest.

c.

return to normal activity.

d.

tolerate bed rest and use diversional activities.

ANS: B

A client with ascites and chronic liver disease will have an ongoing problem with Activity Intolerance. He or she will need to adapt by learning how to balance rest and activity. Bed rest is not commonly prescribed for extended periods of time and in fact the amount of rest to prescribe is debated. The client will probably not return to normal levels of activity.

DIF: Evaluation/Evaluating REF: p. 1153 OBJ: Outcome

MSC: Physiological Integrity Basic Care and Comfort-Rest and Sleep

34. A nurse asks a client with cirrhosis to write his/her name on a piece of paper each day. A student asks why the nurse does this. The best response by the nurse is that

a.

If the client cant write his/her name, it means the client is very confused.

b.

Part of the mini-mental exam and we assess this on all clients.

c.

The physician left orders for this but I dont know why we are doing it.

d.

This is an important safety assessment for the client with cirrhosis.

ANS: D

An important consideration for clients with cirrhosis is the development of encephalopathy and their resulting safety needs. Safety is a priority in health care. Deterioration of handwriting is an early, subtle sign of impending decrease in level of consciousness. If the nurse assesses a subtle change in level of consciousness, the nurse can implement safety precautions. Option c is the poorest choice; if the nurse does not know why she/he is doing something, the nurse needs to find out. Nurses should not just blindly follow orders without understanding the rationale.

DIF: Analysis/Analyzing REF: p. 1157 OBJ: Assessment

MSC: Safe, Effective Care Environment Safety and Infection Control-Accident Prevention

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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