chapter 46 Flashcards
A client contracts hepatitis from contaminated food. During the acute (icteric) phase of the
client’s illness, which of the following serological findings should the nurse expect?
a. Antibody to hepatitis D virus (anti-HDV)
b. Hepatitis B surface antigen (HBsAg)
c. Anti-hepatitis A virus immunoglobulin G (anti-HAV IgG)
d. Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)
D
Hepatitis A is transmitted through the oral–fecal route, and antibody to HAV IgM appears
during the acute phase of hepatitis A. The client would not have antigen for hepatitis B or
antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong
immunity.
Which of the following findings in a blood specimen indicates that the administration of
hepatitis B vaccine to a client has been effective?
a. HBsAg
b. Anti-HBs
c. Anti-HBc IgG
d. Anti-HBc IgM
B
The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to
the vaccine. The other laboratory values indicate current infection with HBV.
A client in the outpatient clinic is diagnosed with acute hepatitis C virus (HCV) infection.
Which of the following actions by the nurse is best?
a. Schedule the client for HCV genotype testing.
b. Administer immune globulin and the HCV vaccine.
c. Instruct the client on ribavirin treatment.
d. Teach that the infection will resolve in a few months.
A
Genotyping of HCV has an important role in managing treatment and is done before drug
therapy is initiated. Since most clients with acute HCV infection convert to the chronic
state, the nurse should not teach the client that the HCV will resolve in a few months.
Immune globulin or vaccine is not available for HCV. Ribavirin is used for chronic HCV
infection.
The nurse is caring for a client who is diagnosed with acute hepatitis B. Which of the
following information should the nurse include in the teaching plan?
a. Ways to increase exercise and activity level
b. Self-administration of a-interferon
c. Adverse effects of nucleoside and nucleotide analogs
d. Measures that will be helpful in improving appetite
D
Maintaining adequate nutritional intake is important for regeneration of hepatocytes.
Interferon and antivirals may be used for chronic hepatitis B, but they are not prescribed
for acute hepatitis B infection. Rest is recommended.
The nurse is caring for a client with chronic hepatitis C who is prescribed combination
therapy of a-interferon and ribavirin. Which of the following findings should the nurse
monitor for the presence of hepatitis C in the client?
a. Leukopenia
b. Hypokalemia
c. Polycythemia
d. Hypoglycemia
A
Therapy with ribavirin and a-interferon may cause leukopenia. The other problems are not
associated with this drug therapy.
Which of the following clients should alert the nurse that screening for hepatitis C should
be done?
a. The client eats frequent meals in fast-food restaurants.
b. The client recently travelled to an undeveloped country.
c. The client had a blood transfusion after surgery in 1998.
d. The client reports a one-time use of IV drugs 20 years ago.
D
Any client with a history of IV drug use should be tested for hepatitis C. Blood
transfusions given after 1992, when an antibody test for hepatitis C became available, do
not pose a risk for hepatitis C. Hepatitis C is not spread by the oral–fecal route and
therefore is not caused by contaminated food or by travelling in underdeveloped countries.
The nurse is caring for a client who is admitted with an abrupt onset of jaundice, nausea,
and abnormal liver function studies. Serological testing is negative for viral causes of
hepatitis. Which of the following questions by the nurse is best?
a. “Is there any history of IV drug use?”
b. “Are you taking corticosteroids for any reason?”
c. “Do you use any over-the-counter (OTC) drugs?”
d. “Have you recently travelled to a foreign country?”
C
The client’s symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms
suggest toxic hepatitis, which can be caused by commonly used OTC drugs such as
acetaminophen. Travel to a foreign country and a history of IV drug use are risk factors for
viral hepatitis. Corticosteroid use does not cause the symptoms listed.
The nurse is caring for a client with cirrhosis who has 4+ pitting edema of the feet and legs.
Which of the following assessments is priority for the nurse to monitor?
a. Hemoglobin
b. Temperature
c. Activity level
d. Albumin
D
The low oncotic pressure caused by hypoalbuminemia is a major pathophysiological factor
in the development of edema. The other parameters also should be monitored, but they are
not directly associated with the client’s current symptoms.
The nurse is preparing a teaching plan for a young adult client who is diagnosed with early
alcoholic cirrhosis. Which of the following topics is most important to include in client
teaching?
a. Need to abstain from alcohol
b. Use of vitamin B supplements
c. Maintenance of a nutritious diet
d. Treatment with lactulose
A
The disease progression can be stopped or reversed by alcohol abstinence. The other
interventions may be used when cirrhosis becomes more severe to decrease symptoms or
complications, but the priority for this client is to stop the progression of the disease.
The nurse is caring for a client with cirrhosis who has scheduled doses of spironolactone
and furosemide and has a serum potassium level of 3.2 mmol/L. Which of the following
actions should the nurse take?
a. Give both drugs as scheduled.
b. Administer the spironolactone.
c. Administer the furosemide and withhold the spironolactone.
d. Withhold both drugs until talking with the health care provider.
B
Spironolactone is a potassium-sparing diuretic and will help to increase the client’s
potassium level. The nurse does not need to talk with the doctor before giving the
spironolactone, although the health care provider should be notified about the low
potassium value. The furosemide will further decrease the client’s potassium level and
should be held until the nurse talks with the health care provider.
Which of the following actions should the nurse implement to evaluate the effectiveness of
treatment for a client who has hepatic encephalopathy?
a. Request that the client stand on one foot.
b. Ask the client to extend both arms to the front.
c. Instruct the client to perform the Valsalva manoeuvre.
d. Have the client walk a few steps with the eyes closed.
B
Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic
encephalopathy. The other tests also might be done as part of the neurological assessment
but would not be diagnostic for hepatic encephalopathy.
The nurse is caring for a client who has advanced cirrhosis and is receiving lactulose.
Which of the following findings by the nurse indicates that the medication is effective?
a. The client is alert and oriented.
b. The client denies nausea or anorexia.
c. The client’s bilirubin level decreases.
d. The client has at least one stool daily.
A
The purpose for lactulose in the client with cirrhosis is to lower ammonia levels and
prevent encephalopathy. Although lactulose may be used to treat constipation, that is not
the purpose for this client. Lactulose will not decrease nausea and vomiting or lower
bilirubin levels.
Which of the following nursing actions should be included in the plan of care for a client
who is being treated for bleeding esophageal varices with balloon tamponade?
a. Monitor the client for shortness of breath.
b. Encourage the client to cough every 4 hours.
c. Deflate the gastric balloon every 8–12 hours.
d. Verify the position of the balloon every 6 hours.
A
A common complication of balloon tamponade is occlusion of the airway by the balloon
so it is important to monitor the client’s respiratory status. In addition, if the gastric
balloon ruptures, the esophageal balloon may slip upward and occlude the airway.
Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon
position is verified after insertion and does not require further verification. The esophageal
balloon is deflated every 8–12 hours to avoid necrosis, but if the gastric balloon is deflated,
the esophageal balloon may occlude the airway.
The nurse is caring for a client with severe cirrhosis who has an episode of bleeding
esophageal varices. Which of the following laboratory tests should the nurse monitor to
detect possible complications of the bleeding episode?
a. Bilirubin
b. Ammonia
c. Potassium
d. Prothrombin time
B
The blood in the gastrointestinal (GI) tract will be absorbed as protein and may result in an
increase in ammonia level because the liver cannot metabolize protein well. The
prothrombin time, bilirubin, and potassium levels also should be monitored, but these will
not be affected by the bleeding episode.
Which of the following nursing actions should be included in the plan of care for a client
with cirrhosis who has ascites and 4+ edema of the feet and legs?
a. Weekly weight of client
b. Reposition the client every 4 hours
c. Restrict sodium intake.
d. Perform passive range-of-motion QID.
C
To maintain skin integrity, restrict sodium intake as ordered to prevent additional fluid
retention. The client should be weighed daily, not weekly. Repositioning the client every 4
hours will not be adequate to maintain skin integrity; clients should be repositioned at least
every two hours. Passive range of motion will not take pressure off areas like the sacrum
that are vulnerable to breakdown.
The nurse is caring for a client who has had a transjugular intrahepatic portosystemic
shunt (TIPS) placement. Which of the following findings indicate that the procedure has
been effective?
a. Lower indirect bilirubin level
b. Increase in serum albumin level
c. Decrease in episodes of variceal bleeding
d. Improvement in alertness and orientation
C
TIPS is used to lower pressure in the portal venous system and decrease the risk of
bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not
affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.
The health care provider plans a paracentesis for a client with ascites caused by liver
cancer. Which of the following actions should the nurse implement to prepare the client
for the procedure?
a. Place the client on NPO status.
b. Assist the client to lie flat in bed.
c. Ask the client to empty the bladder.
d. Position the client on the right side.
C
The client should empty the bladder to decrease the risk of bladder perforation during the
procedure. The client would be positioned in Fowler’s position and would not be able to
lie flat without compromising breathing. Since no sedation is required for paracentesis, the
client does not need to be NPO.
The nurse is assessing a client who had a liver transplant a week previously and obtains
the following data. Which of the following findings is most important to communicate to
the health care provider?
a. Dry lips and oral mucosa
b. Crackles at both lung bases
c. Temperature 38.2°C (100.8°F)
d. No bowel movement for 4 days
C
Infection risk is high in the first few months after liver transplant and fever is frequently
the only sign of infection. The other client data indicate the need for further assessment or
nursing actions, but do not indicate a need for urgent action.
Which of the following laboratory test results is most important for the nurse to monitor
when evaluating the effects of therapy for a client who has acute pancreatitis?
a. Calcium
b. Bilirubin
c. Amylase
d. Potassium
C
Amylase is elevated in acute pancreatitis. Although changes in the other values may occur,
they would not be as useful in evaluating whether the prescribed therapies have been
effective.
Which of the following assessment findings in a client with acute pancreatitis should the
nurse report most quickly to the health care provider?
a. Nausea and vomiting
b. Hypotonic bowel sounds
c. Abdominal tenderness and guarding
d. Muscle twitching and finger numbness
D
Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany
unless calcium gluconate is administered. Numbness or tingling around the lips and in the
fingers is an early indicator of hypocalcemia. Although the other findings also should be
reported to the health care provider, they do not indicate complications that require rapid
action.
The nurse is obtaining a health history from a client with acute pancreatitis. Which of the
following information should the nurse specifically assess when conducting a health
history?
a. Alcohol use
b. Diabetes mellitus
c. High-protein diet
d. Cigarette smoking
A
Alcohol use is one of the most common risk factors for pancreatitis in Canada. In Canada,
the most common cause is gallbladder disease (gallstones) followed by alcoholism.
Cigarette smoking, diabetes, and high-protein diets are not risk factors.
The nurse is educating a client with chronic pancreatitis about the prescribed pancrelipase?
At which of the following times should the nurse teach the client to take the medication?
a. Bedtime
b. With every meal
c. Upon arising in the morning
d. As soon as abdominal pain starts
B
Pancreatic enzymes are used to help with digestion of nutrients and should be taken with
every meal or snacks.
The nurse is providing discharge instructions to a client following a laparoscopic
cholecystectomy. Which of the following client statements indicate that the teaching has
been effective?
a. “I can remove the bandages on my incisions tomorrow and take a shower.”
b. “I can expect some yellow-green drainage from the incision for a few days.”
c. “I should plan to limit my activities and not return to work for 4–6 weeks.”
d. “I will always need to maintain a low-fat diet since I no longer have a gallbladder.”
A
After a laparoscopic cholecystectomy, the client will have Band-Aids in place over the
incisions. Clients are discharged the same (or next) day and have few restrictions on
activities of daily living. Drainage from the incisions would be abnormal, and the client
should be instructed to call the health care provider if this occurs. A low-fat diet may be
recommended for a few weeks after surgery but will not be a lifelong requirement.
Which of the following data obtained by the nurse during the assessment of a client with
cirrhosis is of most concern?
a. The client’s hands flap back and forth when the arms are extended.
b. The client has ascites and a 2-kg weight gain from the previous day.
c. The client’s skin has multiple spider-shaped blood vessels on the abdomen.
d. The client complains of right upper-quadrant pain with abdominal palpation.
A
The asterixis indicates that the client has hepatic encephalopathy, and hepatic coma may
occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for
the client with cirrhosis and do not require a change in treatment. The ascites and weight
gain do indicate the need for treatment but not as urgently as the changes in neurological
status.
