Hinkle 43 Flashcards
A nurse is caring for a client with liver failure and is performing an assessment of the
client’s increased risk of bleeding. The nurse recognizes that this risk is related to the
client’s inability to synthesize prothrombin in the liver. What factor most likely
contributes to this loss of function?
A. Alterations in glucose metabolism
B. Retention of bile salts
C. Inadequate production of albumin by hepatocytes
D. Inability of the liver to use vitamin K
ANS: D
Rationale: Decreased production of several clotting factors may be partially due to
deficient absorption of vitamin K from the GI tract. This probably is caused by the inability
of liver cells to use vitamin K to make prothrombin. This bleeding risk is unrelated to the
roles of glucose, bile salts, or albumin
- A nurse is performing an admission assessment of a client with a diagnosis of cirrhosis.
What technique should the nurse use to palpate the client’s liver?
A. Place hand under the right lower abdominal quadrant and press down lightly
with the other hand.
B. Place the left hand over the abdomen and behind the left side at the 11th rib.
C. Place hand under right lower rib cage and press down lightly with the other
hand.
D. Hold hand 90 degrees to right side of the abdomen and push down
firmly.
ANS: C
Rationale: 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 client with portal hypertension has been admitted to the medical floor. The nurse
should prioritize what assessments?
A. Assessment of blood pressure and assessment for headaches and visual
changes
B. Assessments for signs and symptoms of venous thromboembolism
C. Daily weights and abdominal girth measurement
D. Blood glucose monitoring q4h
ANS: C
Rationale: Obstruction to blood flow through the damaged liver results in increased blood
pressure (portal hypertension) throughout the portal venous system. This can result in
varices and ascites in the abdominal cavity. Assessments related to ascites are daily
weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.
A nurse educator is teaching a group of recent nursing graduates about their
occupational risks for contracting hepatitis B. What preventative measures should the
educator promote? Select all that apply.
A. Immunization
B. Use of standard precautions
C. Consumption of a vitamin-rich diet
D. Annual vitamin K injections
E. Annual vitamin B12 injections
ANS: A, B
Rationale: People who are at high occupational risk for contracting hepatitis B, including
nurses and other health care personnel exposed to blood or blood products, should
receive active immunization. The consistent use of standard precautions is also highly
beneficial. Vitamin supplementation is unrelated to an individual’s risk of HBV.
A client who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize?
A. The client will obtain measurement of drainage from the T-tube.
B. The client will exercise three times a week.
C. The client will take immunosuppressive agents as required.
D. The client will monitor for signs of liver dysfunction.
ANS: C
Rationale: The client is given written and verbal instructions about immunosuppressive
agent doses and dosing schedules. The client is also instructed on steps to follow to
ensure that an adequate supply of medication is available so that there is no chance
of running out of the medication or skipping a dose. Failure to take medications as
instructed may precipitate rejection. The nurse would not teach the client to measure
drainage from a T-tube as the client wouldn’t go home with a T-tube. The nurse may
teach the client about the need to exercise or what the signs of liver dysfunction are, but
the nurse would not stress these topics over the immunosuppressive drug regimen.
A triage nurse in the emergency department is assessing a client who presented with
reports of general malaise. Assessment reveals the presence of jaundice and increased
abdominal girth. What assessment question best addresses the possible etiology of this
client’s presentation?
A. “How many alcoholic drinks do you typically consume in a week?”
B. “To the best of your knowledge, are your immunizations up to date?”
C. “Have you ever worked in an occupation where you might have been exposed to
toxins?”
D. “Has anyone in your family ever experienced symptoms similar to yours?”
ANS: A
Rationale: Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol
use. Immunization status, occupational risks, and family history are also relevant
considerations, but alcohol use is a more common etiologic factor in liver disease.
A nurse is participating in the emergency care of a client who has just developed
variceal bleeding. What intervention should the nurse anticipate?
A. Infusion of intravenous heparin
B. IV administration of albumin
C. STAT administration of vitamin K by the intramuscular route
D. IV administration of octreotide
ANS: D
Rationale: Octreotide—a synthetic analog of the hormone somatostatin—is effective in
decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of
vasopressin. Because of this safety and efficacy profile, octreotide is considered the
preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and
albumin are not given, and heparin would exacerbate, not alleviate, bleeding.
A nurse is caring for a client with hepatic encephalopathy. While making the initial shift
assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse
should document the presence of what sign of liver disease?
A. Asterixis
B. Constructional apraxia
C. Fetor hepaticus
D. Palmar erythema
ANS: A
Rationale: The nurse will document that a client exhibiting a flapping tremor of the hands
is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the
inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to
the
A local public health nurse is informed that a cook in a local restaurant has been
diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at
this restaurant and have never received the hepatitis A vaccine?
A. The hepatitis A vaccine
B. Albumin infusion
C. The hepatitis A and B vaccines
D. An immune globulin injection
ANS: D
Rationale: For people who have not been previously vaccinated, hepatitis A can be
prevented by the intramuscular administration of immune globulin during the incubation
period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will
not protect the client exposed to hepatitis A, as protection will take a few weeks to
develop after the first dose of the vaccine. The hepatitis B vaccine provides protection
against the hepatitis B virus, but plays no role in protection for the client exposed to
hepatitis A. Albumin confers no therapeutic benefit.
- What health promotion teaching should the nurse prioritize to prevent drug-induced
hepatitis?
A. Finish all prescribed courses of antibiotics, regardless of symptom resolution.
B. Adhere to dosing recommendations of over-the-counter analgesics.
C. Ensure that expired medications are disposed of safely.
D. Ensure that pharmacists regularly review drug regimens for potential
interactions.
ANS: B
Rationale: Although any medication can affect liver function, use of acetaminophen
(found in many over-the-counter medications used to treat fever and pain) has been
identified as the leading cause of acute liver failure. Finishing prescribed antibiotics and
avoiding expired medications are unrelated to this disease. Drug interactions are rarely
the cause of drug-induced hepatitis.
Diagnostic testing has revealed that a client’s hepatocellular carcinoma (HCC) is
limited to one lobe. The nurse should anticipate that this client’s plan of care will focus on
what intervention?
A. Cryosurgery
B. Liver transplantation
C. Lobectomy
D. Laser hyperthermia
ANS: C
Rationale: Surgical resection is the treatment of choice when HCC is confined to one lobe
of the liver and the function of the remaining liver is considered adequate for postoperative recovery. Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While cryosurgery and liver transplantation are other surgical options for management of liver cancer, these procedures are not performed at the same frequency as a lobectomy. Laser hyperthermia is a nonsurgical
treatment for liver cancer
A client has been diagnosed with advanced stage breast cancer and will soon begin
aggressive treatment. What assessment findings would most strongly suggest that the
client may have developed liver metastases?
A. Persistent fever and cognitive changes
B. Abdominal pain and hepatomegaly
C. Peripheral edema unresponsive to diuresis
D. Spontaneous bleeding and jaundice
ANS: B
Rationale: The early manifestations of malignancy of the liver include pain—a continuous
dull ache in the right upper quadrant, epigastrium, or back. Weight loss, loss of strength,
anorexia, and anemia may also occur. The liver may be enlarged and irregular on
palpation. Jaundice is present only if the larger bile ducts are occluded by the pressure of
malignant nodules in the hilum of the liver. Fever, cognitive changes, peripheral edema,
and bleeding are atypical signs.
A client is being discharged after a liver transplant and the nurse is performing
discharge education. When planning this client’s continuing care, the nurse should
prioritize what risk diagnosis?
A. Risk for infection related to immunosuppressant use
B. Risk for injury related to decreased hemostasis
C. Risk for unstable blood glucose related to impaired gluconeogenesis
D. Risk for contamination related to accumulation of ammonia
ANS: A
Rationale: Infection is the leading cause of death after liver transplantation. Pulmonary
and fungal infections are common; susceptibility to infection is increased by the
immunosuppressive therapy that is needed to prevent rejection. This risk exceeds the
threats of injury and unstable blood glucose. The diagnosis of Risk for Contamination
relates to environmental toxin exposure.
A nurse is caring for a client with hepatic encephalopathy. The nurse’s assessment
reveals that the client exhibits episodes of confusion, is difficult to arouse from sleep and
has rigid extremities. Based on these clinical findings, the nurse should document what
stage of hepatic encephalopathy?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
ANS: C
Rationale: Clients in the third stage of hepatic encephalopathy exhibit the following
symptoms: stuporous, difficult to arouse, sleep most of the time, exhibits marked
confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of
extremities, marked EEG abnormalities. Clients in stages 1 and 2 exhibit clinical
symptoms that are not as advanced as found in stage 3, and clients in stage 4 are
comatose. In stage 4, there is an absence of asterixis, absence of deep tendon reflexes,
flaccidity of extremities, and EEG abnormalities.
A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving
care on the medical unit. The client’s current medication regimen includes lactulose four
times daily. What desired outcome should the nurse relate to this pharmacologic
intervention?
A. Two to three soft bowel movements daily
B. Significant increase in appetite and food intake
C. Absence of nausea and vomiting
D. Absence of blood or mucus in stool
ANS: A
Rationale: Lactulose is given 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 client’s appetite, symptoms of nausea and vomiting, or the
development of blood and mucus in the stool
A nurse is performing an admission assessment for an 81-year-old client who
generally enjoys good health. When considering normal, age-related changes to hepatic
function, the nurse should anticipate what finding?
A. Similar liver size and texture as in younger adults
B. A nonpalpable liver
C. A slightly enlarged liver with palpably hard edges
D. A slightly decreased size of the liver
ANS: D
Rationale: The most common age-related change in the liver is a decrease in size and
weight. The liver is usually still palpable, however, and is not expected to have hardened
edges.
A nurse is caring for a client with a blocked bile duct from a tumor. What
manifestation of obstructive jaundice should the nurse anticipate?
A. Watery, blood-streaked diarrhea
B. Orange and foamy urine
C. Increased abdominal girth
D. Decreased cognition
ANS: B
Rationale: If the bile duct is obstructed, the bile will be reabsorbed into the blood and
carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy. Bloody diarrhea, ascites, and cognitive changes are not associated with obstructive jaundice.
During a health education session, a participant has asked about the hepatitis E virus.
What prevention measure should the nurse recommend for preventing infection with this
virus?
A. Following proper hand-washing techniques
B. Avoiding chemicals that are toxic to the liver
C. Wearing a condom during sexual contact
D. Limiting alcohol intake
ANS: A
Rationale: Avoiding contact with the hepatitis E virus through good hygiene, including
hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecal–
oral route, principally through contaminated water in areas with poor sanitation.
Consequently, none of the other listed preventative measures is indicated.
A client’s health care provider has ordered a “liver panel” in response to the client’s
development of jaundice. When reviewing the results of this laboratory testing, the nurse
should expect to review what blood tests? Select all that apply.
A. Alanine aminotransferase (ALT)
B. C-reactive protein (CRP)
C. Gamma-glutamyl transferase (GGT)
D. Aspartate aminotransferase (AST)
E. B-type natriuretic peptide (BNP)
ANS: A, C, D
Rationale: Liver function testing includes GGT, ALT, and AST. CRP addresses the
presence of generalized inflammation and BNP is relevant to heart failure; neither is
included in a liver panel.
A client with liver disease has developed ascites; the nurse is collaborating with the
client to develop a nutritional plan. The nurse should prioritize which of the following in
the client’s plan?
A. Increased potassium intake
B. Fluid restriction to 2 L per day
C. Reduction in sodium intake
D. High-protein, low-fat diet
ANS: C
Rationale: Clients with ascites require a sharp reduction in sodium intake. Potassium
intake should not be correspondingly increased. There is no need for fluid restriction or
increased protein intake.
A nurse is amending a client’s plan of care in light of the fact that the client has
recently developed ascites. What should the nurse include in this client’s care plan?
A. Mobilization with assistance at least 4 times daily
B. Administration of beta-adrenergic blockers as prescribed
C. Vitamin B12 injections as prescribed
D. Administration of diuretics as prescribed
ANS: D
Rationale: Use of diuretics along with sodium restriction is successful in 90% of clients
with ascites. Beta-blockers are not used to treat ascites and bed rest is often more
beneficial than increased mobility. Vitamin B12 injections are not necessary.
A nurse is caring for a client who has been admitted for the treatment of advanced
cirrhosis. What assessment should the nurse prioritize in this client’s plan of care?
A. Measurement of abdominal girth and body weight
B. Assessment for variceal bleeding
C. Assessment for signs and symptoms of jaundice
D. Monitoring of results of liver function testing
ANS: B
Rationale: Esophageal varices are a major cause of mortality in clients with
uncompensated cirrhosis. Consequently, this should be a focus of the nurse’s
assessments and should be prioritized over the other listed assessments, even though
each should be performed.
A client 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 client’s treatment?
A. Decisional conflict
B. Deficient knowledge
C. Death anxiety
D. Disturbed thought processes
ANS: C
Rationale: The sudden hemorrhage that accompanies variceal bleeding is intensely
anxiety-provoking. The nurse must address the client’s likely fear of death, which is a
realistic possibility. For most clients, anxiety is likely to be a more acute concern than lack
of knowledge or decisional conflict. The client may or may not experience disturbances in
thought processes.
A client with a diagnosis of esophageal varices has undergone endoscopy to gauge
the progression of this complication of liver disease. Following the completion of this
diagnostic test, what nursing intervention should the nurse perform?
A. Keep client NPO until the results of test are known.
B. Keep client NPO until the client’s gag reflex returns.
C. Administer analgesia until post-procedure tenderness is relieved.
D. Give the client a cold beverage to promote swallowing ability.
ANS: B
Rationale: After the examination, fluids are not given until the client’s gag reflex returns.
Lozenges and gargles may be used to relieve throat discomfort if the client’s physical
condition and mental status permit. The result of the test is known immediately. Food
and fluids are contraindicated until the gag reflex returns.
