Brunner Med-Surg Ch 49

A nurse is participating in the emergency care of a patient 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 (Sandostatin)
Ans: D
Octreotide (Sandostatin)—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 administered and heparin would exacerbate, not alleviate, bleeding.

A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient’s increased risk of bleeding. The nurse recognizes that this risk is related to the patient’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
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 patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient’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
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 with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem?
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
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 is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurse’s most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse’s best response to this assessment finding?
A) Document the presence of normal bile output.
B) Irrigate the drainage system with normal saline as ordered.
C) Aspirate a sample of the drainage for culture.
D) Promptly report this assessment finding to the primary care provider.
Ans: A
Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.

A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patient’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
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 caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient 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
The nurse will document that a patient 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 breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.

Diagnostic testing has revealed that a patient’s hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patient’s plan of care will focus on what intervention?
A) Cryosurgery
B) Liver transplantation
C) Lobectomy
D) Laser hyperthermia
Ans: C
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 patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient 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
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 patient with a liver mass is undergoing a percutaneous liver biopsy. What action should the nurse perform when assisting with this procedure?
A) Position the patient on the right side with a pillow under the costal margin after the procedure.
B) Administer 1 unit of albumin 90 minutes before the procedure as ordered.
C) Administer at least 1 unit of packed red blood cells as ordered the day before the scheduled procedure.
D) Confirm that the patient’s electrolyte levels have been assessed prior to the procedure.
Ans: A
Immediately after a percutaneous liver biopsy, assist the patient to turn onto the right side and place a pillow under the costal margin. Prior administration of albumin or PRBCs is unnecessary. Coagulation tests should be performed, but electrolyte analysis is not necessary.

A nurse is caring for a patient with hepatic encephalopathy. The nurse’s assessment reveals that the patient 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
Patients in the third stage of hepatic encephalopathy exhibit the following symptoms: stuporous, difficult to arouse, sleeps most of the time, exhibits marked confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of extremities, marked EEG abnormalities. Patients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3, and patients 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 patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient’s current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
A) Two to 3 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
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 patient’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 patient 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
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 patient’s physician has ordered a “liver panel” in response to the patient’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
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.

22. A patient with liver disease has developed jaundice; the nurse is collaborating with the patient to develop a nutritional plan. The nurse should prioritize which of the following in the patient’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
Patients 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 patient’s plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patient’s care plan?
A) Mobilization with assistance at least 4 times daily
B) Administration of beta-adrenergic blockers as ordered
C) Vitamin B12 injections as ordered
D) Administration of diuretics as ordered
Ans: D
Use of diuretics along with sodium restriction is successful in 90% of patients 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 patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patient’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
Esophageal varices are a major cause of mortality in patients 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 patient 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 patient NPO until the results of test are known.
B) Keep patient NPO until the patient’s gag reflex returns.
C) Administer analgesia until post-procedure tenderness is relieved.
D) Give the patient a cold beverage to promote swallowing ability.
Ans: B
After the examination, fluids are not given until the patient’s gag reflex returns. Lozenges and gargles may be used to relieve throat discomfort if the patient’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.

A patient with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this patient’s treatment, the nurse should anticipate what intervention?
A) Administration of immune globulins
B) A regimen of antiviral medications
C) Rest and watchful waiting
D) Administration of fresh-frozen plasma (FFP)
Ans: B
There is no benefit from rest, diet, or vitamin supplements in HCV treatment. Studies have demonstrated that a combination of two antiviral agents, Peg-interferon and ribavirin (Rebetol), is effective in producing improvement in patients with hepatitis C and in treating relapses. Immune globulins and FFP are not indicated.

A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse’s risk of acquiring hepatitis C in the workplace?
A) Disposing of sharps appropriately and not recapping needles
B) Performing meticulous hand hygiene at the appropriate moments in care
C) Adhering to the recommended schedule of immunizations
D) Wearing an N95 mask when providing care for patients on airborne precautions
Ans: A
HCV is bloodborne. Consequently, prevention of needlestick injuries is paramount. Hand hygiene, immunizations and appropriate use of masks are important aspects of overall infection control, but these actions do not directly mitigate the risk of HCV.

A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse’s most recent assessment reveals subtle changes in the patient’s cognition and behavior. What is the nurse’s most appropriate response?
A) Ensure that the patient’s sodium intake does not exceed recommended levels.
B) Report this finding to the primary care provider due to the possibility of hepatic encephalopathy.
C) Inform the primary care provider that the patient should be assessed for alcoholic hepatitis.
D) Implement interventions aimed at ensuring a calm and therapeutic care environment.
Ans: B
Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patient’s 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 patient’s physiologic deterioration.

33. A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patient’s fluid volume excess? Select all that apply.
A) Administering diuretics
B) Administering calcium channel blockers
C) Implementing fluid restrictions
D) Implementing a 1500 kcal/day restriction
E) Enhancing patient positioning
Ans: A, C, E
Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize the management of fluid volume excess. Calcium channel blockers and calorie restriction do not address this problem.

A patient with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the patient’s family how to safely perform which of the following actions?
A) Aspirating bile from the catheter using a syringe
B) Removing the catheter when output is 15 mL in 24 hours
C) Instilling antibiotics into the catheter
D) Assessing the patency of the drainage catheter
Ans: D
Families should be taught to provide basic catheter care, including assessment of patency. Antibiotics are not instilled into the catheter and aspiration using a syringe is contraindicated. The family would not independently remove the catheter; this would be done by a member of the care team when deemed necessary.

A nurse has entered the room of a patient with cirrhosis and found the patient on the floor. The patient states that she fell when transferring to the commode. The patient’s vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse’s most appropriate action?
A) Remove the patient’s commode and supply a bedpan.
B) Complete an incident report and submit it to the unit supervisor.
C) Have the patient assessed by the physician due to the risk of internal bleeding.
D) Perform a focused abdominal assessment in order to rule out injury.
Ans: C
A fall would necessitate thorough medical assessment due to the patient’s risk of bleeding. The nurse’s abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate.

A patient with liver cancer is being discharged home with a hepatic artery catheter in place. The nurse should be aware that this catheter will facilitate which of the following?
A) Continuous monitoring for portal hypertension
B) Administration of immunosuppressive drugs during the first weeks after transplantation
C) Real-time monitoring of vascular changes in the hepatic system
D) Delivery of a continuous chemotherapeutic dose
Ans: D
In most cases, the hepatic artery catheter has been inserted surgically and has a prefilled infusion pump that delivers a continuous chemotherapeutic dose until completed. The hepatic artery catheter does not monitor portal hypertension, deliver immunosuppressive drugs, or monitor vascular changes in the hepatic system.

A 55-year-old female patient with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment?
A) Destruction of the patient’s liver tumor
B) Restoration of portal vein patency
C) Destruction of a liver abscess
D) Reversal of metastasis
Ans: A
Using radiofrequency ablation, a tumor up to 5 cm in size can be destroyed in one treatment session. This technique does not address circulatory function or abscess formation. It does not allow for the reversal of metastasis.

A nursing student is reviewing for an upcoming anatomy and physiology examination. Which of the following would the student correctly identify as a function of the liver? Select all that apply.

a) Carbohydrate metabolism
b) Glucose metabolism
c) Zinc storage
d) Ammonia conversion
e) Protein metabolism

Glucose metabolism
• Ammonia conversion
• Protein metabolism
Functions of the liver include the metabolism of glucose, protein, fat, and drugs; conversion of ammonia; storage of vitamins and iron; formation of bile; and excretion of bilirubin. The liver is not responsible for the metabolism of carbohydrates or the storage of zinc. (less)

The nurse is preparing a care plan for a patient with hepatic cirrhosis. Which of the following nursing diagnoses are appropriate? Select all that apply.

a) Activity intolerance related to fatigue, general debility, muscle wasting, and discomfort
b) Altered nutrition, more than body requirements, related to decreased activity and bed rest
c) Risk for injury related to altered clotting mechanisms
d) Disturbed body image related to changes in appearance, sexual dysfunction, and role function
e) Urinary incontinence related to general debility and muscle wasting

• Risk for injury related to altered clotting mechanisms
• Disturbed body image related to changes in appearance, sexual dysfunction, and role function
• Activity intolerance related to fatigue, general debility, muscle wasting, and discomfort
Risks for injury, activity intolerance, and disturbed body image are priority nursing diagnoses. The appropriate nursing diagnosis related to nutrition would be altered nutrition, less than body requirements, related to chronic gastritis, decreased GI motility, and anorexia. Urinary incontinence is not generally a concern with hepatic cirrhosis.

Which of the following the are early manifestations of liver cancer? Select all that apply.

a) Fever
b) Continuous aching in the back
c) Vomiting
d) Pain
e) Increased appetite
f) Jaundice

• Pain
• Continuous aching in the back

Early manifestations of liver cancer include pain and continuous dull aching in the right upper quadrant epigastrium or back. Weight loss, anorexia, and anemia may occur. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver. Fever and vomiting are not associated manifestations.

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superior vena cava syndrome compression or obstruction of superior vena cava usually associated with cancer of lungs and lymphomas but may also result from thrombus that develops around a central venous catheter periorbital edema, facial edema, jugular vein distention, dyspnea …

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