Nokea
A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis?
- A. A liver biopsy
- B. A CT scan
- C. A prothrombin time
- D. Platelet count
Correct Answer: A
Rationale: A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding.
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A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?
- A. Cure the cirrhosis.
- B. Treat the esophageal varices.
- C. Reduce fluid accumulation and venous pressure.
- D. Promote optimal neurologic function.
Correct Answer: C
Rationale: Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.
The nurse is reviewing laboratory work that is consistent with a client being positive for hepatitis and in the incubation phase of the illness. What should the nurse be concerned with at this stage of the illness?
- A. The client is infectious.
- B. The client may have enlargement of the liver and spleen.
- C. The client will have weight loss.
- D. The client has jaundice.
Correct Answer: A
Rationale: In the incubation phase, the virus replicates within the liver, and the client is asymptomatic. Late in this phase, the virus can be found in blood, bile, and stools. At this point, the client is considered infectious.
A client with cirrhosis is complaining of severe pruritus related to the accumulation of bile salts. What can be prescribed for the client to relieve the itching?
- A. Cholestyaramine
- B. Kanamyycin
- C. Lactulose
- D. Cyclosporine
Correct Answer: A
Rationale: Cholestyramine may be prescribed to bind bile salts and relieve pruritus. Kanamycin is prescribed to reduce the bacterial count in the intestine. Lactulose is used to decrease the amount of ammonia level in the blood. Cyclosporine is used to prevent rejection of a transplanted organ.
The nurse is caring for a client with cirrhosis of the liver. What symptom(s) would indicate to the nurse that the client is experiencing central nervous system effects of the disease? Select all that apply.
- A. Asterixis
- B. Joint stiffness
- C. Positive Babinski reflex
- D. Cough
- E. Fetor hepaticus
Correct Answer: A,C,E
Rationale: Hepatic encephalopathy is a CNS manifestation of liver failure that is a complication of cirrhosis. Indications of CNS effects include disorientation, confusion, personality changes, memory loss, a flapping tremor called asterixis, a positive Babinski reflex, sulfurous breath odor (fetor hepaticus), and lethargy to deep coma. Cough and joint stiffness are not indicators of CNS effects of cirrhosis.
The nurse is assessing a client with cirrhosis of the liver. Which stool characteristic would the nurse expect the client to report?
- A. Yellow-green
- B. Black and tarry
- C. Blood tinged
- D. Clay-colored or whitish
Correct Answer: D
Rationale: Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.