Nokea
A client with cirrhosis is complaining to the nurse of itching. The client asks the nurse if the itching is from taking warm baths. What is the best response by the nurse?
- A. The itching is caused by the accumulation of bile salts.
- B. The itching is related to dry skin from the warm baths.
- C. The itching is most likely a side effect from some of the medications used in treatment.
- D. The itching is related to a psychological response from the illness.
Correct Answer: A
Rationale: Skin may itch (pruritus) from accumulated bile salts related to the diseased liver. It is not related to the baths or a psychological response from the illness. Medication side effect may cause itching, but the most likely cause is the accumulation of bile salts.
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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 administering medications to a client who has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent?
- A. Spirofolactone
- B. Cholestyaramine
- C. Lactulose
- D. Kanamyycin
Correct Answer: C
Rationale: Lactulose is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients. Potassium-sparing diuretics such as spironolactone are used to treat ascites. Cholestyramine is a bile acid sequestrant and reduces pruritus. Kanamycin decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.
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.
The nurse is caring for a client with severe acute pancreatitis with a glucose level of 750 mg/dL. What does the nurse understand is the cause of this level of hyperglycemia?
- A. Severe acute pancreatitis causes an increase in circulating calcium.
- B. The client has not been taking the insulin and eating simple carbohydrates.
- C. The client has diabetes as well as pancreatitis.
- D. Severe acute pancreatitis causes an imbalance of glucagon, insulin, and somatostatin.
Correct Answer: D
Rationale: Complications from severe acute pancreatitis are serious and sometimes fatal. Hyperglycemia results from an imbalance of glucagon, insulin, and somatostatin. Increase in circulating calcium does not result in an increase in glucose levels. The nurse cannot assume that the client has diabetes and is noncompliant.
The nurse is caring for a client with chronic pancreatitis. Which symptom would indicate the client has developed secondary diabetes?
- A. Increased appetite and thirst
- B. Vomiting and diarrhea
- C. Low blood pressure and pulse
- D. Decreased urination and constipation
Correct Answer: A
Rationale: When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. Vomiting, diarrhea, low blood pressure and pulse, and constipation do not indicate the development of secondary diabetes.