Nokea
A client with esophageal varices is scheduled to undergo injection sclerotherapy. Which client statement indicates that the nurse's teaching was successful?
- A. The physician will use a balloon to compress the vessels.
- B. I might need to have this procedure done again.
- C. I seems odd that a rubber band can block off the vessels.
- D. A catheter will be inserted through my belly to fix the vessels.
Correct Answer: B
Rationale: Persistent portal hypertension allows varices to form again, making it necessary to repeat injection sclerotherapy or variceal banding regularly. Injection sclerotherapy involves passing an endoscope orally to locate the varix. Balloon tamponade is used to compress actively bleeding esophageal varices as a temporary measure. Variceal banding involves using a rubber band over the varix to restrict blood flow that eventually leads to sloughing.
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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.
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 comes to the clinic to see the health care provider for right upper abdominal discomfort, nausea, and frequent belching especially after eating a meal high in fat. What disorder do these symptoms correlate with?
- A. Hepatitis
- B. Biliary colic
- C. Cholelithiasis
- D. Cholecystitis
Correct Answer: C
Rationale: With cholelithiasis, initially, clients experience belching, nausea, and right upper quadrant discomfort, with pain or cramps after high-fat meal. Symptoms become acute when a stone blocks bile flow from the gallbladder. With acute cholecystitis, clients usually are very sick with fever, vomiting, tenderness over the liver, and severe pain called biliary colic. The symptoms do not correlate with hepatitis.
When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which intervention should the nurse consider?
- A. Report the condition to the physician immediately.
- B. Measure abdominal girth according to a set routine.
- C. Provide the client with nonprescription laxatives.
- D. Ask the client about food intake.
Correct Answer: B
Rationale: If the abdomen appears enlarged, the nurse measures it according to a set routine. Measuring the abdominal girth is the most accurate method of determining an increase or decrease in abdominal distention. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis. The nurse would report to the physician about abdominal enlargement along with other parameters of the assessment.
When inspecting the abdomen of a client with cirrhosis, the nurse observes that the veins over the abdomen are dilated. How does the nurse document this finding?
- A. Gynecomastia
- B. Cutaneous spider angioma
- C. Caput medusae
- D. Palinar erythema
Correct Answer: C
Rationale: Caput medus is a term used to denote the appearance of dilated veins over the client's abdomen. Gynecomastia refers to enlarged breasts in a male, which may occur because the dysfunctional liver is unable to metabolize estrogen. Palmer erythema refers to the bright pink appearance of the palms and cutaneous spider angioma refers to tiny, spider-like blood vessels that may be apparent in a client with cirrhosis due to the liver's inability to inactivate estrogen.