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A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially limiting complications of this disorder? (Select all that apply.)
- A. Elevated aspartate transaminase
- B. Elevated international normalized ratio (INR)
- C. Elevated serum albumin
- D. Decreased serum alkaline phosphatase
- E. Elevated serum ammonia
- F. Elevated serum ALT (AST) (PT)
Correct Answer: B,E,F
Rationale: Because INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage, and elevated ammonia levels increase the client's confusion, these are critical findings. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.
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A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance. Which statement best explains the rationale for a low-protein diet?
- A. A low-protein diet will help the liver rest and restore function.
- B. Less protein in the diet will help prevent confusion associated with liver failure.
- C. Increasing dietary protein will help the client gain weight and muscle.
- D. Low dietary protein is needed to prevent fluid overload.
Correct Answer: B
Rationale: A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing dietary protein will cause complications of liver failure and should not be suggested. Increased intravascular protein may help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.
An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a steering wheel imprint across the client's chest. Which action should the nurse take?
- A. Ask the client where he or she was sitting during the crash.
- B. Assess the client by gently palpating the abdomen for tenderness.
- C. Notify the laboratory to draw blood for blood type and crossmatch.
- D. Develop a handwashing plan to prevent infection.
Correct Answer: B
Rationale: The liver is often injured by a steering wheel in a motor vehicle crash. Because the client's chest was marked by the steering wheel, the nurse should perform an abdominal assessment. Assessing the client's position in the crash is not needed because of the steering wheel imprint. The client may or may not need a blood transfusion. A handwashing plan is not relevant to this situation.
After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching?
- A. Some medications have been known to cause hepatitis A.
- B. I may have been exposed when we ate shrimp last weekend.
- C. I was infected with hepatitis A through a recent blood transfusion.
- D. My infection with Epstein-Barr virus can co-infect me with hepatitis A.
Correct Answer: B
Rationale: The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection, not a co-infection with hepatitis A.
A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first?
- A. Sedate the client to prevent tube dislodgement.
- B. Maintain balloon pressure at 15 to 25 mm Hg.
- C. Irrigate the gastric lumen with normal saline.
- D. Assist the client for airway patency.
Correct Answer: D
Rationale: Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration. The client should be sedated, and balloon pressure should be maintained between 15 and 25 mm Hg. Irrigation with saline may be performed, but these actions are not a higher priority than airway patency.
A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, 'All of my family hates me.' How should the nurse respond?
- A. You should make peace with your family.
- B. This is not unusual. My family hates me too.
- C. You should find a friend or recovery group for support.
- D. You must attend Alcoholics Anonymous.
Correct Answer: C
Rationale: Clients who have chronic cirrhosis may have alienated relatives over the years because of substance abuse. The nurse should assist the client to identify a friend, neighbor, or person in his or her recovery group for support. Suggesting that the client make peace with family may not be possible and is not client-centered. Sharing personal experiences or mandating attendance at Alcoholics Anonymous is not appropriate.