Nokea
A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this disorder? (Select all that apply.)
- A. How frequently do you drink alcohol?
- B. Have you ever had sex with a man?
- C. Do you have a family history of cancer?
- D. Have you ever worked as a plumber?
- E. Were you previously incarcerated?
Correct Answer: A,B,E
Rationale: Alcohol consumption is a major cause of cirrhosis. Sexual practices, particularly unprotected sex with men, increase the risk of hepatitis B or C, which can lead to cirrhosis. Incarceration is a risk factor due to potential exposure to hepatitis C through shared needles or unsanitary conditions. Family history of cancer and working as a plumber are not directly associated with cirrhosis.
You may also like to solve these questions
A nurse cares for a client with hepatitis C. The client's brother states, 'I do not want to contract this infection, so I will not go into his room.' How should the nurse respond?
- A. If you wear a gown and gloves, you will not get this virus.
- B. Hepatitis C is not spread through casual contact.
- C. This virus is only transmitted through a fecal specimen.
- D. I can give you an update on your brother's status from here.
Correct Answer: B
Rationale: Although family members may be afraid that they will contract hepatitis C, the nurse should educate the client's family about how the virus is spread. Hepatitis C is spread via blood-to-blood transmission and is associated with illicit IV drug use, needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. Sharing the client's status without consent would violate privacy.
A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should the nurse recognize as a potential complication?
- A. Nausea and vomiting
- B. Dizziness and syncope
- C. Fever and chills
- D. Mid-sternal chest pain
Correct Answer: D
Rationale: Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea, vomiting, dizziness, syncope, fever, and chills are not typical side effects of vasopressin.
A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, 'I do not want to take this medication because it causes diarrhea.' How should the nurse respond?
- A. Diarrhea is expected; that's how your body gets rid of ammonia.
- B. You may take Kaopectate liquid daily for loose stools.
- C. Do not take any more of the medication until your stools firm up.
- D. We will need to send a stool specimen to the laboratory.
Correct Answer: A
Rationale: The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected therapeutic effect for him or her to remain compliant. The nurse should not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.
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.
A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B?
- A. A 20-year-old college student who has had several sexual partners
- B. A 46-year-old woman who takes acetaminophen daily for headaches
- C. A 63-year-old businessman who travels frequently across the country
- D. An 18-year-old woman who recently ate raw shellfish for dinner
Correct Answer: A
Rationale: Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route. A person with multiple sexual partners has more opportunities to contract the infection. Hepatitis B is not transmitted through medications, casual contact with other travelers, or raw shellfish. Although an overdose of acetaminophen can cause liver cirrhosis, this is not associated with hepatitis B. Hepatitis A is spread through ingestion of contaminated shellfish.