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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.
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A nurse obtains a clients health history at a community health clinic. Which statement alerts the nurse to a possible health threat to the client?
- A. I drink two glasses of red wine each week.
- B. I take a lot of Tylenol for my arthritis pain.
- C. I have a cousin who died of liver cancer.
- D. I got a hepatitis vaccine before traveling.
Correct Answer: B
Rationale: Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explain other drug options with the client to manage his or her arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis vaccine do not place the client at risk for a liver disorder, and therefore do not require any health teaching.
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 assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of carcinoma of the liver?
- A. A 25-year-old with a history of blunt liver trauma
- B. A 48-year-old with a history of diabetes mellitus
- C. A 30-year-old who has a history of cirrhosis
- D. An 82-year-old who has chronic malnutrition
Correct Answer: C
Rationale: The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause. Blunt liver trauma, diabetes mellitus, and chronic malnutrition do not increase a person's risk for developing liver cancer.
A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.)
- A. Apply lotion to the client's dry skin areas.
- B. Use a basin with warm water to bathe the client.
- C. For oral care, use a soft toothbrush.
- D. Provide supplemental warm water for gargles.
- E. Bathe with antibacterial and water-based soaps.
Correct Answer: A,C,D
Rationale: Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush should be used to prevent gum bleeding, and the client's nails should be trimmed short to prevent scratching. Clients should use cool, not warm, water on their skin and should not use excessive amounts of soap.
A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites?
- A. Monitor intake and output.
- B. Monitor vital signs and diet.
- C. Increase oral fluid intake.
- D. Weigh the client daily.
Correct Answer: B
Rationale: A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.