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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.
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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.
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.
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.
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.
A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, 'I am experiencing right flank pain and have a temperature of 101 F.' How should the nurse respond?
- A. Report the client's symptoms to the responsible health care provider.
- B. You should go to the hospital immediately to have your new liver checked out.
- C. You should take an additional dose of cyclosporine today.
- D. Take acetaminophen (Tylenol) every 4 hours until you feel better.
Correct Answer: B
Rationale: Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. Anti-rejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse should not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.