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A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate?
- A. Watery, blood-streaked diarrhea
- B. Orange and foamy urine
- C. Increased abdominal girth
- D. Decreased cognition
Correct Answer: B
Rationale: If the bile duct is obstructed, the bile will be reabsorbed into the blood and carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy. Bloody diarrhea, ascites, and cognitive changes are not associated with obstructive jaundice.
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A nurse is caring for a patient with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL. For what complication is this patient at risk?
- A. Chronic jaundice
- B. Pigment stones in portal circulation
- C. Central nervous system damage
- D. Hepatomegaly
Correct Answer: C
Rationale: Prolonged jaundice, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin exceeding 20 to 25 mg/dL) poses a risk for CNS damage. There are not specific risks of hepatomegaly or chronic jaundice resulting from high bilirubin.
A patients physician has ordered a liver panel in response to the patients development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply.
- A. Alanine aminotransferase (ALT)
- B. C-reactive protein (CRP)
- C. Gamma-glutamyl transferase (GGT)
- D. Aspartate aminotransferase (AST)
- E. B-type natriuretic peptide (BNP)
Correct Answer: A,C,D
Rationale: Liver function testing includes GGT, ALT, and AST. CRP addresses the presence of generalized inflammation and BNP is relevant to heart failure; neither is included in a liver panel.
A patient with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the patients treatment?
- A. Decisional Conflict
- B. Deficient Knowledge
- C. Death Anxiety
- D. Disturbed Thought Processes
Correct Answer: C
Rationale: The sudden hemorrhage that accompanies variceal bleeding is intensely anxiety-provoking. The nurse must address the patients likely fear of death, which is a realistic possibility. For most patients, anxiety is likely to be a more acute concern than lack of knowledge or decisional conflict. The patient may or may not experience disturbances in thought processes.
A 55-year-old female patient with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment?
- A. Destruction of the patients liver tumor
- B. Restoration of portal vein patency
- C. Destruction of a liver abscess
- D. Reversal of metastasis
Correct Answer: A
Rationale: Using radiofrequency ablation, a tumor up to 5 cm in size can be destroyed in one treatment session. This technique does not address circulatory function or abscess formation. It does not allow for the reversal of metastasis.
During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus?
- A. Following proper hand-washing techniques
- B. Avoiding chemicals that are toxic to the liver
- C. Wearing a condom during sexual contact
- D. Limiting alcohol intake
Correct Answer: A
Rationale: Avoiding contact with the hepatitis E virus through good hygiene, including hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecal-oral route, principally through contaminated water in areas with poor sanitation. Consequently, none of the other listed preventative measures is indicated.