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A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurses most recent assessment reveals subtle changes in the patients cognition and behavior. What is the nurses most appropriate response?
- A. Ensure that the patients sodium intake does not exceed recommended levels.
- B. Report this finding to the primary care provider due to the possibility of hepatic encephalopathy.
- C. Inform the primary care provider that the patient should be assessed for alcoholic hepatitis.
- D. Implement interventions aimed at ensuring a calm and therapeutic care environment.
Correct Answer: B
Rationale: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patients mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the patients physiologic deterioration.
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A patient is being discharged after a liver transplant and the nurse is performing discharge education. When planning this patients continuing care, the nurse should prioritize which of the following risk diagnoses?
- A. Risk for Infection Related to Immunosuppressant Use
- B. Risk for Injury Related to Decreased Hemostasis
- C. Risk for Unstable Blood Glucose Related to Impaired Gluconeogenesis
- D. Risk for Contamination Related to Accumulation of Ammonia
Correct Answer: A
Rationale: Infection is the leading cause of death after liver transplantation. Pulmonary and fungal infections are common; susceptibility to infection is increased by the immunosuppressive therapy that is needed to prevent rejection. This risk exceeds the threats of injury and unstable blood glucose. The diagnosis of Risk for Contamination relates to environmental toxin exposure.
A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patients liver?
- A. Place hand under the right lower abdominal quadrant and press down lightly with the other hand.
- B. Place the left hand over the abdomen and behind the left side at the 11th rib.
- C. Place hand under right lower rib cage and press down lightly with the other hand.
- D. Hold hand 90 degrees to right side of the abdomen and push down firmly.
Correct Answer: C
Rationale: To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant.
A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patients increased risk of bleeding. The nurse recognizes that this risk is related to the patients inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function?
- A. Alterations in glucose metabolism
- B. Retention of bile salts
- C. Inadequate production of albumin by hepatocytes
- D. Inability of the liver to use vitamin K
Correct Answer: D
Rationale: Decreased production of several clotting factors may be partially due to deficient absorption of vitamin K from the GI tract. This probably is caused by the inability of liver cells to use vitamin K to make prothrombin. This bleeding risk is unrelated to the roles of glucose, bile salts, or albumin.
A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurses most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurses best response to this assessment finding?
- A. Document the presence of normal bile output.
- B. Irrigate the drainage system with normal saline as ordered.
- C. Aspirate a sample of the drainage for culture.
- D. Promptly report this assessment finding to the primary care provider.
Correct Answer: A
Rationale: Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.
A nurse is caring for a patient with hepatic encephalopathy. The nurses assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy?
- A. Stage I
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct Answer: C
Rationale: Patients in the third stage of hepatic encephalopathy exhibit the following symptoms: stuporous, difficult to arouse, sleeps most of the time, exhibits marked confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of extremities, marked EEG abnormalities. Patients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3, and patients in stage 4 are comatose. In stage 4, there is an absence of asterixis, absence of deep tendon reflexes, flaccidity of extremities, and EEG abnormalities.