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A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?
- A. Asterixis
- B. Constructional apraxia
- C. Fetor hepaticus
- D. Palmar erythema
Correct Answer: A
Rationale: The nurse will document that a patient exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.
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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 has entered the room of a patient with cirrhosis and found the patient on the floor. The patient states that she fell when transferring to the commode. The patients vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurses most appropriate action?
- A. Remove the patients commode and supply a bedpan.
- B. Complete an incident report and submit it to the unit supervisor.
- C. Have the patient assessed by the physician due to the risk of internal bleeding.
- D. Perform a focused abdominal assessment in order to rule out injury.
Correct Answer: C
Rationale: A fall would necessitate thorough medical assessment due to the patients risk of bleeding. The nurses abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate.
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.
Diagnostic testing has revealed that a patients hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patients plan of care will focus on what intervention?
- A. Cryosurgery
- B. Liver transplantation
- C. Lobectomy
- D. Laser hyperthermia
Correct Answer: C
Rationale: Surgical resection is the treatment of choice when HCC is confined to one lobe of the liver and the function of the remaining liver is considered adequate for postoperative recovery. Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While cryosurgery and liver transplantation are other surgical options for management of liver cancer, these procedures are not performed at the same frequency as a lobectomy. Laser hyperthermia is a nonsurgical treatment for liver cancer.
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.