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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.
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A previously healthy adults sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what?
- A. IV administration of immune globulins
- B. Transfusion of packed red blood cells and fresh-frozen plasma (FFP)
- C. Liver transplantation
- D. Lobectomy
Correct Answer: C
Rationale: Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery.
A patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient may have developed liver metastases?
- A. Persistent fever and cognitive changes
- B. Abdominal pain and hepatomegaly
- C. Peripheral edema unresponsive to diuresis
- D. Spontaneous bleeding and jaundice
Correct Answer: B
Rationale: The early manifestations of malignancy of the liver include pain a continuous dull ache in the right upper quadrant, epigastrium, or back. Weight loss, loss of strength, anorexia, and anemia may also occur. The liver may be enlarged and irregular on palpation. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver. Fever, cognitive changes, peripheral edema, and bleeding are atypical signs.
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 patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem?
- A. Assessment of blood pressure and assessment for headaches and visual changes
- B. Assessments for signs and symptoms of venous thromboembolism
- C. Daily weights and abdominal girth measurement
- D. Blood glucose monitoring q4h
Correct Answer: C
Rationale: Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.
A patient with liver cancer is being discharged home with a hepatic artery catheter in place. The nurse should be aware that this catheter will facilitate which of the following?
- A. Continuous monitoring for portal hypertension
- B. Administration of immunosuppressive drugs during the first weeks after transplantation
- C. Real-time monitoring of vascular changes in the hepatic system
- D. Delivery of a continuous chemotherapeutic dose
Correct Answer: D
Rationale: In most cases, the hepatic artery catheter has been inserted surgically and has a prefilled infusion pump that delivers a continuous chemotherapeutic dose until completed. The hepatic artery catheter does not monitor portal hypertension, deliver immunosuppressive drugs, or monitor vascular changes in the hepatic system.