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A nurse obtains a clients health history at a community health clinic. Which statement alerts the nurse to a possible health threat to the client?
- A. I drink two glasses of red wine each week.
- B. I take a lot of Tylenol for my arthritis pain.
- C. I have a cousin who died of liver cancer.
- D. I got a hepatitis vaccine before traveling.
Correct Answer: B
Rationale: Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explain other drug options with the client to manage his or her arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis vaccine do not place the client at risk for a liver disorder, and therefore do not require any health teaching.
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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.
A nurse cares for a client with hepatitis C. The client's brother states, 'I do not want to contract this infection, so I will not go into his room.' How should the nurse respond?
- A. If you wear a gown and gloves, you will not get this virus.
- B. Hepatitis C is not spread through casual contact.
- C. This virus is only transmitted through a fecal specimen.
- D. I can give you an update on your brother's status from here.
Correct Answer: B
Rationale: Although family members may be afraid that they will contract hepatitis C, the nurse should educate the client's family about how the virus is spread. Hepatitis C is spread via blood-to-blood transmission and is associated with illicit IV drug use, needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. Sharing the client's status without consent would violate privacy.
After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching?
- A. Some medications have been known to cause hepatitis A.
- B. I may have been exposed when we ate shrimp last weekend.
- C. I was infected with hepatitis A through a recent blood transfusion.
- D. My infection with Epstein-Barr virus can co-infect me with hepatitis A.
Correct Answer: B
Rationale: The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection, not a co-infection with hepatitis A.
A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.)
- A. Apply lotion to the client's dry skin areas.
- B. Use a basin with warm water to bathe the client.
- C. For oral care, use a soft toothbrush.
- D. Provide supplemental warm water for gargles.
- E. Bathe with antibacterial and water-based soaps.
Correct Answer: A,C,D
Rationale: Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush should be used to prevent gum bleeding, and the client's nails should be trimmed short to prevent scratching. Clients should use cool, not warm, water on their skin and should not use excessive amounts of soap.
After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the client's understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for further teaching?
- A. I should drink bottled water during my travels.
- B. I will not eat off others' plates or share utensils.
- C. I should eat plenty of fresh fruits and vegetables.
- D. I will wash my hands frequently and thoroughly.
Correct Answer: C
Rationale: The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by tap water. Drinking bottled water, not sharing plates, glasses, or eating utensils, and frequent handwashing are good ways to prevent illness.