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A patient has been admitted to the critical care unit with a diagnosis of toxic hepatitis. When planning the patients care, the nurse should be aware of what potential clinical course of this health problem? Place the following events in the correct sequence. 1. Fever rises. 2. Hematemesis. 3. Clotting abnormalities. 4. Vascular collapse. 5. Coma.
- A. 1,2,5,4,3
- B. 1,2,3,4,5
- C. 2,3,1,4,5
- D. 3,1,2,5,4
Correct Answer: B
Rationale: Recovery from acute toxic hepatitis is rapid if the hepatotoxin is identified early and removed or if exposure to the agent has been limited. Recovery is unlikely if there is a prolonged period between exposure and onset of symptoms. There are no effective antidotes. The fever rises; the patient becomes toxic and prostrated. Vomiting may be persistent, with the emesis containing blood. Clotting abnormalities may be severe, and hemorrhages may appear under the skin. The severe GI symptoms may lead to vascular collapse. Delirium, coma, and seizures develop, and within a few days the patient may die of fulminant hepatic failure unless he or she receives a liver transplant.
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A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patients presentation?
- A. How many alcoholic drinks do you typically consume in a week?
- B. To the best of your knowledge, are your immunizations up to date?
- C. Have you ever worked in an occupation where you might have been exposed to toxins?
- D. Has anyone in your family ever experienced symptoms similar to yours?
Correct Answer: A
Rationale: Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use. Immunization status, occupational risks, and family history are also relevant considerations, but alcohol use is a more common etiologic factor in liver disease.
A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patients plan of care?
- A. Measurement of abdominal girth and body weight
- B. Assessment for variceal bleeding
- C. Assessment for signs and symptoms of jaundice
- D. Monitoring of results of liver function testing
Correct Answer: B
Rationale: Esophageal varices are a major cause of mortality in patients with uncompensated cirrhosis. Consequently, this should be a focus of the nurses assessments and should be prioritized over the other listed assessments, even though each should be performed.
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 local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine?
- A. The hepatitis A vaccine
- B. Albumin infusion
- C. The hepatitis A and B vaccines
- D. An immune globulin injection
Correct Answer: D
Rationale: For people who have not been previously vaccinated, hepatitis A can be prevented by the intramuscular administration of immune globulin during the incubation period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will not protect the patient exposed to hepatitis A, as protection will take a few weeks to develop after the first dose of the vaccine. The hepatitis B vaccine provides protection again the hepatitis B virus, but plays no role in protection for the patient exposed to hepatitis A. Albumin confers no therapeutic benefit.
A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding?
- A. Similar liver size and texture as in younger adults
- B. A nonpalpable liver
- C. A slightly enlarged liver with palpably hard edges
- D. A slightly decreased size of the liver
Correct Answer: D
Rationale: The most common age-related change in the liver is a decrease in size and weight. The liver is usually still palpable, however, and is not expected to have hardened edges.