Nokea
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.
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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 patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patients fluid volume excess? Select all that apply.
- A. Administering diuretics
- B. Administering calcium channel blockers
- C. Implementing fluid restrictions
- D. Implementing a 1500 kcal/day restriction
- E. Enhancing patient positioning
Correct Answer: A,C,E
Rationale: Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize the management of fluid volume excess. Calcium channel blockers and caloric restriction do not address this problem.
A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate?
- A. Infusion of intravenous heparin
- B. IV administration of albumin
- C. STAT administration of vitamin K by the intramuscular route
- D. IV administration of octreotide (Sandostatin)
Correct Answer: D
Rationale: Octreotide (Sandostatin) a synthetic analog of the hormone somatostatin is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not administered and heparin would exacerbate, not alleviate, bleeding.
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 patients physician has ordered a liver panel in response to the patients development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply.
- A. Alanine aminotransferase (ALT)
- B. C-reactive protein (CRP)
- C. Gamma-glutamyl transferase (GGT)
- D. Aspartate aminotransferase (AST)
- E. B-type natriuretic peptide (BNP)
Correct Answer: A,C,D
Rationale: Liver function testing includes GGT, ALT, and AST. CRP addresses the presence of generalized inflammation and BNP is relevant to heart failure; neither is included in a liver panel.