Nokea
The nurse clarifies that deterioration progresses through stages before presenting with liver disease. The first stage is destruction. What is the last stage?
- A. Liver disease
- B. Inflammation
- C. Hepatic insufficiency
- D. Destruction
- E. Fibrotic regeneration
Correct Answer: A
Rationale: Liver deterioration follows a pattern of stages: destruction, inflammation, fibrotic regeneration; hepatic insufficiency then presents as liver disease.
You may also like to solve these questions
What should the nurse monitor in caring for the patient undergoing a paracentesis?
- A. The urinary output
- B. Hypervolemia
- C. Fluid removal over at least 30 minutes
- D. Seizure
Correct Answer: C
Rationale: The fluid removed during a paracentesis is removed over a period of 30 to 90 minutes to prevent sudden changes in blood pressure leading to syncope. The bed should be in a high Fowler's position. Food and fluid restriction is usually not necessary.
The patient with cirrhosis has a rising ammonia level and is becoming disoriented. The patient's hands flap when the patient stretches out the arm. How will the nurse interpret this?
- A. As an attempt to get the nurse's attention
- B. As asterixis
- C. As an indication of respiratory obstruction from varices
- D. As spasticity
Correct Answer: B
Rationale: Asterixis is the 'flapping tremor' seen as the patient deteriorates into ammonia intoxication or hepatic encephalopathy.
Why is morphine contraindicated in the patient with pancreatitis?
- A. Meperidine is less expensive.
- B. Tylenol is more effective at managing this type of pain.
- C. Morphine may cause spasms of the sphincter of Oddi.
- D. These patients do not experience pain.
Correct Answer: C
Rationale: A common complaint is constant, severe pain; in such cases, meperidine is often administered. Morphine may cause spasms of the sphincter of Oddi.
The nurse is aware that an elevated serum amylase is diagnostic of pancreatitis at an early stage as an elevation can be assessed as early as how many hours after the onset of pancreatic disease?
- A. 2 hours
- B. 8 hours
- C. 24 hours
- D. 36 hours
Correct Answer: A
Rationale: An increase in the serum amylase can be detected as early as 2 hours after the onset of pancreatic disease. In simple acute pancreatitis, the level returns to normal in about 36 hours. In chronic disease, it remains elevated.
Which nursing intervention should be completed immediately after the health care provider has performed a needle liver biopsy?
- A. Assisting to ambulate for the bathroom
- B. Keeping the patient on the right side for a minimum of 2 hours
- C. Taking vital signs every 4 hours
- D. Keeping the patient on the left side for a minimum of 4 hours
Correct Answer: B
Rationale: Keep the patient lying on the right side with a rolled towel against the puncture site for minimum of 2 hours to splint the puncture site. It compresses the liver capsule against the chest wall to decrease the risk of hemorrhage or bile leak. Vital signs are taken every 15 minutes for 30 minutes, then every 30 minutes for 2 hours.