Nokea
The nurse is assessing a client with cirrhosis of the liver. Which stool characteristic would the nurse expect the client to report?
- A. Yellow-green
- B. Black and tarry
- C. Blood tinged
- D. Clay-colored or whitish
Correct Answer: D
Rationale: Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.
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When inspecting the abdomen of a client with cirrhosis, the nurse observes that the veins over the abdomen are dilated. How does the nurse document this finding?
- A. Gynecomastia
- B. Cutaneous spider angioma
- C. Caput medusae
- D. Palinar erythema
Correct Answer: C
Rationale: Caput medus is a term used to denote the appearance of dilated veins over the client's abdomen. Gynecomastia refers to enlarged breasts in a male, which may occur because the dysfunctional liver is unable to metabolize estrogen. Palmer erythema refers to the bright pink appearance of the palms and cutaneous spider angioma refers to tiny, spider-like blood vessels that may be apparent in a client with cirrhosis due to the liver's inability to inactivate estrogen.
A nurse is preparing a presentation for a local community group about hepatitis. Which information would the nurse include?
- A. Hepatitis B is transmitted primarily by the oral-fecal route.
- B. Hepatitis A is frequently spread by sexual contact.
- C. Hepatitis C increases a person's risk for liver cancer.
- D. Infection with hepatitis G is similar to hepatitis A.
Correct Answer: C
Rationale: Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route, hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.
The nurse is caring for a client with severe acute pancreatitis with a glucose level of 750 mg/dL. What does the nurse understand is the cause of this level of hyperglycemia?
- A. Severe acute pancreatitis causes an increase in circulating calcium.
- B. The client has not been taking the insulin and eating simple carbohydrates.
- C. The client has diabetes as well as pancreatitis.
- D. Severe acute pancreatitis causes an imbalance of glucagon, insulin, and somatostatin.
Correct Answer: D
Rationale: Complications from severe acute pancreatitis are serious and sometimes fatal. Hyperglycemia results from an imbalance of glucagon, insulin, and somatostatin. Increase in circulating calcium does not result in an increase in glucose levels. The nurse cannot assume that the client has diabetes and is noncompliant.
A client had an open cholecystectomy with a T-tube insertion, and the nurse is measuring the bile drainage every 8 hours. When should the nurse notify the health care provider?
- A. If more than 17 oz (500 mL) of bile drainage is present in 24 hours
- B. If the bile drainage tubing is slack
- C. If there is 34 oz (100 mL) in the drainage pouch after 8 hours
- D. If there is 34 oz (10 mL) per hour of drainage in 24 hours
Correct Answer: A
Rationale: The nurse measures bile drainage every 8 hours or according to agency policy. If more than 17 oz (500 mL) of bile drains within 24 hours or if drainage is significantly reduced, the nurse notifies the health care provider. The nurse should ensure that there is no tension on the bile drainage tubing; slack drainage tubing is an expected finding. About 34 oz (100 mL) in the drainage pouch after 8 hours, and 34 oz (10 mL) per hour of drainage in 24 hours are less than 17 oz (100 mL) in 24 hours and are therefore not findings that require health care provider notification.
The nurse is caring for a client with cirrhosis of the liver. What symptom(s) would indicate to the nurse that the client is experiencing central nervous system effects of the disease? Select all that apply.
- A. Asterixis
- B. Joint stiffness
- C. Positive Babinski reflex
- D. Cough
- E. Fetor hepaticus
Correct Answer: A,C,E
Rationale: Hepatic encephalopathy is a CNS manifestation of liver failure that is a complication of cirrhosis. Indications of CNS effects include disorientation, confusion, personality changes, memory loss, a flapping tremor called asterixis, a positive Babinski reflex, sulfurous breath odor (fetor hepaticus), and lethargy to deep coma. Cough and joint stiffness are not indicators of CNS effects of cirrhosis.