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The nurse is assessing a client with suspected cholelithiasis. What can the nurse expect to observe?
- A. Stools that contain blood and mucus
- B. Bowel sounds that are absent
- C. Stools that appear small and dry
- D. Urine that appears dark brown
Correct Answer: D
Rationale: When a client is being assessed for cholelithiasis, the urine appears dark brown, whereas the stools may be light-colored. Bowel sounds are present because cholelithiasis does not cause lack of bowel motility. The stool does not contain blood or mucus.
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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 who has undergone surgery for a liver disorder and has started shivering. Which intervention would be appropriate?
- A. Provide the client with warm fluids.
- B. Cover the client with a light blanket.
- C. Ensure that the room temperature is below 70?°F.
- D. Place the client on a hypothermia blanket.
Correct Answer: B
Rationale: The nurse should cover the client with a light blanket to prevent shivering. This is because the client who has undergone surgery for liver disorder also faces the risk of hyperthermia related to infection, rejection, or both. Providing the client with warm fluids will not control shivering. The client is covered with a hypothermia blanket if the temperature rises to 105?°F. The room temperature need not be below 70?°F.
A client comes to the clinic to see the health care provider for right upper abdominal discomfort, nausea, and frequent belching especially after eating a meal high in fat. What disorder do these symptoms correlate with?
- A. Hepatitis
- B. Biliary colic
- C. Cholelithiasis
- D. Cholecystitis
Correct Answer: C
Rationale: With cholelithiasis, initially, clients experience belching, nausea, and right upper quadrant discomfort, with pain or cramps after high-fat meal. Symptoms become acute when a stone blocks bile flow from the gallbladder. With acute cholecystitis, clients usually are very sick with fever, vomiting, tenderness over the liver, and severe pain called biliary colic. The symptoms do not correlate with hepatitis.
A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?
- A. Cure the cirrhosis.
- B. Treat the esophageal varices.
- C. Reduce fluid accumulation and venous pressure.
- D. Promote optimal neurologic function.
Correct Answer: C
Rationale: Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.
The nurse is assisting the physician with a procedure to remove ascitic fluid from a client with cirrhosis. What procedure does the nurse ensure the client understands will be performed?
- A. Thoracentesis
- B. Abdominal paracentesis
- C. Abdominal CT scan
- D. Upper endoscopy
Correct Answer: B
Rationale: Abdominal paracentesis may be performed to remove ascitic fluid. Abdominal fluid is rapidly removed by careful introduction of a needle through the abdominal wall, allowing the fluid to drain. Fluid is removed from the lung via a thoracentesis. Fluid cannot be removed with an abdominal CT scan, but the scan can assist with placement of the needle. Fluid cannot be removed via an upper endoscopy.