Nokea
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.
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A client has a blockage of the passage of bile from a stone in the common bile duct. What type of jaundice does the nurse suspect this client has?
- A. Hemolytic jaundice
- B. Hepatocellular jaundice
- C. Obstructive jaundice
- D. Cirrhosis of the liver
Correct Answer: C
Rationale: Obstructive jaundice is caused by a block in the passage of bile between the liver and intestinal tract. Hemolytic jaundice is caused by excess destruction of red blood cells. Hepatocellular jaundice is caused by liver disease. Cirrhosis of the liver would be an example of hepatocellular jaundice.
A client with cirrhosis is complaining to the nurse of itching. The client asks the nurse if the itching is from taking warm baths. What is the best response by the nurse?
- A. The itching is caused by the accumulation of bile salts.
- B. The itching is related to dry skin from the warm baths.
- C. The itching is most likely a side effect from some of the medications used in treatment.
- D. The itching is related to a psychological response from the illness.
Correct Answer: A
Rationale: Skin may itch (pruritus) from accumulated bile salts related to the diseased liver. It is not related to the baths or a psychological response from the illness. Medication side effect may cause itching, but the most likely cause is the accumulation of bile salts.
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.
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.
A client has developed drug-induced hepatitis from a drug reaction to antidepressants. What treatment does the nurse anticipate the client will receive to treat the reaction?
- A. Paracentesis
- B. Liver transplantation
- C. High-dose corticosteroids
- D. Azathioprine
Correct Answer: C
Rationale: Drug-induced hepatitis occurs when a drug reaction damages the liver. This form of hepatitis can be severe and fatal. High-dose corticosteroids usually administered first to treat the reaction. Liver transplantation may be necessary. Paracentesis should be used to withdraw fluid for the treatment of ascites. Azathioprine (Imuran) may be used for autoimmune hepatitis.