Nokea
The nurse is caring for a client with chronic pancreatitis. Which symptom would indicate the client has developed secondary diabetes?
- A. Increased appetite and thirst
- B. Vomiting and diarrhea
- C. Low blood pressure and pulse
- D. Decreased urination and constipation
Correct Answer: A
Rationale: When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. Vomiting, diarrhea, low blood pressure and pulse, and constipation do not indicate the development of secondary diabetes.
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A client is about to undergo a liver biopsy. Which should the nurse administer to the client before the procedure?
- A. Potassium
- B. Vitamin K
- C. Vitamin B
- D. Oral bile acids
Correct Answer: B
Rationale: Clients about to undergo a liver biopsy may require vitamin K before the procedure to reduce the risk of bleeding. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client about to undergo a liver biopsy, they are given to dissolve gallstones. Vitamin B has no implications in the procedure.
A client with esophageal varices is scheduled to undergo injection sclerotherapy. Which client statement indicates that the nurse's teaching was successful?
- A. The physician will use a balloon to compress the vessels.
- B. I might need to have this procedure done again.
- C. I seems odd that a rubber band can block off the vessels.
- D. A catheter will be inserted through my belly to fix the vessels.
Correct Answer: B
Rationale: Persistent portal hypertension allows varices to form again, making it necessary to repeat injection sclerotherapy or variceal banding regularly. Injection sclerotherapy involves passing an endoscope orally to locate the varix. Balloon tamponade is used to compress actively bleeding esophageal varices as a temporary measure. Variceal banding involves using a rubber band over the varix to restrict blood flow that eventually leads to sloughing.
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 reviewing laboratory work that is consistent with a client being positive for hepatitis and in the incubation phase of the illness. What should the nurse be concerned with at this stage of the illness?
- A. The client is infectious.
- B. The client may have enlargement of the liver and spleen.
- C. The client will have weight loss.
- D. The client has jaundice.
Correct Answer: A
Rationale: In the incubation phase, the virus replicates within the liver, and the client is asymptomatic. Late in this phase, the virus can be found in blood, bile, and stools. At this point, the client is considered infectious.
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.