Nokea
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.
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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.
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.
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 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.
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.