Nokea
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.
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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 scheduled to have a laparoscopic cholecystectomy as an outpatient. The client asks the nurse when it will be possible to resume normal activities. What information should the nurse provide?
- A. Normal activities may be resumed the day after surgery.
- B. Normal activities may be resumed in 1 week.
- C. Normal activities may be resumed in 1 weeks.
- D. Normal activities may be resumed in 1 month.
Correct Answer: B
Rationale: A prolonged recovery period usually is unnecessary. Most clients resume normal activities within 1 week.
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.
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 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.