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When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which intervention should the nurse consider?
- A. Report the condition to the physician immediately.
- B. Measure abdominal girth according to a set routine.
- C. Provide the client with nonprescription laxatives.
- D. Ask the client about food intake.
Correct Answer: B
Rationale: If the abdomen appears enlarged, the nurse measures it according to a set routine. Measuring the abdominal girth is the most accurate method of determining an increase or decrease in abdominal distention. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis. The nurse would report to the physician about abdominal enlargement along with other parameters of the assessment.
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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.
The nurse is admitting a client to their room at the hospital and observes that the client's skin and sclera are jaundiced. What does the nurse expect the client's total bilirubin levels to be?
- A. 0.2 mg/dL
- B. 1.0 mg/dL
- C. 2.0 mg/dL
- D. 3.0 mg/dL
Correct Answer: D
Rationale: Normally, total bilirubin concentration ranges from 0.2 to 1.3 mg/dL. If the serum bilirubin level exceeds 2.5 mg/dL, jaundice is visible, notably on the skin, oral mucous membranes, and, especially, sclera.
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.
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 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.