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Which of the following data obtained by the nurse during the assessment of a patient with cirrhosis is of most concern?
- A. The patient's hands flap back and forth when the arms are extended.
- B. The patient has ascites and a 2-kg weight gain from the previous day.
- C. The patient's skin has multiple spider-shaped blood vessels on the abdomen.
- D. The patient complains of right upper-quadrant pain with abdominal palpation.
Correct Answer: A
Rationale: The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain do indicate the need for treatment but not as urgently as the changes in neurological status.
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After receiving change-of-shift report, which of the following patients should the nurse assess first?
- A. 50-year-old with persistent pancreatitis who has gnawing abdominal pain
- B. 48-year-old who has compensated cirrhosis and is complaining of anorexia
- C. 45-year-old with cirrhosis and severe ascites who has an oral temperature of 38.8°C (101.8°F)
- D. 36-year-old who is recovering from a laparoscopic cholecystectomy and has severe shoulder pain
Correct Answer: C
Rationale: This patient's history and fever suggest spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.
Which of the following nursing actions is a priority when the nurse is caring for a patient with pancreatic cancer?
- A. Offer high-calorie, high-protein dietary choices.
- B. Offer psychological support for anxiety or depression.
- C. Educate about the need to avoid scratching pruritic areas.
- D. Administer prescribed opioids to relieve pain as needed.
Correct Answer: D
Rationale: Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to education, or manage anxiety or depression.
Which of the following actions should be included in the plan of care for a patient who has recently been diagnosed with asymptomatic non-alcoholic fatty liver disease (NAFLD)?
- A. Teach symptoms of variceal bleeding
- B. Review the patient's current medication list.
- C. Draw blood for hepatitis serology testing.
Correct Answer: C
Rationale: Reviewing the patient's current medication list is essential to identify potential hepatotoxic drugs and manage risk factors like diabetes or hyperlipidemia, which are associated with NAFLD progression. Teaching about variceal bleeding is irrelevant for asymptomatic NAFLD, as varices are a complication of advanced liver disease. Hepatitis serology is not indicated unless viral hepatitis is suspected.
The nurse is admitting a patient with acute bleeding from esophageal varices who asks the nurse the purpose for the ordered pantoprazole. Which of the following responses by the nurse is best?
- A. The medication will reduce the risk for aspiration.
- B. The medication will decrease nausea and anorexia.
- C. The medication will inhibit the development of gastric ulcers.
- D. The medication will prevent irritation to the esophageal varices.
Correct Answer: D
Rationale: Pantoprazole is a proton pump inhibitor. Supportive measures during an acute variceal bleed include administration of fresh-frozen plasma and packed red blood cells, vitamin K, and proton pump inhibitors. Although pantoprazole does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purpose for its use in this patient.
A patient in the outpatient clinic is diagnosed with acute hepatitis C virus (HCV) infection. Which of the following actions by the nurse is best?
- A. Schedule the patient for HCV genotype testing.
- B. Administer immune globulin and the HCV vaccine.
- C. Instruct the patient on ribavirin treatment.
- D. Teach that the infection will resolve in a few months.
Correct Answer: A
Rationale: Genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated. Since most patients with acute HCV infection convert to a persistent state, the nurse should not teach the patient that the HCV will resolve in a few months. Immune globulin or vaccine is not available for HCV. Ribavirin is used for persistent HCV infection.