Question 1

A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patients increased risk of bleeding. The nurse recognizes that this risk is related to the patients inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function?

Accepted Answer

Decreased production of several clotting factors may be partially due to deficient absorption of vitamin $\mathrm{K}$ from the GI tract. This probably is caused by the inability of liver cells to use vitamin $\mathrm{K}$ to make prothrombin. This bleeding risk is unrelated to the roles of glucose, bile salts, or albumin.

Question 2

A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patients liver?

Accepted Answer

To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant.

Question 3

A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize
Which of the following assessments related to the manifestations of this health problem?

Accepted Answer

Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.

Question 4

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply.

Accepted Answer

People who are at high risk, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. The consistent use of standard precautions is also highly beneficial. Vitamin supplementation is unrelated to an individuals risk of HBV.

Question 5

A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurses most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurses best response to this assessment finding?

Accepted Answer

Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.

Question 6

A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize?

Accepted Answer

The patient is given written and verbal instructions about immunosuppressive agent doses and dosing schedules. The patient is also instructed on steps to follow to ensure that an adequate supply of medication is available so that there is no chance of running out of the medication or skipping a dose. Failure to take medications as instructed may precipitate rejection. The nurse would not teach the patient to measure drainage from a T-tube as the patient wouldnt go home with a T-tube. The nurse may teach the patient about the need to exercise or what the signs of liver dysfunction are, but the nurse would not stress these topics over the immunosuppressive drug regimen.

Question 7

A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patients presentation?

Accepted Answer

Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use. Immunization status, occupational risks, and family history are also relevant considerations, but alcohol use is a more common etiologic factor in liver disease.

Question 8

A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate?

Accepted Answer

Octreotide (Sandostatin)a synthetic analog of the hormone somatostatinis effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin $\mathrm{K}$ and albumin are not administered and heparin would exacerbate, not alleviate, bleeding.

Question 9

A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

Accepted Answer

The nurse will document that a patient exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.

Question 10

A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine?

Accepted Answer

For people who have not been previously vaccinated, hepatitis A can be prevented by the intramuscular administration of immune globulin during the incubation period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will not protect the patient exposed to hepatitis A, as protection will take a few weeks to develop after the first dose of the vaccine. The hepatitis B vaccine provides protection again the hepatitis B virus, but plays no role in protection for the patient exposed to hepatitis A. Albumin confers no therapeutic benefit.

Question 11

A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis?

Accepted Answer

Although any medication can affect liver function, use of acetaminophen (found in many over-thecounter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Finishing prescribed antibiotics and avoiding expired medications are unrelated to this disease. Drug interactions are rarely the cause of drug-induced hepatitis.

Question 12

Diagnostic testing has revealed that a patients hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patients plan of care will focus on what intervention?

Accepted Answer

Surgical resection is the treatment of choice when HCC is confined to one lobe of the liver and the function of the remaining liver is considered adequate for postoperative recovery. Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While cryosurgery and liver transplantation are other surgical options for management of liver cancer, these procedures are not performed at the same frequency as a lobectomy. Laser hyperthermia is a nonsurgical treatment for liver cancer.

Question 13

A patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient may have developed liver metastases?

Accepted Answer

The early manifestations of malignancy of the liver include paina continuous dull ache in the right upper quadrant, epigastrium, or back. Weight loss, loss of strength, anorexia, and anemia may also occur. The liver may be enlarged and irregular on palpation. Jaundice is present only if the larger bile ducts are
occluded by the pressure of malignant nodules in the hilum of the liver. Fever, cognitive changes, peripheral edema, and bleeding are atypical signs.

Question 14

A patient is being discharged after a liver transplant and the nurse is performing discharge education. When planning this patients continuing care, the nurse should prioritize which of the following risk diagnoses?

Accepted Answer

Infection is the leading cause of death after liver transplantation. Pulmonary and fungal infections are common; susceptibility to infection is increased by the immunosuppressive therapy that is needed to prevent rejection. This risk exceeds the threats of injury and unstable blood glucose. The diagnosis of Risk for Contamination relates to environmental toxin exposure.

Question 15

A patient with a liver mass is undergoing a percutaneous liver biopsy. What action should the nurse perform when assisting with this procedure?

Accepted Answer

Immediately after a percutaneous liver biopsy, assist the patient to turn onto the right side and place a pillow under the costal margin. Prior administration of albumin or PRBCs is unnecessary. Coagulation tests should be performed, but electrolyte analysis is not necessary.

Question 16

A nurse is caring for a patient with hepatic encephalopathy. The nurses assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based
On these clinical findings, the nurse should document what stage of hepatic encephalopathy?

Accepted Answer

Patients in the third stage of hepatic encephalopathy exhibit the following symptoms: stuporous, difficult to arouse, sleeps most of the time, exhibits marked confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of extremities, marked EEG abnormalities. Patients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3 , and patients in stage 4 are comatose. In stage 4 , there is an absence of asterixis, absence of deep tendon reflexes, flaccidity of extremities, and EEG abnormalities.

Question 17

A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patients current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

Accepted Answer

Lactulose (Cephulac) is administered to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the patients appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.

Question 18

A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding?

Accepted Answer

The most common age-related change in the liver is a decrease in size and weight. The liver is usually still palpable, however, and is not expected to have hardened edges.

Question 19

A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate?

Accepted Answer

If the bile duct is obstructed, the bile will be reabsorbed into the blood and carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy. Bloody diarrhea, ascites, and cognitive changes are not associated with obstructive jaundice.

Question 20

During a health education session, a participant has asked about the hepatitis $E$ virus. What prevention measure should the nurse recommend for preventing infection with this virus?

Accepted Answer

Avoiding contact with the hepatitis $\mathrm{E}$ virus through good hygiene, including hand-washing, is the major method of prevention. Hepatitis $E$ is transmitted by the fecaloral route, principally through contaminated water in areas with poor sanitation. Consequently, none of the other listed preventative measures is indicated.

Quiz 48: Assessment and Management of Patients With Hepatic Disorders