<P> client with cirrhosis is admitted to the hospital.

Which of the following a

<Q>A
<TYPE>single</TYPE>
ssessments made by the nurse would indicate the development of portal hypertensi
<MC3>Elevated In
<MC2>Asterixis</MC2>
<MC1>Hematemesis</MC1>
on?</Q>
<F>Rationale:
<CORRECT>1</CORRECT>
<MC4>Confusion</MC4>
blood
cirrhosis,
pressure</MC3>
the liver becomes fibrotic, which obstructs the veno
us blood flow through the liver. This increases the vascular pressure in the por
tal system and causes congestion in the spleen and development of varicosities i
n the esophagus. Bleeding esophageal varices are a complication of portal hypert
ension and result in vomiting of blood and possible hemorrhage and death (option
1). Asterixis is flapping of the hands when they are held up and indicates ence
phalopathy (option 2). The client with cirrhosis is more inclined to hypotension
because of the loss of circulating blood volume (option 3). Confusion indicates
Cognitive
Client
Integrated
Content
Strategy:
the onset
Need:
Area:
Level:
For
ofPhysiological
Process:
encephalopathy.
Adult
eachAnalysis
distracter
NursingIntegrity:
Health: Process:
Gastrointestinal
identifyAssessment
Reduction
which complication
of Risk Potential
is directly related to
Reference:
it. SelectLeMone,
the distracter
P., & Burke,
that K.
is (2008).
vascular<i>Medical-surgical
in nature. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 714-715.</F>
should teach the client with liver disease to avoid which of these
over-the-counter
<MC1>Ranitidine
<MC2>Psyllium
<MC3>Ascorbic
<MC4>Acetaminophen
<F>Rationale:
<CORRECT>4</CORRECT>
(Metamucil)</MC2>
acid
Any(Zantac)</MC1>
medications
medication
(Vitamin C)</MC3>
(Tylenol)</MC4>
afterisdischarge?</Q>
that metabolized by the liver and has not been p
rescribed by the primary care provider should be avoided, such as acetaminophen,
sedatives, and barbiturates (option 4). Ranitidine is a histamine₂ r
eception antagonist and may be used to treat the dyspepsia that accompanies live
r disease (option 1). Psyllium is a bulk laxative and may be prescribed to preve
nt the occurrence of constipation and subsequent encephalopathy (option 2). Asco
rbic acid is Vitamin C and may be prescribed to someone with liver disease becau
se theseNeed:
Cognitive
Client
Integrated
Content
Strategy:Area:
clients
Level:
The
Process:
Physiological
Adult
coreareissue
Application
Nursing
Health:
typically
ofIntegrity:
Process:
Gastrointestinal
the malnourished
question
Implementation
Pharmacological
is knowledge
(option 3).of
anddrugs
Parenteral
that are
Therapies
metaboli
zed or biotransformed by the liver. Review each distracter to determine whether
that drug has side effects or adverse effects that could increase the severity o
f the liver disease, and choose the one that is most harmful as the answer to th
e question. Recall that acetaminophen is a prime drug that is commonly used and
harmful to LeMone,
Reference: the liver. P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 716.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse is doing discharge teaching for a client who has cirrhosis and asci
tes. Which of the following foods used by the client as snacks should the nurse
instruct the
<MC1>Whole
<MC3>Potato
<MC2>Cookies</MC2>
<MC4>Hard
<F>Rationale:
<CORRECT>3</CORRECT>
candy</MC4>
wheat
chips</MC3>
client
A low-sodium
bread</MC1>
to avoid?</Q>
diet is recommended for clients who have cirrhosis an
d ascites. Potato chips are high in sodium (option 3). Cookies (option 2) and ha
rd candy (option 4) are high in sugar. While they provide no nutrient value, the
y do increase the calorie intake, which is important for tissue metabolism. Whol
e wheat bread (option 1) is high in complex carbohydrates and fiber and is a goo
d nutrient
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
The
source
Process:
Physiological
Adult
critical
Application
forHealth:
Teaching/Learning
fiber
wordsIntegrity:
and
Gastrointestinal
in the
carbohydrates.
question
Reduction
areof<i>cirrhosis</i>
Risk Potential and <i>ascites
</i>. Consider the relationship between ascites, fluid retention, and sodium and
Reference:
choose theLeMone,
item that P.,is& Burke,
highestK.overall
(2008).in<i>Medical-surgical
sodium, such as salty nursing:
snacks.Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. client
<Q>The
<TYPE>single</TYPE>
<P>
</P> 716-717.</F>
who has liver disease asks the nurse why he bruises so easily. Whi
ch of the following
<MC1>"Your liver is unable
information
to make
should
the proteins
the nursethat
include
are needed
in the toresponse?</Q>
make clotting
<MC2>"Your
<MC3>"Your
<MC4>"Your
<F>Rationale:
<CORRECT>1</CORRECT>
factors."</MC1>
liverThecan't
can
is
liver
breaking
nostore
longerVitamin
synthesizes
down
metabolize
blood
clotting
C any
cells
drugs
longer."</MC4>
factors
tooandrapidly."</MC3>
render
I, II,them
VII,inactive."</MC2>
IX, and X as we
ll as prothrombin and fibrinogen (option 1). These proteins are needed for adequ
ate clotting, so their reduction leads to increased risk of bleeding. The inabil
ity of the liver to detoxify drugs actually raises the serum level of the drug (
option 2). The spleen breaks down red blood cells, not the liver (option 3). The
Cognitive
Client
Integrated
Content
Strategy:
liver Need:
stores
Area:
Level:
The
Process:
Physiological
theApplication
Adult
question
fatHealth:
Nursing
soluble
is focused
Integrity:
Process:
Gastrointestinal
vitamins
on the
Implementation
Physiological
A,normal
D, E, function
and Adaptation
K (option
of the4).kidney directly
related to clotting. Eliminate any distracters that are unrelated to the clottin
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
g.
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 722.</F>
<Q>The
<TYPE>multi</TYPE>
<P>
</P> nurse is caring for a client who had a liver biopsy approximately 15 minu
tes ago. The client is supine in bed, the nurse notes that the client's skin is
pale and cool, and he reports lightheadedness. The nurse's immediate response is
<MC1>Place
<MC2>Leave
<MC3>Obtain
<MC4>Check
<MC5>Call
<F>Rationale:
<CORRECT>[1,3]</CORRECT>
to do which
emergency
client
urine
vital
ofThethe
output.</MC4>
onresponse
in
signs.</MC3>
liver
following?
hisisright
supine highly
position.</MC2>
team.</MC5>
Select
side.</MC1>
vascular
all that
and is
apply.</Q>
therefore prone to bleeding fo
llowing a biopsy. Following a biopsy, the best position for the client is to lie
on his right side to apply pressure to the vessels of the liver and prevent ble
eding. Because this client could be experiencing early signs of shock, the nurse
should quickly check vital signs. This would provide additional data to report
to the healthcare provider. After this initial response, the nurse calls the hea
lthcare provider and prepares for fluid administration of fluid to treat suspect
Strategy:
ed
Cognitive
Client
Integrated
Content
hypovolemia.
Need:
Area:
Level:
Correlate
Process:
Physiological
Adult
Analysis
Nursing
Health:
the anatomy
Integrity:
Process:
Gastrointestinal
of theImplementation
Reduction
liver withoftheRiskclinical
Potential
signs of the clie
nt. Select first the distracter that will provide compression to the vascular li
ver and increase homeostasis. Then choose the distracter that will provide quick
information about hypovolemia from bleeding, such as vital signs. Recall that n
urses do not report a single piece of data when a client's situation is deterior
ating; rather, the nurse quickly gathers data that are directly relevant to the
suspected problem.
References: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critica
l thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educati
on, pp. 595-596; Smith, S. F., Duell, D. J., & Martin, B. C. (2004). <i>Clinical
nursing skills: Basic to advanced skills</i> (6th ed.). Upper Saddle River, NJ:
<Q>The
<TYPE>single</TYPE>
<P>
</P>
Pearsonclient
Education,
who hasp.esophageal
617.</F> varices is started on propranolol (Inderal). Th
e nurse explains to a new nurse orientee that this drug is ordered for this part
icular clientesophageal
<MC1>Prevent
<MC2>Decrease
<MC3>Decrease
<MC4>Decrease
<F>Rationale:
<CORRECT>1</CORRECT>
to do which
systemic
portal
myocardial
Nonselective
hypertension</MC3>
blood
bleeding</MC1>
workload</MC4>
ofbeta
theadrenergic
pressure</MC2>
following?</Q>
blockers exert multiple systemic effe
cts. By decreasing contractility and heart rate, they decrease myocardial worklo
ad (option 4) and systolic blood pressure (option 2). These actions make it an e
ffective medication to decrease the occurrence of esophageal bleeding (option 1)
. ThereNeed:
Cognitive
Client
Integrated
Content
Strategy:isThe
Area:
Level:
noPhysiological
Process:
effect
Adult
mechanism
Analysis
Nursing
Health:
on of
portal
Integrity:
action
Process:
Gastrointestinal
hypertension
of propranolol
Implementation
Pharmacological
(option
is directly
3).and Parenteral
related to
Therapies
its effe
ctiveness in the treatment of esophageal varices. Correlate these two content ar
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
eas.
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. client
<Q>The
<TYPE>single</TYPE>
<P>
</P> 716-717.</F>
who had a cholecystectomy asks why a T-tube has been inserted. The
<MC1>"T-tubes
<MC2>"T-tubes
<MC3>"T-tubes
<MC4>"T-tubes
<F>Rationale:
<CORRECT>1</CORRECT>
best responseManipulation
drain
are
help
by always
the
ussmall
edema
nurse
monitor
inserted
fluid
gallstones."</MC2>
ofis:</Q>
forandcommon
the following
infection."</MC4>
bile bile
to gallbladder
keep
ductthecauses
ductsurgery."</MC3>
patent."</MC1>that may
inflammation
occlude the duct, preventing bile excretion. Insertion of the T-tube prevents th
e inflammation from occluding the common bile duct (option 1). While it may drai
n some small stones that were not removed during the procedure (option 2), that
is not the intent. Not all clients have a T-tube after a cholecystectomy, only t
hose with significant risk for edema (option 3). The T-tube actually can increas
e the risk of infec-tion because it is a direct opening into the abdomen (option
Cognitive
Client
Integrated
Content
Strategy:
4). Need:
Area:
Level:
Remember
Process:
Physiological
Adult
Application
that
Nursing
Health:
tissue
Integrity:
Process:
Gastrointestinal
edema follows
Implementation
Reduction
surgical
of Riskmanipulation
Potential of a body par
t. The T-tube
Reference: LeMone,
is intended
P., & Burke,
to prevent
K. (2008).
the edema
<i>Medical-surgical
from occluding the nursing:
duct. Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 701.</F>(Cephulac) is ordered for the client with cirrhosis. Which of the f
<Q>Lactulose
<TYPE>single</TYPE>
<P>
</P>
ollowing serum laboratory tests should the nurse monitor to determine if the dru
g is having theLactulose
<F>Rationale:
<CORRECT>2</CORRECT>
<MC4>Lactate</MC4>
<MC3>Sodium</MC3>
<MC2>Ammonia</MC2>
<MC1>Albumin</MC1> desired (Cephulac)
effect?</Q>is a disaccharide laxative used to decrease t
he absorption of ammonia in the intestines, thereby lowering the serum ammonia a
nd resulting in improvement in hepatic encephalopathy (option 2). Albumin is dec
reased because of ascites (option 1). Sodium is decreased with massive diuretic
therapy to treat the ascites (option 3). Lactate is a measure of anaerobic metab
olism (option
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Understanding
Process:
Physiological
4).Application
Adult Nursing
Health:
theIntegrity:
Process: Evaluation
Gastrointestinal
indication Pharmacological
for lactulose inandcirrhosis
Parenteral
enables
Therapies
you to
Reference:
answer eliminate
LeMone,the
P.,incorrect
& Burke, K. distracters
(2008). <i>Medical-surgical
and identify the correct
nursing:
response.
Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. client
<Q>The
<TYPE>single</TYPE>
<P>
</P> 716-717.</F>
is admitted to the hospital with acute pancreatitis. The nurse tak
ing a history should question the client about which of these risks for developi
ng pancreatitis?</Q>
<MC1>Inflammatory
<MC3>Diabetes
<MC2>Alcoholism</MC2>
<MC4>High-fiber
<F>Rationale:
<CORRECT>2</CORRECT>
mellitus</MC3>
Pancreatitis
diet</MC4>
bowel disease</MC1>
is typically associated with alcoholism (option 2) an
d gallstones. Inflammatory bowel disease is unrelated to the pancreas (option 1)
. Diabetes is caused by an inability of the pancreas to secrete insulin, but thi
s is unrelated to pancreatitis (option 3). A high-fiber diet is believed to decr
ease theNeed:
Cognitive
Client
Integrated
Content
Strategy:Area:
risk
Level:
Delete
Process:
Physiological
of any
Adult
colon
Application
Nursing
Health:
distracters
cancerIntegrity:
Process:
Gastrointestinal
(option
thatAssessment
4). directly related
Physiological
are Adaptation
to other GI diseases.
Reference:
Then selectLeMone,
the distracter
P., & Burke, thatK.has(2008).
a direct
<i>Medical-surgical
link with pancreatitis.
nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. client
<Q>The
<TYPE>single</TYPE>
<P>
</P> 726-727.</F>
with chronic pancreatitis is being discharged. The nurse should an
ticipate teaching
<MC1>Pancrelipase
<MC2>Morphine
<MC4>Lactulose
<MC3>Biotin</MC3>
<F>Rationale:
<CORRECT>1</CORRECT>
sulfate</MC2>
The
(Cephulac)</MC4>
the client
(Pancrease)</MC1>
client withabout
chronicwhich
pancreatitis
of these medications?</Q>
may require pancreatic enzyme
supplements such as pancrelipase (Lipancreatin) to aid in digestion of food (op
tion 1). Morphine is related to the management of pain in acute pancreatitis (op
tion 2). Lactulose is used to prevent encephalopathy of liver disease (option 4)
. BiotinNeed:
Cognitive
Client
Integrated
Content
Strategy:Area:
isRemember
Level:
Process:
aPhysiological
B vitamin
Adult
Application
that
Nursing
Health:
(option
as Integrity:
inflammation
Process:
Gastrointestinal
3). Planning
Pharmacological
subsides it isand often
Parenteral
replacedTherapies
with scar
tissue. As pancreatitis progresses, viable tissue is lost to scar tissue formati
on, resulting
Reference: LeMone,
in a P.,
loss&ofBurke,
function.
K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. 728-729.</F>
</P>