ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 47 : Caring for Clients With Disorders of the Liver, Gallbladder, or Pancreas Questions
Question 1 of 5
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?
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.
Question 2 of 5
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?
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.
Question 3 of 5
The nurse is assessing a client with cirrhosis of the liver. Which stool characteristic would the nurse expect the client to report?
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.
Question 4 of 5
A client with cirrhosis is complaining to the nurse of itching. The client asks the nurse if the itching is from taking warm baths. What is the best response by the nurse?
Correct Answer: A
Rationale: Skin may itch (pruritus) from accumulated bile salts related to the diseased liver. It is not related to the baths or a psychological response from the illness. Medication side effect may cause itching, but the most likely cause is the accumulation of bile salts.
Question 5 of 5
A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis?
Correct Answer: A
Rationale: A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding.