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 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 2 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 3 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.
Question 4 of 5
The nurse is administering medications to a client who has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent?
Correct Answer: C
Rationale: Lactulose is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients. Potassium-sparing diuretics such as spironolactone are used to treat ascites. Cholestyramine is a bile acid sequestrant and reduces pruritus. Kanamycin decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.
Question 5 of 5
A client with cirrhosis is complaining of severe pruritus related to the accumulation of bile salts. What can be prescribed for the client to relieve the itching?
Correct Answer: A
Rationale: Cholestyramine may be prescribed to bind bile salts and relieve pruritus. Kanamycin is prescribed to reduce the bacterial count in the intestine. Lactulose is used to decrease the amount of ammonia level in the blood. Cyclosporine is used to prevent rejection of a transplanted organ.