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 caring for a client with severe acute pancreatitis with a glucose level of 750 mg/dL. What does the nurse understand is the cause of this level of hyperglycemia?
Correct Answer: D
Rationale: Complications from severe acute pancreatitis are serious and sometimes fatal. Hyperglycemia results from an imbalance of glucagon, insulin, and somatostatin. Increase in circulating calcium does not result in an increase in glucose levels. The nurse cannot assume that the client has diabetes and is noncompliant.
Question 2 of 5
The nurse is caring for a client with cirrhosis of the liver. What symptom(s) would indicate to the nurse that the client is experiencing central nervous system effects of the disease? Select all that apply.
Correct Answer: A,C,E
Rationale: Hepatic encephalopathy is a CNS manifestation of liver failure that is a complication of cirrhosis. Indications of CNS effects include disorientation, confusion, personality changes, memory loss, a flapping tremor called asterixis, a positive Babinski reflex, sulfurous breath odor (fetor hepaticus), and lethargy to deep coma. Cough and joint stiffness are not indicators of CNS effects of cirrhosis.
Question 3 of 5
When inspecting the abdomen of a client with cirrhosis, the nurse observes that the veins over the abdomen are dilated. How does the nurse document this finding?
Correct Answer: C
Rationale: Caput medus is a term used to denote the appearance of dilated veins over the client's abdomen. Gynecomastia refers to enlarged breasts in a male, which may occur because the dysfunctional liver is unable to metabolize estrogen. Palmer erythema refers to the bright pink appearance of the palms and cutaneous spider angioma refers to tiny, spider-like blood vessels that may be apparent in a client with cirrhosis due to the liver's inability to inactivate estrogen.
Question 4 of 5
A nurse is preparing a presentation for a local community group about hepatitis. Which information would the nurse include?
Correct Answer: C
Rationale: Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route, hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.
Question 5 of 5
When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which intervention should the nurse consider?
Correct Answer: B
Rationale: If the abdomen appears enlarged, the nurse measures it according to a set routine. Measuring the abdominal girth is the most accurate method of determining an increase or decrease in abdominal distention. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis. The nurse would report to the physician about abdominal enlargement along with other parameters of the assessment.