ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 49 : Assessment and Management of Patients with Hepatic Disorders Questions
Question 1 of 5
A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurses most recent assessment reveals subtle changes in the patients cognition and behavior. What is the nurses most appropriate response?
Correct Answer: B
Rationale: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patients mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the patients physiologic deterioration.
Question 2 of 5
A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patients fluid volume excess? Select all that apply.
Correct Answer: A,C,E
Rationale: Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize the management of fluid volume excess. Calcium channel blockers and caloric restriction do not address this problem.
Question 3 of 5
A patient with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the patients family how to safely perform which of the following actions?
Correct Answer: D
Rationale: Families should be taught to provide basic catheter care, including assessment of patency. Antibiotics are not instilled into the catheter and aspiration using a syringe is contraindicated. The family would not independently remove the catheter; this would be done by a member of the care team when deemed necessary.
Question 4 of 5
A patient with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the patients prioritization for receiving a donor liver be determined?
Correct Answer: B
Rationale: The patient would undergo a classification of the degree of medical need through an objective determination known as the Model of End-Stage Liver Disease (MEL
D) classification, which stratifies the level of illness of those awaiting a liver transplant. This algorithm considers multiple variables, not solely age, prognosis, potential for adherence, and the rejection of alternative options.
Question 5 of 5
A nurse has entered the room of a patient with cirrhosis and found the patient on the floor. The patient states that she fell when transferring to the commode. The patients vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurses most appropriate action?
Correct Answer: C
Rationale: A fall would necessitate thorough medical assessment due to the patients risk of bleeding. The nurses abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate.