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 hepatic encephalopathy. The nurses assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy?
Correct Answer: C
Rationale: Patients in the third stage of hepatic encephalopathy exhibit the following symptoms: stuporous, difficult to arouse, sleeps most of the time, exhibits marked confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of extremities, marked EEG abnormalities. Patients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3, and patients in stage 4 are comatose. In stage 4, there is an absence of asterixis, absence of deep tendon reflexes, flaccidity of extremities, and EEG abnormalities.
Question 2 of 5
A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patients current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
Correct Answer: A
Rationale: Lactulose (Cephulac) is administered to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the patients appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.
Question 3 of 5
A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding?
Correct Answer: D
Rationale: The most common age-related change in the liver is a decrease in size and weight. The liver is usually still palpable, however, and is not expected to have hardened edges.
Question 4 of 5
A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate?
Correct Answer: B
Rationale: If the bile duct is obstructed, the bile will be reabsorbed into the blood and carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy. Bloody diarrhea, ascites, and cognitive changes are not associated with obstructive jaundice.
Question 5 of 5
During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus?
Correct Answer: A
Rationale: Avoiding contact with the hepatitis E virus through good hygiene, including hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecal-oral route, principally through contaminated water in areas with poor sanitation. Consequently, none of the other listed preventative measures is indicated.