ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 58 : Care of Patients with Liver Problems Questions
Question 1 of 5
A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially limiting complications of this disorder? (Select all that apply.)
Correct Answer: B,E,F
Rationale: Because INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage, and elevated ammonia levels increase the client's confusion, these are critical findings. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.
Question 2 of 5
A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.)
Correct Answer: A,C,D
Rationale: Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush should be used to prevent gum bleeding, and the client's nails should be trimmed short to prevent scratching. Clients should use cool, not warm, water on their skin and should not use excessive amounts of soap.
Question 3 of 5
A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this disorder? (Select all that apply.)
Correct Answer: A,B,E
Rationale: Alcohol consumption is a major cause of cirrhosis. Sexual practices, particularly unprotected sex with men, increase the risk of hepatitis B or C, which can lead to cirrhosis. Incarceration is a risk factor due to potential exposure to hepatitis C through shared needles or unsanitary conditions. Family history of cancer and working as a plumber are not directly associated with cirrhosis.
Question 4 of 5
A nurse obtains a clients health history at a community health clinic. Which statement alerts the nurse to a possible health threat to the client?
Correct Answer: B
Rationale: Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explain other drug options with the client to manage his or her arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis vaccine do not place the client at risk for a liver disorder, and therefore do not require any health teaching.
Question 5 of 5
A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites?
Correct Answer: B
Rationale: A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.