ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 49 Questions
Question 1 of 5
A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate?
Correct Answer: D
Rationale: Octreotide (Sandostatin) a synthetic analog of the hormone somatostatin is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not administered and heparin would exacerbate, not alleviate, bleeding.
Question 2 of 5
A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patients liver?
Correct Answer: C
Rationale:
To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant.
Question 3 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 4 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 5 of 5
A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem?
Correct Answer: C
Rationale: Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.