Which information provided by the nurse is most accurate?
answer
B: there are several types of cirrhosis
question
Which question is most important for the nurse to include when assessing the client for etiologic factors related to cirrhosis?
answer
C: "have you been exposed to toxic substances where you work?"
question
Which nursing interventions are important prior to a paracentesis? (Select all that apply)
answer
A: ensure the client has signed a consent.
B: instruct the client to empty his bladder
C: position the client in an upright position
E: apply a sphygmomanometer to monitor the blood pressure
question
Maintaining bedrest for 24 to 48 hours is an important nursing intervention following which procedure?
answer
D: angiography with portal pressure measurements
question
What education should be provided to Mr. Hershey after his paracentesis?
answer
B: Mr. Hershey's vital signs will be checked frequently for the next few hours.
question
In the client with cirrhosis, what lab values does the nurse anticipate will be increased from the normal value? (Select all that apply).
answer
A: total serum bilirubin
B: serum ammonia
D: APTT, PT/INR
question
Which clinical manifestation is likely to occur as the result of the prolonged APTT and PT/INR?
answer
D: petechiae
question
Which assessment would the nurse expect to find in the client with cirrhosis? (Select all that apply).
answer
A: fruity breath
C: decreased appetite
E: ascites
question
Which medication places Frank at risk for hyperkalemia?
answer
A: spironolactone (aldactone)
question
It is most important for the nurse to implement which intervention?
answer
D: continue the albumin infusion
question
What is the best response for the nurse to use when responding to Frank?
answer
B: "Tell me why you feel people are judging you."
question
What is the best response by the nurse?
answer
A: Your lab values indicate damage to your liver. This occurs after many years of drinking. That is what makes me think you are an alcoholic.
question
Who should the nurse notify of Frank's action?
answer
C: Frank's HCP
question
In which situations is the use of physical restraints appropriate? (Select all that apply).
answer
A: a combative and agitated client who is pulling at the indwelling catheters and IV lines.
C: A client who is at high risk for injury to self for whom no other safety measures have been successful.
E: a disoriented client who is trying to dislodge a tracheostomy tube.
question
What is Frank's Glasgow Come Scale rating obtained in this assessment?
answer
8
question
What is the primary underlying cause of hepatic encephalopathy?
answer
A: increased serum ammonia
question
What outcome indicates to the nurse that the lactulose and Xifaxan are having the desired effect?
answer
A: increased mental alertness
question
Which interventions should be initiated during the acute phase of cirrhosis? (Select all that apply).
answer
A: bed rest
B: increased intake of vitamin A, D, E and folic acid
E: use moisturizing lotion to the skin to minimize scratching
question
Which intervention should be implemented related to the diagnosis of fluid volume excess?
answer
B: measure abdominal girth daily
question
Which nursing interventions should be implemented related to the diagnosis of fluid volume excess? (Select all that apply).
answer
A: maintain a diet low in sodium intake
B: measure abdominal girth daily
C: administer PRN antiemetics before meals
question
What intervention is a priority for the nurse?
answer
D: assist Frank to bed an position him side lying
question
In what order should the nurse perform the following actions?
answer
1. apply oxygen
2. ensure patency of the IV
3. notify the HCP
4. transfer to critical care
question
What information should the nurse provide to Frank? (Select all that apply).
answer
B: get plenty of rest and regular exercise
C: avoid the consumption of raw shellfish
E: consider joining the alcoholic anonymous (AA) group
question
Which member of the inter professional team is the best choice for the nurse to contact to help Frank meet his goal?
answer
D: social worker
question
What is the best response by the nurse?
answer
B: "I would really appreciate it if you could find some time to meet with this client"
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