1. Answer: A. The client is oriented to time, place, and person.
Hepatic coma is the most advanced stage of hepatic encephalopathy. As hepatic coma resolves, improvement in the client’s level of consciousness occurs. The client should be able to express orientation to time, place, and person. Ecchymotic areas are related to decreased synthesis of clotting factors. Although oral intake may be related to level of consciousness, it is more closely related to anorexia. The serum albumin level reflects hepatic synthetic ability, not level of consciousness.
2. Answer: D. Keeping the client’s fingernails short and smooth
The client with pruritus experiences itching, which may lead to skin breakdown and possibly infection from scratching. Keeping his fingernails short and smooth helps prevent skin breakdown and infection from scratching. Applying pressure when giving I.M. injections and administering vitamin K subcutaneously are important if the client develops bleeding problems. Decreasing the client’s dietary intake is appropriate if the client’s ammonia levels are increased.
3. Answer: C. Low-fat, high-carbohydrate meals
For the client with cholecystitis, fat intake should be reduced. The calories from fat should be substituted with carbohydrates. Reducing carbohydrate intake would be contraindicated. Any diet high in fat may lead to another attack of cholecystitis.
4. Answer: A. Fever and chills
Septicemia is a common complication after a percutaneous transhepatic cholangiography. Evidence of fever and chills, possibly indicative of septicemia, is important. Hypotension, not hypertension, is associated with septicemia. Tachycardia, not bradycardia, is most likely to occur. Nausea and diarrhea may occur but are not classic signs of sepsis.
5. Answer: B. Using good sanitation with dishes and shared bathrooms
Hepatitis A is transmitted through the fecal oral route or from contaminated water or food. Measures to protect the family include good handwashing, personal hygiene and sanitation, and use of standard precautions. Complete isolation is not required. Avoiding contact with blood-soiled clothing or dressings or avoiding the sharing of needles or syringes are precautions needed to prevent transmission of hepatitis B.
6. Answer: B. “Avoid taking other medications within 2 hours of this one.”
Antacids neutralize gastric acid and decrease the absorption of other medications. The client should be instructed to avoid taking other medications within 2 hours of the antacid. Water, which dilutes the antacid, should not be taken with antacid. A histamine receptor antagonist should be taken even when pain subsides. Daily weights are indicated if the client is taking a diuretic, not an antacid.
7. Answer: D. Nausea, vomiting, and anorexia
Acute cholecystitis is an acute inflammation of the gallbladder commonly manifested by the following: anorexia, nausea, and vomiting; biliary colic; tenderness and rigidity the right upper quadrant (RUQ) elicited on palpation (e.g., Murphy’s sign); fever; fat intolerance; and signs and symptoms of jaundice. Ecchymosis, petechiae, and coffee-ground emesis are clinical manifestations of esophageal bleeding. The coffee-ground appearance indicates old bleeding. Jaundice, dark urine, and steatorrhea are clinical manifestations of the icteric phase of hepatitis.
8. Answer: C. Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction
With acute pancreatitis, the client is kept on nothing-by-mouth status to inhibit pancreatic stimulation and secretion of pancreatic enzymes. NG intubation with low intermittent suction is used to relieve nausea and vomiting, decrease painful abdominal distention, and remove hydrochloric acid. Vasopressin would be appropriate for a client diagnosed with bleeding esophageal varices. Paracentesis and diuretics would be appropriate for a client diagnosed with portal hypertension and ascites. A low-fat diet and increased fluid intake would further aggravate the pancreatitis.
9. Answer: B. Breaks down fat into fatty acids and glycerol
Lipase hydrolyses or breaks down fat into fatty acids and glycerol. Lipase is not involved with the transport of fatty acids into the brush border. Fat itself triggers cholecystokinin release. Protein breakdown into dipeptides and amino acids is the function of trypsin, not lipase.
10. Answer: D. Documenting precise intake and output
For the client with ascites receiving diuretic therapy, careful intake and output measurement is essential for safe diuretic therapy. Diuretics lead to fluid losses, which if not monitored closely and documented, could place the client at risk for serious fluid and electrolyte imbalances. Hypokalemia, not hyperkalemia, commonly occurs with diuretic therapy. Because urine output increases, a client should be assessed for hypovolemia, not hypervolemia. Weights are also an accurate indicator of fluid balance. However, for this client, weights should be obtained daily, not weekly.
11. Answer: A. Passage of two or three soft stools daily
Lactulose reduces serum ammonia levels by inducing catharsis, subsequently decreasing colonic pH and inhibiting fecal flora from producing ammonia from urea. Ammonia is removed with the stool. Two or three soft stools daily indicate effectiveness of the drug. Watery diarrhea indicates overdose. Daily deterioration in the client’s handwriting indicates an increase in the ammonia level and worsening of hepatic encephalopathy. Frothy, foul-smelling stools indicate steatorrhea, caused by impaired fat digestion.
12. Answer: C. “Jaundice produces pruritus due to impaired bile acid excretion.”
Jaundice is a symptom characterized by increased bilirubin concentration in the blood. Bile acid excretion is impaired, increasing the bile acids in the skin and causing pruritus. Jaundice is not associated with pressure ulcer formation. However, edema and hypoalbuminemia are. Jaundice itself does not impair urea production or lead to decreased tissue perfusion.
13. Answer: D. Obtaining cooperation and reducing fear
An esophageal tamponade tube would be inserted in critical situations. Typically, the client is fearful and highly anxious. The nurse therefore explains about the placement to help obtain the client’s cooperation and reduce his fear. This type of tube is used only short term and is not indicated for home use. The tube is large and uncomfortable. The client would not be helping to insert the tube. A client’s anxiety should be decreased, not maintained, and depending on the degree of hemorrhage, the client may not be alert.
14. Answer: B. Counseling to stop alcohol consumption
Chronic pancreatitis typically results from repeated episodes of acute pancreatitis. More than half of chronic pancreatitis cases are associated with alcoholism. Counseling to stop alcohol consumption would be the most helpful for the client. Dietary protein modification is not necessary for chronic pancreatitis. Daily exercise and liberalizing fluid intake would be helpful but not the most beneficial intervention.
15. Answer: A, C, D
Hepatic encephalopathy results from an increased ammonia level due to the liver’s inability to covert ammonia to urea, which leads to neurologic dysfunction and possible brain damage. The nurse should monitor the client’s neurologic status, serum ammonia level, and handwriting. Monitoring the client’s hemoglobin and hematocrit levels and insertion of an esophageal tamponade tube address esophageal bleeding. Keeping fingernails short address jaundice.