AH4 - Week 12 - Lippincott Ch. 3 Test 7 The Client with Cirrhosis - Exam 4

46. A client with cirrhosis is receiving lactulose.
During the assessment, the nurse notes increased
confusion and asterixis. The nurse should:

1. Assess for gastrointestinal (GI) bleeding.
2. Hold the lactulose.
3. Increase protein in the diet.
4. Monitor serum bilirubin levels
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1. Assess for gastrointestinal (GI) bleeding.

Clients with cirrhosis can develop hepatic
encephalopathy caused by increased ammonia
levels. Asterixis, a apping tremor, is a characteris-
tic symptom o increased ammonia levels. Bacterial
action on increased protein in the bowel will
increase ammonia levels and cause the encephalop-
athy to worsen. GI bleeding and protein consumed
in the diet increase protein in the intestine and can
elevate ammonia levels. Lactulose is given to reduce
ammonia ormation in the intestine and should not
be held since neurological symptoms are worsening.
Bilirubin is associated with jaundice
3. Potassium.

Hypokalemia is a precipitating actor
in hepatic encephalopathy. A decrease in creati-
nine results rom muscle atrophy; an increase in creatinine would indicate renal insufciency. With
liver dysunction, increased aldosterone levels are
seen. A decrease in serum protein will decrease
colloid osmotic pressure and promote edema.
48. A client has advanced cirrhosis of the liver.
The client's spouse asks the nurse why his abdomen
is swollen, making it very difficult for him to fasten
his pants. How should the nurse respond to provide
the most accurate explanation of the disease process?

1. "He must have been eating too many foods
with salt in them. Salt pulls water with it."
2. "The swelling in his ankles must have moved
up closer to his heart so the fluid circulates
3. "He must have forgotten to take his daily
water pill."
4. "Blood is not able to flow readily through the
liver now, and the liver cannot make protein
to keep fluid inside the blood vessels.
4. "Blood is not able to flow readily through the
liver now, and the liver cannot make protein
to keep fluid inside the blood vessels.

Portal hypertension and hypoalbumin-
emia as a result o cirrhosis cause a uid shit into
the peritoneal space causing ascites. In a cardiac or
kidney problem, not cirrhosis, sodium can promote
edema ormation and subsequent decreased urine
output. Edema does not migrate upward toward the
heart to enhance its circulation. Although diuretics
promote the excretion o excess uid, occasionally
orgetting or omitting a dose will not yield the asci-
tes ound in cirrhosis o the liver
49. A nurse is developing a care plan for a client
with hepatic encephalopathy. Which of the following are goals for the care for this client?
Select all that apply.

1. Preventing constipation.
2. Administering lactulose to reduce blood
ammonia levels.
3. Monitoring coordination while walking.
4. Checking the pupil reaction.
5. Providing food and fluids high in carbohydrate.
6. Encouraging physical activity.
1, 2, 3, 4, 5
1. Preventing constipation.
2. Administering lactulose to reduce blood
ammonia levels.
3. Monitoring coordination while walking.
4. Checking the pupil reaction.
5. Providing food and fluids high in carbohydrate.

Constipation leads to increased
ammonia production. Lactulose is a hyperosmotic
laxative that reduces blood ammonia by acidiying
the colon contents, which retards diusion o non-
ionic ammonia rom the colon to the blood while
promoting its migration rom the blood to the colon.
Hepatic encephalopathy is considered a toxic or
metabolic condition that causes cerebral edema; it
aects a person's coordination and pupil reaction to
light and accommodation. Food and uids high in
carbohydrates should be given because the liver is not
synthesizing and storing glucose. Because exercise
produces ammonia as a byproduct o metabolism,
physical activity should be limited, not encouraged.
3. Anorexia.

Early clinical maniestations o cirrhosis
are subtle and usually include gastrointestinal
symptoms, such as anorexia, nausea, vomiting,
and changes in bowel patterns. These changes are
caused by the liver's altered ability to metabolize
carbohydrates, proteins, and ats. Peripheral edema,
ascites, and jaundice are later signs o liver ailure
and portal hypertension
2. Hyperkalemia.

Spironolactone (Aldactone) is a potas-
sium-sparing diuretic; thereore, clients should be
monitored closely or hyperkalemia. Other common
adverse eects include abdominal cramping, diar-
rhea, dizziness, headache, and rash. Constipation
and dysuria are not common adverse eects o
spironolactone. An irregular pulse is not an adverse
eect o spironolactone but could develop i serum
potassium levels are not closely monitored
53. A client with jaundice has pruritus and areas
of irritation from scratching. What measures can the
nurse discuss to prevent skin breakdown?
Select all that apply.

1. Avoid lotions containing calamine.
2. Add baking soda to the water in a tub bath.
3. Keep nails short and clean.
4. Rub the skin when it itches with knuckles
instead of nails.
5. Massage skin with alcohol.
6. Increase sodium intake in diet.
2, 3, 4
2. Add baking soda to the water in a tub bath.
3. Keep nails short and clean.
4. Rub the skin when it itches with knuckles
instead of nails.

Baking soda baths can decrease pru-
ritis. Keeping nails short and rubbing with knuckles
can decrease breakdown when scratching cannot be
resisted, such as during sleep. Calamine lotions help
relieve itching. Alcohol will increase skin dryness.
Sodium in the diet will increase edema and weaken
skin integrity.
54. Which of the following health promotion
activities would be appropriate for the nurse to suggest that the client with cirrhosis add to the daily
routine at home?

1. Supplement the diet with daily
2. Abstain from drinking alcohol.
3. Take a sleeping pill at bedtime.
4. Limit contact with other people whenever
2. Abstain from drinking alcohol

General health promotion measures
include maintaining good nutrition, avoiding inec-
tion, and abstaining rom alcohol. Rest and sleep
are essential, but an impaired liver may not be able
to detoxiy sedatives and barbiturates. Such drugs
must be used cautiously, i at all, by clients with
cirrhosis. The client does not need to limit contact
with others but should exercise caution to stay away
rom ill people.
55. The nurse is reviewing the chart information
for a client with increased ascites. The data include
the following: temperature 37.2°C, heart rate 118,
shallow respirations 26, blood pressure 128/76, and
SpO2 89% on room air. Which action should receive
priority by the nurse?

1. Assess heart sounds.
2. Obtain a prescription for blood cultures.
3. Prepare for a paracentesis.
4. Raise the head of the bed.
4. Raise the head of the bed

Elevating the head o the bed will allow or
increased lung expansion by decreasing the ascites
pressing on the diaphragm. The client requires reas-
sessment. A paracentesis is reserved or symptom-
atic clients with ascites with impaired respiration or
abdominal pain not responding to other measures
such as sodium restriction and diuretics. There is
no indication or blood cultures. Heart sounds are
assessed with the routine physical assessment.
56. Which of the following positions would be appropriate for a client with severe ascites? 1. Fowler's. 2. Side-lying. 3. Reverse Trendelenburg. 4. Sims1. Fowler's. Ascites can compromise the action o the diaphragm and increase the client's risk o respira- tory problems. Ascites also greatly increases the risk o skin breakdown. Frequent position changes are important, but the preerred position is Fowler's. Placing the client in Fowler's position helps acili- tate the client's breathing by relieving pressure on the diaphragm. The other positions do not relieve pressure on the diaphragm.57. The client with cirrhosis receives 100 mL of 25% serum albumin IV. Which finding would best indicate that the albumin is having its desired effect? 1. Increased urine output. 2. Increased serum albumin level. 3. Decreased anorexia. 4. Increased ease of breathing.1. Increased urine output. Normal serum albumin is administered to reduce ascites. Hypoalbuminemia, a mechanism underlying ascites ormation, results in decreased colloid osmotic pressure. Administering serum albu- min increases the plasma colloid osmotic pressure, which causes uid to ow rom the tissue space into the plasma. Increased urine output is the best indi- cation that the albumin is having the desired eect. An increased serum albumin level and increased ease o breathing may indirectly imply that the administration o albumin is eective in relieving the ascites. However, it is not as direct an indicator as increased urine output. Anorexia is not aected by the administration o albumin.58. A client with a Sengstaken-Blakemore tube has a sudden drop in SpO2 and increase in respiratory rate to 40 breaths/min. The nurse should do which of the following in order from first to last? 1. Affirm airway obstruction by the tube. 2. Remove the tube. 3. Deflate the tube by cutting with bedside scissors. 4. Apply oxygen via face mask1, 3, 2, 4 1. Affirm airway obstruction by the tube. 3. Deflate the tube by cutting with bedside scissors. 2. Remove the tube. 4. Apply oxygen via face mask The nurse should frst assess the client to determine i the tube is obstructing the airway; assessment is done by assessing air ow. Once obstruction is established, the tube should be deated and then quickly removed. A set o scissors should always be at the bedside to allow or emergency deation o the balloon. Oxygen via ace mask should then be applied once the tube is removed.59. The health care provider instructs a client with alcohol-induced cirrhosis to stop drinking alcohol. The expected outcome of this intervention is: 1. Absence of delirium tremens. 2. Having a balanced diet. 3. Improved liver function. 4. Reduced weight.3. Improved liver function. The goal o abstinence rom alcohol in clients with alcohol-induced cirrhosis is to improve the liver unction; most clients have improved liver unction when they abstain rom alcohol. Clients with cirrhosis do not necessarily have delirium tre- mens. Abstaining rom alcohol may allow the client to improve nutritional status, but additional dietary counseling may be needed to achieve that goal. Clients with cirrhosis may have weight gain rom ascites, but this is managed with diuretics60. The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing? 1. Decreased mental status. 2. Elevated blood pressure. 3. Decreased urine output. 4. Labored respirations.1. Decreased mental status. The client should be monitored closely or changes in mental status. Ammonia has a toxic eect on central nervous system tissue and produces an altered level o consciousness, marked by drows- iness and irritability. I this process is unchecked, the client may lapse into coma. Increasing ammonia levels are not detected by changes in blood pressure, urine output, or respirations.61. A client's serum ammonia level is elevated, and the physician prescribes 30 mL of lactulose. Which of the following is an adverse effect of this drug? 1. Increased urine output. 2. Improved level o consciousness. 3. Increased bowel movements. 4. Nausea and vomiting3. Increased bowel movements. Lactulose increases intestinal motility, thereby trapping and expelling ammonia in the eces. An increase in the number o bowel move- ments is expected as an adverse eect. Lactulose does not aect urine output. Any improvements in mental status would be the result o increased ammonia elimination, not an adverse eect o the drug. Nausea and vomiting are not common adverse eects o lactulose.62. The nurse has a prescription to administer 2 oz of lactulose to a client who has cirrhosis. How many milliliters of lactulose should the nurse administer? ________________ mL.60 mL 30 ml = 1 oz The ollowing ormula is used to calculate the correct dosage: 30ml/1oz- X ml/2 oz X = 60 ml63. A client is to be discharged with a prescription for lactulose. The nurse teaches the client and the client's spouse how to administer this medication. Which of the following statements would indicate that the client has understood the information? 1. "I'll take it with Maalox." 2. "I'll mix it with apple juice." 3. "I'll take it with a laxative." 4. "I'll mix the crushed tablets in some gelatin."2. "I'll mix it with apple juice." The taste o lactulose is a problem or some clients. Mixing it with ruit juice, water, or milk can make it more palatable. Lactulose should not be given with antacids, which may inhibit its action. Lactulose should not be taken with a laxative because diarrhea is an adverse eect o the drug. Lactulose comes in the orm o syrup or oral or rectal administration.64. The nurse is providing discharge instructions for a client with cirrhosis. Which of the following statements best indicates that the client has under- stood the teaching? 1. "I should eat a high-protein, high-carbohydrate diet to provide energy." 2. "It is safer for me to take acetaminophen (Tylenol) for pain instead of aspirin." 3. "I should avoid constipation to decrease chances of bleeding." 4. "If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured."3. "I should avoid constipation to decrease chances of bleeding." Clients with cirrhosis should be instructed to avoid constipation and straining at stool to prevent hemorrhage. The client with cirrhosis has bleeding tendencies because o the liver's inability to produce clotting actors. A low-protein and high- carbohydrate diet is recommended. Clients with cirrhosis should not take acetaminophen (Tylenol), which is potentially hepatotoxic. Aspirin also should be avoided i esophageal varices are present. Cirrhosis is a chronic disease.65. The nurse is preparing a client for a paracentesis. The nurse should: 1. Have the client void immediately before the procedure. 2. Place the client in a side-lying position. 3. Initiate an IV line to administer sedatives. 4. Place the client on nothing-by-mouth (NPO) status 6 hours before the procedure1. Have the client void immediately before the procedure. Immediately beore a paracentesis, the cli- ent should empty the bladder to prevent peroration. The client will be placed in a high Fowler's position or seated on the side o the bed or the procedure. IV sedatives are not usually administered. The client does not need to be NPO.66. A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: 1. Institute range-of-motion (ROM) exercise every 4 hours. 2. Massage the abdomen once a shift. 3. Use an alternating air pressure mattress. 4. Elevate the lower extremities.3. Use an alternating air pressure mattress. Edematous tissue is easily traumatized and must receive meticulous care. An alternating air pressure mattress will help decrease pressure on the edematous tissue. ROM exercises are important to maintain joint unction, but they do not necessarily prevent skin breakdown. When abdominal skin is stretched taut due to ascites, it must be cleaned very careully. The abdomen should not be massaged. Elevation o the lower extremities promotes venous return and decreases swelling.