Chapter 58: Care of Patients with Liver Problems Ignatavicius: Medical-Surgical Nursing, 8th Edition 100% elaborated correct answers

MULTIPLE CHOICE 1. A nurse obtains a client’s health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this client? a. “I drink two glasses of red wine each week.” b. “I take a lot of Tylenol for my arthritis pain.” c. “I have a cousin who died of liver cancer.” d. “I got a hepatitis vaccine before traveling.” ANS: B 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 explore 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. DIF: Applying/Application REF: 1202 KEY: Cirrhosis| acetaminophen| medication safety MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the client daily. ANS: B 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. DIF: Applying/Application REF: 1202 KEY: Cirrhosis| nutritional requirements MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 18 to 14 breaths/min