HESI Case Study: Cirrhosis Exam Test with Answers Graded A
Which nursing intervention best promotes With a confirmed diagnosis of Laennec's
accurate and effective communication? - cirrhosis, which assessment finding warrants
ANSWER -Explain that there are several immediate intervention? (Select all that apply.
types of cirrhosis. One, some, or all options may be correct.) -
ANSWER --Hematemesis
-Melena
The nurse continues the focused risk
assessment by asking about etiologic factors
related to cirrhosis. Which assessment finding Which medication places the client at risk for
provides the most likely indication that the client hyperkalemia? - ANSWER -Spironolactone.
is at high risk for cirrhosis? - ANSWER -
Previous diagnosis of Hepatitis C.
While administering the albumin infusion via a
vein in the right hand, the nurse notes that the
Which nursing interventions are important prior to peripheral edema in the client's arms and hands
a paracentesis? (Select all that apply. One, has changed from 3+ to 2+. It is most important
some, or all options may be correct.) - for the nurse to implement which intervention? -
ANSWER --Ensure the client has signed a ANSWER -Continue the albumin infusion.
consent.
-Instruct the client to empty their bladder.
-Position the client in an upright position. What is the best approach for the nurse to use
-Apply sphygmomanometer to monitor blood when responding to the client? - ANSWER -
pressure. Ask the client why he feels people are judging
them.
After the client undergoes the paracentesis,
which nursing assessment warrants immediate The client asks the nurse what makes everyone
intervention? - ANSWER -Increasing think that they are an alcoholic. The client states
abdominal pain when they drink, they don't have to think about
problems and that others must feel the same
way. How should the nurse respond to the client?
In the client with cirrhosis, which lab values does - ANSWER -Explain that their lab values
the nurse anticipate will be increased from the are consistent with alcohol abuse.
normal value? (Select all that apply. One, some,
or all options may be correct.) - ANSWER -
Total serum bilirubin Who should the nurse notify of the client's action?
AST/ALT (Select all that apply. One, some, or all options
APTT, PT/INR may be correct.) - ANSWER -The charge
nurse.
The client's HCP.
Based on the prolonged APTT and PT/INR what
clinical manifestation would the nurse anticipate
visualizing upon assessment? - ANSWER - The nurse discusses the situation with another
Petechiae nurse who states that the client should have been
sedated and restrained to keep them from
leaving. In which situations is the use of physical
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Which nursing intervention best promotes With a confirmed diagnosis of Laennec's
accurate and effective communication? - cirrhosis, which assessment finding warrants
ANSWER -Explain that there are several immediate intervention? (Select all that apply.
types of cirrhosis. One, some, or all options may be correct.) -
ANSWER --Hematemesis
-Melena
The nurse continues the focused risk
assessment by asking about etiologic factors
related to cirrhosis. Which assessment finding Which medication places the client at risk for
provides the most likely indication that the client hyperkalemia? - ANSWER -Spironolactone.
is at high risk for cirrhosis? - ANSWER -
Previous diagnosis of Hepatitis C.
While administering the albumin infusion via a
vein in the right hand, the nurse notes that the
Which nursing interventions are important prior to peripheral edema in the client's arms and hands
a paracentesis? (Select all that apply. One, has changed from 3+ to 2+. It is most important
some, or all options may be correct.) - for the nurse to implement which intervention? -
ANSWER --Ensure the client has signed a ANSWER -Continue the albumin infusion.
consent.
-Instruct the client to empty their bladder.
-Position the client in an upright position. What is the best approach for the nurse to use
-Apply sphygmomanometer to monitor blood when responding to the client? - ANSWER -
pressure. Ask the client why he feels people are judging
them.
After the client undergoes the paracentesis,
which nursing assessment warrants immediate The client asks the nurse what makes everyone
intervention? - ANSWER -Increasing think that they are an alcoholic. The client states
abdominal pain when they drink, they don't have to think about
problems and that others must feel the same
way. How should the nurse respond to the client?
In the client with cirrhosis, which lab values does - ANSWER -Explain that their lab values
the nurse anticipate will be increased from the are consistent with alcohol abuse.
normal value? (Select all that apply. One, some,
or all options may be correct.) - ANSWER -
Total serum bilirubin Who should the nurse notify of the client's action?
AST/ALT (Select all that apply. One, some, or all options
APTT, PT/INR may be correct.) - ANSWER -The charge
nurse.
The client's HCP.
Based on the prolonged APTT and PT/INR what
clinical manifestation would the nurse anticipate
visualizing upon assessment? - ANSWER - The nurse discusses the situation with another
Petechiae nurse who states that the client should have been
sedated and restrained to keep them from
leaving. In which situations is the use of physical
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