NUR 414 Final Exam QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS)
The physician orders Lactulose 30 mL by mouth per day for a client with cirrhosis. What finding
below demonstrates the medication is working effectively?
A.
Improvement in level of consciousness
B.
Presence of asterixis
C.
Decreased albumin levels
D.
Absence of fruity breath - correct answer A. Improvement in level of consciousness
A patient with cirrhosis may experience a complication called hepatic encephalopathy. This will
cause the patient to become confused (they may enter into a coma), have pungent, musty
smelling breath (fetor hepaticus), asterixis (involuntary flapping of the hands). This is due to the
buildup of ammonia in the blood, which affects the brain. Lactulose can be prescribed to help
decrease the ammonia levels. Therefore, if the medication is working properly to decrease the
level of ammonia the patient would have improving mental status, decreased ammonia blood
level, decreasing or absence of asterixis, and decreased ammonia blood level. Fruity breath is
associated with DKA not hepatic encephalopathy.
During the morning assessment of a client with cirrhosis, you note the client is disoriented to
person and place. In addition, while assessing the upper extremities, the client's hands
demonstrate a flapping motion. What lab result would explain these abnormal assessment
findings?
A.
Ammonia level of 68 µ/dL
B.
Creatinine level of 2.9 mg/dL
C.
Potassium level of 3.7 mmol/L
D.
Calcium level of 10.9 mg/dL - correct answer A. Ammonia level of 68 µ/dL
,NUR 414 Final Exam QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS)
Based on the assessment findings and the fact the client has cirrhosis, the client is experiencing
hepatic encephalopathy. This is due to the buildup of toxins in the blood, specifically ammonia.
The flapping motion of the hands is called "asterixis". Therefore, an increased ammonia level
would confirm these abnormal assessment findings
(Normal ammonia: 10-80)
A patient diagnosed with hepatitis develops splenomegaly. When reviewing the laboratory
report, which of the following results will the healthcare provider anticipate?
A.
Polycythemia
B.
Leukocytosis
C.
Thrombocytopenia
D.
Neutrophilia - correct answer C. Thrombocytopenia
The spleen acts as a reservoir for platelets. When the spleen is enlarged, as with splenomegaly,
up to 90 percent of a person's thrombocytes can be sequestered within the enlarged spleen.
A client diagnosed with viral hepatitis develops liver failure and hepatic encephalopathy. Which
of these measures should the healthcare provider include in this client's plan of care?
A.
Provide high-protein feedings
B.
Monitor the blood glucose
C.
Institute droplet precautions
D.
Weigh once a week - correct answer B. Monitor the blood glucose
, NUR 414 Final Exam QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS)
Interventions for this patient include blood glucose monitoring (because of decreased glycogen
synthesis and storage), monitoring PT and INR (because of decreased clotting factors), checking
reflexes (because of the neurological effects of increased ammonia), providing diet/feedings
that are low in protein (to decrease ammonia levels), and following standard precautions. The
client should be weighed every day.
A client with cirrhosis of the liver develops ascites, and the health care provider prescribes
spironolactone. What should the nurse monitor the client for?
A.
Hyperkalemia
B.
Tachycardia
C.
Hypoglycemia
D.
Ecchymosis - correct answer A. Hyperkalemia
Spironolactone (Aldactone) is a potassium-sparing diuretic that is used to treat clients with
ascites; therefore, the nurse should monitor the client for signs and symptoms of hyperkalemia.
Bruising and purpura are associated with cirrhosis, not with the administration of
spironolactone. Spironolactone does not cause tachycardia. Spironolactone does not cause
hypoglycemia.
A health care provider schedules a paracentesis for a client with ascites. What should the nurse
include in the client's teaching plan?
A.
Consume a diet low in fat for three days before the procedure.
B.
Stay on a liquid diet for 24 hours after the procedure.
C.
Empty the bladder immediately before the procedure.
ANSWERS)
The physician orders Lactulose 30 mL by mouth per day for a client with cirrhosis. What finding
below demonstrates the medication is working effectively?
A.
Improvement in level of consciousness
B.
Presence of asterixis
C.
Decreased albumin levels
D.
Absence of fruity breath - correct answer A. Improvement in level of consciousness
A patient with cirrhosis may experience a complication called hepatic encephalopathy. This will
cause the patient to become confused (they may enter into a coma), have pungent, musty
smelling breath (fetor hepaticus), asterixis (involuntary flapping of the hands). This is due to the
buildup of ammonia in the blood, which affects the brain. Lactulose can be prescribed to help
decrease the ammonia levels. Therefore, if the medication is working properly to decrease the
level of ammonia the patient would have improving mental status, decreased ammonia blood
level, decreasing or absence of asterixis, and decreased ammonia blood level. Fruity breath is
associated with DKA not hepatic encephalopathy.
During the morning assessment of a client with cirrhosis, you note the client is disoriented to
person and place. In addition, while assessing the upper extremities, the client's hands
demonstrate a flapping motion. What lab result would explain these abnormal assessment
findings?
A.
Ammonia level of 68 µ/dL
B.
Creatinine level of 2.9 mg/dL
C.
Potassium level of 3.7 mmol/L
D.
Calcium level of 10.9 mg/dL - correct answer A. Ammonia level of 68 µ/dL
,NUR 414 Final Exam QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS)
Based on the assessment findings and the fact the client has cirrhosis, the client is experiencing
hepatic encephalopathy. This is due to the buildup of toxins in the blood, specifically ammonia.
The flapping motion of the hands is called "asterixis". Therefore, an increased ammonia level
would confirm these abnormal assessment findings
(Normal ammonia: 10-80)
A patient diagnosed with hepatitis develops splenomegaly. When reviewing the laboratory
report, which of the following results will the healthcare provider anticipate?
A.
Polycythemia
B.
Leukocytosis
C.
Thrombocytopenia
D.
Neutrophilia - correct answer C. Thrombocytopenia
The spleen acts as a reservoir for platelets. When the spleen is enlarged, as with splenomegaly,
up to 90 percent of a person's thrombocytes can be sequestered within the enlarged spleen.
A client diagnosed with viral hepatitis develops liver failure and hepatic encephalopathy. Which
of these measures should the healthcare provider include in this client's plan of care?
A.
Provide high-protein feedings
B.
Monitor the blood glucose
C.
Institute droplet precautions
D.
Weigh once a week - correct answer B. Monitor the blood glucose
, NUR 414 Final Exam QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS)
Interventions for this patient include blood glucose monitoring (because of decreased glycogen
synthesis and storage), monitoring PT and INR (because of decreased clotting factors), checking
reflexes (because of the neurological effects of increased ammonia), providing diet/feedings
that are low in protein (to decrease ammonia levels), and following standard precautions. The
client should be weighed every day.
A client with cirrhosis of the liver develops ascites, and the health care provider prescribes
spironolactone. What should the nurse monitor the client for?
A.
Hyperkalemia
B.
Tachycardia
C.
Hypoglycemia
D.
Ecchymosis - correct answer A. Hyperkalemia
Spironolactone (Aldactone) is a potassium-sparing diuretic that is used to treat clients with
ascites; therefore, the nurse should monitor the client for signs and symptoms of hyperkalemia.
Bruising and purpura are associated with cirrhosis, not with the administration of
spironolactone. Spironolactone does not cause tachycardia. Spironolactone does not cause
hypoglycemia.
A health care provider schedules a paracentesis for a client with ascites. What should the nurse
include in the client's teaching plan?
A.
Consume a diet low in fat for three days before the procedure.
B.
Stay on a liquid diet for 24 hours after the procedure.
C.
Empty the bladder immediately before the procedure.
