NUR 2243 – Exam 1 | Nursing Care for Hepatitis, Cirrhosis, Ascites, and Hepatic
Encephalopathy
The client should be supported to explore feelings about the disease process and altered
appearance so that appropriate interventions can be planned. Restricting visitors would
reinforce the client's negative self-esteem. To assist the client in adapting to changes in
appearance, it is important for the nurse to encourage participation in self-care to foster
independence and self-esteem. The client should be encouraged to ask questions to clarify
misconceptions, to learn ways to prevent the spread of hepatitis, to reduce fear, and to make
appropriate decisions.
A client with viral hepatitis has no appetite, and food makes the client nauseated. Which
nursing intervention is appropriate?
a. Encourage foods that are
high in protein
b. Monitor for fluid and
electrolyte imbalance
c. Explain that high fat diets
usually are better tolerated
d. Explain that most daily
calories need to be
consumed in the evening hours ANS: B
If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte
imbalance. It is important to explain to the client that most calories should be eaten in the
morning hours because nausea is most common in the afternoon and evening. Clients should
select a diet high in calories because energy is required for healing. Protein increases the
,workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are
better tolerated.
The nurse is developing a teaching plan for a client with viral hepatitis. The nurse should plan to
include which information in the teaching session?
a. The diet should be low in
calories
b. Meals should be large to
conserve energy
c. Activity should be limited
to prevent fatigue
d. Alcohol intake should be
limited to 2 ounces per
day ANS: C
Rest is necessary for the client with hepatitis, and the client with viral hepatitis should limit
activity to avoid fatigue. The diet should be optimal in calories, proteins, and carbohydrates.
The client should take in several small meals per day. Alcohol is strictly forbidden.
The nurse is assigned to care for a client with a Sengstaken-Blakemore tube. Which laboratory
result is most focused on evaluating the effectiveness of this tube?
a. Sodium
b. Creatinine
c. Hemoglobin
,d. Ammonia ANS: C
A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis with
ruptured esophageal varices if other treatment measures are unsuccessful. The tube has an
esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured
esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct
position and prevents migration of the esophageal balloon, which could harm the client.
Evaluation of the client's hemoglobin level trends will determine if the tube is effective.
Sodium, creatinine, and ammonia levels are not related to monitoring for blood loss.
The nurse has been caring for a client who required a Sengstaken-Blakemore tube because
other treatment measures for esophageal varices were unsuccessful. The health care provider
(HCP) arrives on the nursing unit and deflates the esophageal balloon. Which assessment
finding by the nurse is the most important and should be reported to the HCP immediately?
a. Hematemesis
b. Bloody diarrhea
c. Swelling of the abdomen
d. An elevated temp rise in
blood pressure ANS: A
A Sengstaken-Blakemore tube may be inserted in a client with a diagnosis of cirrhosis with
bleeding esophageal varices. It has both an esophageal and a gastric balloon. The esophageal
balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The
pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to
esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the
client may begin to bleed again from the esophageal varices, manifested as vomiting of blood
(hematemesis). The remaining options are unrelated to deflating the esophageal balloon.
The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs
of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal
hypertension?
, a. Flat neck veins
b. Abdominal distention
c. Hemoglobin of 14.2
d. Platelet count of 600,000 ANS: B
With portal hypertension, proteins shift from the blood vessels via the larger pores of the
sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off
the excess proteins and water, they leak through the liver capsule into the peritoneal cavity.
This is called ascites, and abdominal distention would be the consequence. Increased portal
pressure can lead to findings associated with right-sided heart failure, such as distended jugular
veins. Thrombocytopenia, leukopenia, and anemia are caused by the splenomegaly that results
from backup of blood from the portal vein into the spleen (portal hypertension).
The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions
should be included in the care plan for this client? Select all that apply.
a. Monitor daily weights
b. Measure abdominal girth
c. Monitor respiratory status
d. Place client in supine
position
e. Assist client with care as
needed ANS: A, B, C, E
Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby
impairing the client's breathing patterns. The client should be placed in a semi Fowler's position
with the arms supported on a pillow to allow for free diaphragm movement. The correct
Encephalopathy
The client should be supported to explore feelings about the disease process and altered
appearance so that appropriate interventions can be planned. Restricting visitors would
reinforce the client's negative self-esteem. To assist the client in adapting to changes in
appearance, it is important for the nurse to encourage participation in self-care to foster
independence and self-esteem. The client should be encouraged to ask questions to clarify
misconceptions, to learn ways to prevent the spread of hepatitis, to reduce fear, and to make
appropriate decisions.
A client with viral hepatitis has no appetite, and food makes the client nauseated. Which
nursing intervention is appropriate?
a. Encourage foods that are
high in protein
b. Monitor for fluid and
electrolyte imbalance
c. Explain that high fat diets
usually are better tolerated
d. Explain that most daily
calories need to be
consumed in the evening hours ANS: B
If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte
imbalance. It is important to explain to the client that most calories should be eaten in the
morning hours because nausea is most common in the afternoon and evening. Clients should
select a diet high in calories because energy is required for healing. Protein increases the
,workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are
better tolerated.
The nurse is developing a teaching plan for a client with viral hepatitis. The nurse should plan to
include which information in the teaching session?
a. The diet should be low in
calories
b. Meals should be large to
conserve energy
c. Activity should be limited
to prevent fatigue
d. Alcohol intake should be
limited to 2 ounces per
day ANS: C
Rest is necessary for the client with hepatitis, and the client with viral hepatitis should limit
activity to avoid fatigue. The diet should be optimal in calories, proteins, and carbohydrates.
The client should take in several small meals per day. Alcohol is strictly forbidden.
The nurse is assigned to care for a client with a Sengstaken-Blakemore tube. Which laboratory
result is most focused on evaluating the effectiveness of this tube?
a. Sodium
b. Creatinine
c. Hemoglobin
,d. Ammonia ANS: C
A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis with
ruptured esophageal varices if other treatment measures are unsuccessful. The tube has an
esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured
esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct
position and prevents migration of the esophageal balloon, which could harm the client.
Evaluation of the client's hemoglobin level trends will determine if the tube is effective.
Sodium, creatinine, and ammonia levels are not related to monitoring for blood loss.
The nurse has been caring for a client who required a Sengstaken-Blakemore tube because
other treatment measures for esophageal varices were unsuccessful. The health care provider
(HCP) arrives on the nursing unit and deflates the esophageal balloon. Which assessment
finding by the nurse is the most important and should be reported to the HCP immediately?
a. Hematemesis
b. Bloody diarrhea
c. Swelling of the abdomen
d. An elevated temp rise in
blood pressure ANS: A
A Sengstaken-Blakemore tube may be inserted in a client with a diagnosis of cirrhosis with
bleeding esophageal varices. It has both an esophageal and a gastric balloon. The esophageal
balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The
pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to
esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the
client may begin to bleed again from the esophageal varices, manifested as vomiting of blood
(hematemesis). The remaining options are unrelated to deflating the esophageal balloon.
The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs
of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal
hypertension?
, a. Flat neck veins
b. Abdominal distention
c. Hemoglobin of 14.2
d. Platelet count of 600,000 ANS: B
With portal hypertension, proteins shift from the blood vessels via the larger pores of the
sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off
the excess proteins and water, they leak through the liver capsule into the peritoneal cavity.
This is called ascites, and abdominal distention would be the consequence. Increased portal
pressure can lead to findings associated with right-sided heart failure, such as distended jugular
veins. Thrombocytopenia, leukopenia, and anemia are caused by the splenomegaly that results
from backup of blood from the portal vein into the spleen (portal hypertension).
The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions
should be included in the care plan for this client? Select all that apply.
a. Monitor daily weights
b. Measure abdominal girth
c. Monitor respiratory status
d. Place client in supine
position
e. Assist client with care as
needed ANS: A, B, C, E
Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby
impairing the client's breathing patterns. The client should be placed in a semi Fowler's position
with the arms supported on a pillow to allow for free diaphragm movement. The correct
