NUR 414 FINAL EXAM QUESTIONS & 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 - Answers - 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 - Answers - A. Ammonia level of 68 µ/dL
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 - Answers - 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 - Answers - B. Monitor the blood glucose
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 - Answers - 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 client with a 20-year history of excessive alcohol use is admitted to the hospital with
jaundice and ascites. A priority nursing action during the first 48 hours after the client's
admission is to:
A.
Determine the client's reasons for drinking.
B.
Monitor the client's vital signs
C.
Improve the client's nutritional status.
D.
Increase the client's fluid intake. - Answers - B. Monitor the client's vital signs
A client's vital signs, especially the pulse and temperature, will increase before the client
demonstrates any of the more severe symptoms of withdrawal from alcohol. Increasing
intake is contraindicated initially because it may cause cerebral edema. Improving
nutritional status becomes a priority after the problems of the withdrawal period have
subsided. Determining the client's reasons for drinking is not a priority until after the
detoxification process.
The nurse is providing discharge instructions to a client who is recovering from an acute
case of viral hepatitis. Which statement by the client indicates a need for further
education?
A.
"I will avoid alcohol."
B.
"I will take acetaminophen for pain"
C.
"I will be sure to take naps throughout the day."
D.
"I will eat small frequent meals." - Answers - B. "I will take acetaminophen for pain."
Acetaminophen is damaging to the liver and is contraindicated in clients with hepatitis.
Clients should avoid alcohol, eat small frequent meals, and be sure to get plenty of rest.
The nurse is caring for a client who is scheduled to have a percutaneous liver biopsy.
Which findings warrant the postponement of the procedure? Select all that apply.
A.
Hemoglobin less than 9 g/dL
B.
Platelet count of 160,000/mm3
C.
Marked ascites
D.
Ecchymosis and purpura
E.
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 - Answers - 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 - Answers - A. Ammonia level of 68 µ/dL
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 - Answers - 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 - Answers - B. Monitor the blood glucose
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 - Answers - 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 client with a 20-year history of excessive alcohol use is admitted to the hospital with
jaundice and ascites. A priority nursing action during the first 48 hours after the client's
admission is to:
A.
Determine the client's reasons for drinking.
B.
Monitor the client's vital signs
C.
Improve the client's nutritional status.
D.
Increase the client's fluid intake. - Answers - B. Monitor the client's vital signs
A client's vital signs, especially the pulse and temperature, will increase before the client
demonstrates any of the more severe symptoms of withdrawal from alcohol. Increasing
intake is contraindicated initially because it may cause cerebral edema. Improving
nutritional status becomes a priority after the problems of the withdrawal period have
subsided. Determining the client's reasons for drinking is not a priority until after the
detoxification process.
The nurse is providing discharge instructions to a client who is recovering from an acute
case of viral hepatitis. Which statement by the client indicates a need for further
education?
A.
"I will avoid alcohol."
B.
"I will take acetaminophen for pain"
C.
"I will be sure to take naps throughout the day."
D.
"I will eat small frequent meals." - Answers - B. "I will take acetaminophen for pain."
Acetaminophen is damaging to the liver and is contraindicated in clients with hepatitis.
Clients should avoid alcohol, eat small frequent meals, and be sure to get plenty of rest.
The nurse is caring for a client who is scheduled to have a percutaneous liver biopsy.
Which findings warrant the postponement of the procedure? Select all that apply.
A.
Hemoglobin less than 9 g/dL
B.
Platelet count of 160,000/mm3
C.
Marked ascites
D.
Ecchymosis and purpura
E.
