Cirrhosis HESI Case Study (evolve) Question and Answers
A Complication OccursThe client's condition remains stable. The client is getting plenty of rest, alternating with
periods of exercise. The client is having difficulty following the prescribed diet however, occasionally friends
will bring in chips and soft drinks. Late one afternoon, the client calls for the nurse and reports that they feel
dizzy and that they are vomiting bright red blood. When the nurse arrives, the client is standing in the middle
of the room. The client is pale and skin feels cold and clammy.
What intervention is a priority for the nurse?
Take and record the client's blood pressure.
Go to the med cart to obtain an antiemetic.
Call for the laboratory to draw a STAT CBC.
Assist the client to bed and position them side lying.
Submit - ansAssist the client to bed and position them side lying.
The client is showing evidence of impending shock. Because they are vomiting, the safest position for the client
would be side lying to prevent aspiration.
After the client undergoes the paracentesis, which nursing assessment warrants immediate intervention?
Cloudy, yellow tinged fluid draining from puncture site
Unchanged abdominal girth measurement
Faint, hypoactive bowel sounds
Increasing abdominal pain - ansIncreasing abdominal pain
This may be the result of diaphragmatic, liver, or spleen perforation and may be life threatening.
Case OutcomeThe social worker is able to meet with the client. The social worker arranges a meeting with a
substance abuse counselor and the client says that they will attend Alcoholics Anonymous meetings with a
sponsor. The client is discharged from the hospital in stable condition with plans to stop drinking and to
maintain a healthy lifestyle.
, During the client's discharge education, which complication of cirrhosis should the nurse instruct the client to
report immediately?
Two pound weight gain in one week.
Progressive evidence of cachexia.
Prolonged icteric sclera.
Hemoptysis after taking ibuprofen for a headache. - ansHemoptysis after taking ibuprofen for a headache.
Hemoptysis is coughing up blood. This may be evidence of a life threatening esophageal bleed.
Client Teaching: Lifestyle ManagementThe client is experiencing bleeding esophageal varices. They are given a
liter bolus of sodium chloride 0.9% IV and they are scheduled for immediate endoscopic sclerotherapy.
Following endoscopic sclerotherapy, the client's bleeding stops and condition stabilizes. The client tells the
nurse that they think it's time to learn about their condition. The client expressed fear of dying. The nurse
provides the client with the information about managing diet and fluid intake. Dietary management includes a
well-balanced diet that is low in sodium, fat, and physical irritants with a mild fluid restriction.
The nurse provides additional discharge teaching regarding lifestyle management. Which information should
the nurse provide to the client? (Select all that apply. One, some, or all options may be correct.)
Select all that apply
Reduce alcohol intake to one drink daily.
Get plenty of r - ansGet plenty of rest and regular exercise.
This is important to maintain the client's health.
Avoid the consumption of raw shellfish.
This is a priority because of the existing damage to the liver. Raw shellfish has a risk of causing hepatitis.
Consider joining an Alcoholic Anonymous (AA) group.
A Complication OccursThe client's condition remains stable. The client is getting plenty of rest, alternating with
periods of exercise. The client is having difficulty following the prescribed diet however, occasionally friends
will bring in chips and soft drinks. Late one afternoon, the client calls for the nurse and reports that they feel
dizzy and that they are vomiting bright red blood. When the nurse arrives, the client is standing in the middle
of the room. The client is pale and skin feels cold and clammy.
What intervention is a priority for the nurse?
Take and record the client's blood pressure.
Go to the med cart to obtain an antiemetic.
Call for the laboratory to draw a STAT CBC.
Assist the client to bed and position them side lying.
Submit - ansAssist the client to bed and position them side lying.
The client is showing evidence of impending shock. Because they are vomiting, the safest position for the client
would be side lying to prevent aspiration.
After the client undergoes the paracentesis, which nursing assessment warrants immediate intervention?
Cloudy, yellow tinged fluid draining from puncture site
Unchanged abdominal girth measurement
Faint, hypoactive bowel sounds
Increasing abdominal pain - ansIncreasing abdominal pain
This may be the result of diaphragmatic, liver, or spleen perforation and may be life threatening.
Case OutcomeThe social worker is able to meet with the client. The social worker arranges a meeting with a
substance abuse counselor and the client says that they will attend Alcoholics Anonymous meetings with a
sponsor. The client is discharged from the hospital in stable condition with plans to stop drinking and to
maintain a healthy lifestyle.
, During the client's discharge education, which complication of cirrhosis should the nurse instruct the client to
report immediately?
Two pound weight gain in one week.
Progressive evidence of cachexia.
Prolonged icteric sclera.
Hemoptysis after taking ibuprofen for a headache. - ansHemoptysis after taking ibuprofen for a headache.
Hemoptysis is coughing up blood. This may be evidence of a life threatening esophageal bleed.
Client Teaching: Lifestyle ManagementThe client is experiencing bleeding esophageal varices. They are given a
liter bolus of sodium chloride 0.9% IV and they are scheduled for immediate endoscopic sclerotherapy.
Following endoscopic sclerotherapy, the client's bleeding stops and condition stabilizes. The client tells the
nurse that they think it's time to learn about their condition. The client expressed fear of dying. The nurse
provides the client with the information about managing diet and fluid intake. Dietary management includes a
well-balanced diet that is low in sodium, fat, and physical irritants with a mild fluid restriction.
The nurse provides additional discharge teaching regarding lifestyle management. Which information should
the nurse provide to the client? (Select all that apply. One, some, or all options may be correct.)
Select all that apply
Reduce alcohol intake to one drink daily.
Get plenty of r - ansGet plenty of rest and regular exercise.
This is important to maintain the client's health.
Avoid the consumption of raw shellfish.
This is a priority because of the existing damage to the liver. Raw shellfish has a risk of causing hepatitis.
Consider joining an Alcoholic Anonymous (AA) group.
