Cirrhosis NCLEX Exam 4 Test Questions with Answers Graded A+
The nurse is reviewing the record of a client with a dx
of cirrhosis and notes that there is documentation of the Ask the pt to extend the arms
presence of asterixis. How should the nurse assess for its
presence? Asterixis is irregular flapping movements of the fingers
and wrists when the hands and arms are outstretched,
Dorsiflex the foot with the palms down, wrists bent up, and fingers spread.
Measure abdominal girth It is the most common and reliable sign that hepati en-
Ask pt to extend the arms cephalopathy is developing.
Instruct pt to lean forward
The nurse is reviewing the lab results for a pt with cirrhosis
and notes that the ammonia level is elevated. Which diet
Low-protein diet
does the nurse anticipate to be presribed for this pt?
Protein provided by the diet is transported to the liver
Low-protein
via the portal vein. The liver breaks down protein, which
High-protein
results in the formation of ammonia.
Moderate-fat
High-carb
During assessment of a pt with obstructive jaundice, the
nurse would expect to find:
clay colored stools clay colored stool
dark urine and stool
pyrexia and pruritis
elevated urinary urobilinogen
A pt has been told she has NAFLD. The nursing teaching
plan should include B
a. having genetic testing done NAFLD can progress to cirrhosis. NO definitive treat-
b. recommend a heart healthy diet ment; therapy directed at reducing risk like diabetes, body
c. the necessity to reduce weight rapidly weight, and harmful medications.
d. avoiding alcohol until liver enzymes return to normal
1/9
, Cirrhosis NCLEX Exam 4 Test Questions with Answers Graded A+
The pt with advanced cirrhosis asks why his abdomen is
so swollen. The nurse's best response is based on the B
knowledge that
Ascites is accumulation of serious fluid in peritoneal cavity.
a. a lack of clotting factors promotes the collection of With portal hypertension, protein shifts from the blood
blood in the abdominal cavity into the lymph. When the lymph system is unable to carry
b. portal hypertension and hypoalbuminemia cause fluid excess, it leaks thru the liver into the peritoneal cavity.
shift into the peritoneal space. osmotic pressure of the proteins pulls additional fluid into
c. decreased peristalsis in the GI tract contributes to gas cavity. Second mechanism of ascites if hypoalbuminemia
formation and distention of the bowel from the liver unable to synthesize albumin, resulting in
d. bile salts in the blood irritate the peritoneal mem- decreased colloidal oncotic pressure.
branes, causing edema and pocketing of fluid.
The health care provider orders lactulose for a patient
with hepatic encephalopathy. The nurse will monitor for D
ettectiveness of this medication for this pt by assessing
what? hepatic encephalopathy is associated with elevated am-
monia levels. Lactulose traps ammonia in the intestinal
a. relief of constipation tract. It's laxative ettect then expels ammonia from the
b. relief of ab pain colon, resulting in decreased ammonia levels, correcting
c. decreased liver enzymes hepatic encephalopathy.
d. decreased ammonia levels
When planning care for a pt with cirrhosis, the nurse will
give highest priority to which nursing diagnosis?
a. impaired skin integrity related to edema, ascites, and
pruritis D
b. imbalanced nutrition: less than body requirements re-
lated to anorexia airway and breathing are always highest priority.
c. excess fluid volume related to portal hypertension and
hyperaldosteronism
d. inettective breathing pattern related to pressure on
diaphragm and reduced lung volume
2/9
The nurse is reviewing the record of a client with a dx
of cirrhosis and notes that there is documentation of the Ask the pt to extend the arms
presence of asterixis. How should the nurse assess for its
presence? Asterixis is irregular flapping movements of the fingers
and wrists when the hands and arms are outstretched,
Dorsiflex the foot with the palms down, wrists bent up, and fingers spread.
Measure abdominal girth It is the most common and reliable sign that hepati en-
Ask pt to extend the arms cephalopathy is developing.
Instruct pt to lean forward
The nurse is reviewing the lab results for a pt with cirrhosis
and notes that the ammonia level is elevated. Which diet
Low-protein diet
does the nurse anticipate to be presribed for this pt?
Protein provided by the diet is transported to the liver
Low-protein
via the portal vein. The liver breaks down protein, which
High-protein
results in the formation of ammonia.
Moderate-fat
High-carb
During assessment of a pt with obstructive jaundice, the
nurse would expect to find:
clay colored stools clay colored stool
dark urine and stool
pyrexia and pruritis
elevated urinary urobilinogen
A pt has been told she has NAFLD. The nursing teaching
plan should include B
a. having genetic testing done NAFLD can progress to cirrhosis. NO definitive treat-
b. recommend a heart healthy diet ment; therapy directed at reducing risk like diabetes, body
c. the necessity to reduce weight rapidly weight, and harmful medications.
d. avoiding alcohol until liver enzymes return to normal
1/9
, Cirrhosis NCLEX Exam 4 Test Questions with Answers Graded A+
The pt with advanced cirrhosis asks why his abdomen is
so swollen. The nurse's best response is based on the B
knowledge that
Ascites is accumulation of serious fluid in peritoneal cavity.
a. a lack of clotting factors promotes the collection of With portal hypertension, protein shifts from the blood
blood in the abdominal cavity into the lymph. When the lymph system is unable to carry
b. portal hypertension and hypoalbuminemia cause fluid excess, it leaks thru the liver into the peritoneal cavity.
shift into the peritoneal space. osmotic pressure of the proteins pulls additional fluid into
c. decreased peristalsis in the GI tract contributes to gas cavity. Second mechanism of ascites if hypoalbuminemia
formation and distention of the bowel from the liver unable to synthesize albumin, resulting in
d. bile salts in the blood irritate the peritoneal mem- decreased colloidal oncotic pressure.
branes, causing edema and pocketing of fluid.
The health care provider orders lactulose for a patient
with hepatic encephalopathy. The nurse will monitor for D
ettectiveness of this medication for this pt by assessing
what? hepatic encephalopathy is associated with elevated am-
monia levels. Lactulose traps ammonia in the intestinal
a. relief of constipation tract. It's laxative ettect then expels ammonia from the
b. relief of ab pain colon, resulting in decreased ammonia levels, correcting
c. decreased liver enzymes hepatic encephalopathy.
d. decreased ammonia levels
When planning care for a pt with cirrhosis, the nurse will
give highest priority to which nursing diagnosis?
a. impaired skin integrity related to edema, ascites, and
pruritis D
b. imbalanced nutrition: less than body requirements re-
lated to anorexia airway and breathing are always highest priority.
c. excess fluid volume related to portal hypertension and
hyperaldosteronism
d. inettective breathing pattern related to pressure on
diaphragm and reduced lung volume
2/9
