EXAM 4- CIRRHOSIS NCLEX 2024 EXAM LATEST UPDATE
QUESTIONS WITH COMPLETE SOLUTIONS ANSWERED
GRADED A++
The nurse is reviewing the record of a client with a dx of cirrhosis and notes that
there is documentation of the presence of asterixis. How should the nurse assess
for its presence?
Dorsiflex the foot
Measure abdominal girth
Ask pt to extend the arms
Instruct pt to lean forward
Ask the pt to extend the arms
Asterixis is irregular flapping movements of the fingers and wrists when the hands and
arms are outstretched, with the palms down, wrists bent up, and fingers spread. It is the
most common and reliable sign that hepati encephalopathy is developing.
The nurse is reviewing the lab results for a pt with cirrhosis and notes that the
ammonia level is elevated. Which diet does the nurse anticipate to be presribed
for this pt?
Low-protein
High-protein
Moderate-fat
High-carb
Low-protein diet
, Protein provided by the diet is transported to the liver via the portal vein. The liver
breaks down protein, which results in the formation of ammonia.
During assessment of a pt with obstructive jaundice, the nurse would expect to
find:
clay colored stools
dark urine and stool
pyrexia and pruritis
elevated urinary urobilinogen
clay colored stool
A pt has been told she has NAFLD. The nursing teaching plan should include
a. having genetic testing done
b. recommend a heart healthy diet
c. the necessity to reduce weight rapidly
d. avoiding alcohol until liver enzymes return to normal
B
NAFLD can progress to cirrhosis. NO definitive treatment; therapy directed at reducing
risk like diabetes, body weight, and harmful medications.
The pt with advanced cirrhosis asks why his abdomen is so swollen. The nurse's
best response is based on the knowledge that
a. a lack of clotting factors promotes the collection of blood in the abdominal
cavity
b. portal hypertension and hypoalbuminemia cause fluid shift into the peritoneal
space.
c. decreased peristalsis in the GI tract contributes to gas formation and distention
of the bowel
d. bile salts in the blood irritate the peritoneal membranes, causing edema and
pocketing of fluid.
QUESTIONS WITH COMPLETE SOLUTIONS ANSWERED
GRADED A++
The nurse is reviewing the record of a client with a dx of cirrhosis and notes that
there is documentation of the presence of asterixis. How should the nurse assess
for its presence?
Dorsiflex the foot
Measure abdominal girth
Ask pt to extend the arms
Instruct pt to lean forward
Ask the pt to extend the arms
Asterixis is irregular flapping movements of the fingers and wrists when the hands and
arms are outstretched, with the palms down, wrists bent up, and fingers spread. It is the
most common and reliable sign that hepati encephalopathy is developing.
The nurse is reviewing the lab results for a pt with cirrhosis and notes that the
ammonia level is elevated. Which diet does the nurse anticipate to be presribed
for this pt?
Low-protein
High-protein
Moderate-fat
High-carb
Low-protein diet
, Protein provided by the diet is transported to the liver via the portal vein. The liver
breaks down protein, which results in the formation of ammonia.
During assessment of a pt with obstructive jaundice, the nurse would expect to
find:
clay colored stools
dark urine and stool
pyrexia and pruritis
elevated urinary urobilinogen
clay colored stool
A pt has been told she has NAFLD. The nursing teaching plan should include
a. having genetic testing done
b. recommend a heart healthy diet
c. the necessity to reduce weight rapidly
d. avoiding alcohol until liver enzymes return to normal
B
NAFLD can progress to cirrhosis. NO definitive treatment; therapy directed at reducing
risk like diabetes, body weight, and harmful medications.
The pt with advanced cirrhosis asks why his abdomen is so swollen. The nurse's
best response is based on the knowledge that
a. a lack of clotting factors promotes the collection of blood in the abdominal
cavity
b. portal hypertension and hypoalbuminemia cause fluid shift into the peritoneal
space.
c. decreased peristalsis in the GI tract contributes to gas formation and distention
of the bowel
d. bile salts in the blood irritate the peritoneal membranes, causing edema and
pocketing of fluid.
