Exam 4- Cirrhosis NCLEX
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1. 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.
2. 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.
3. 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
4. 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
, Exam 4- Cirrhosis NCLEX
Study online at https://quizlet.com/_5d8kgq
NAFLD can progress to cirrhosis. NO definitive treatment; therapy directed at reduc-
ing risk like diabetes, body weight, and harmful medications.
5. 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 peri-
toneal 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.: B
Ascites is accumulation of serious fluid in peritoneal cavity. With portal hypertension,
protein shifts from the blood into the lymph. When the lymph system is unable
to carry excess, it leaks thru the liver into the peritoneal cavity. osmotic pressure
of the proteins pulls additional fluid into cavity. Second mechanism of ascites if
hypoalbuminemia from the liver unable to synthesize albumin, resulting in decreased
colloidal oncotic pressure.
6. The health care provider orders lactulose for a patient with hepatic en-
cephalopathy. The nurse will monitor for effectiveness of this medication for
this pt by assessing what?
a. relief of constipation
b. relief of ab pain
c. decreased liver enzymes
d. decreased ammonia levels: D
hepatic encephalopathy is associated with elevated ammonia levels. Lactulose traps
ammonia in the intestinal tract. It's laxative effect then expels ammonia from the
colon, resulting in decreased ammonia levels, correcting hepatic encephalopathy.
7. 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
b. imbalanced nutrition: less than body requirements related to anorexia
c. excess fluid volume related to portal hypertension and hyperaldosteronism
d. ineffective breathing pattern related to pressure on diaphragm and reduced
Study online at https://quizlet.com/_5d8kgq
1. 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.
2. 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.
3. 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
4. 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
, Exam 4- Cirrhosis NCLEX
Study online at https://quizlet.com/_5d8kgq
NAFLD can progress to cirrhosis. NO definitive treatment; therapy directed at reduc-
ing risk like diabetes, body weight, and harmful medications.
5. 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 peri-
toneal 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.: B
Ascites is accumulation of serious fluid in peritoneal cavity. With portal hypertension,
protein shifts from the blood into the lymph. When the lymph system is unable
to carry excess, it leaks thru the liver into the peritoneal cavity. osmotic pressure
of the proteins pulls additional fluid into cavity. Second mechanism of ascites if
hypoalbuminemia from the liver unable to synthesize albumin, resulting in decreased
colloidal oncotic pressure.
6. The health care provider orders lactulose for a patient with hepatic en-
cephalopathy. The nurse will monitor for effectiveness of this medication for
this pt by assessing what?
a. relief of constipation
b. relief of ab pain
c. decreased liver enzymes
d. decreased ammonia levels: D
hepatic encephalopathy is associated with elevated ammonia levels. Lactulose traps
ammonia in the intestinal tract. It's laxative effect then expels ammonia from the
colon, resulting in decreased ammonia levels, correcting hepatic encephalopathy.
7. 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
b. imbalanced nutrition: less than body requirements related to anorexia
c. excess fluid volume related to portal hypertension and hyperaldosteronism
d. ineffective breathing pattern related to pressure on diaphragm and reduced
