Exam 4- Cirrhosis NCLEX with Verified Answers Graded A
The nurse is reviewing the record of a client with teaching plan should include
a dx of cirrhosis and notes that there is
documentation of the presence of asterixis. How a. having genetic testing done
should the nurse assess for its presence? b. recommend a heart healthy diet
c. the necessity to reduce weight rapidly
Dorsiflex the foot d. avoiding alcohol until liver enzymes return to
Measure abdominal girth normal - ANSWER -B
Ask pt to extend the arms
Instruct pt to lean forward - ANSWER -Ask NAFLD can progress to cirrhosis. NO definitive
the pt to extend the arms treatment; therapy directed at reducing risk like
diabetes, body weight, and harmful medications.
Asterixis is irregular flapping movements of the
fingers and wrists when the hands and arms are
outstretched, with the palms down, wrists bent The pt with advanced cirrhosis asks why his
up, and fingers spread. It is the most common abdomen is so swollen. The nurse's best
and reliable sign that hepati encephalopathy is response is based on the knowledge that
developing.
a. a lack of clotting factors promotes the
collection of blood in the abdominal cavity
The nurse is reviewing the lab results for a pt b. portal hypertension and hypoalbuminemia
with cirrhosis and notes that the ammonia level is cause fluid shift into the peritoneal space.
elevated. Which diet does the nurse anticipate to c. decreased peristalsis in the GI tract contributes
be presribed for this pt? to gas formation and distention of the bowel
d. bile salts in the blood irritate the peritoneal
Low-protein membranes, causing edema and pocketing of
High-protein fluid. - ANSWER -B
Moderate-fat
High-carb - ANSWER -Low-protein diet Ascites is accumulation of serious fluid in
peritoneal cavity. With portal hypertension,
Protein provided by the diet is transported to the protein shifts from the blood into the lymph.
liver via the portal vein. The liver breaks down When the lymph system is unable to carry
protein, which results in the formation of excess, it leaks thru the liver into the peritoneal
ammonia. cavity. osmotic pressure of the proteins pulls
additional fluid into cavity. Second mechanism of
ascites if hypoalbuminemia from the liver unable
During assessment of a pt with obstructive to synthesize albumin, resulting in decreased
jaundice, the nurse would expect to find: colloidal oncotic pressure.
clay colored stools
dark urine and stool The health care provider orders lactulose for a
pyrexia and pruritis patient with hepatic encephalopathy. The nurse
elevated urinary urobilinogen - ANSWER - will monitor for effectiveness of this medication
clay colored stool for this pt by assessing what?
a. relief of constipation
A pt has been told she has NAFLD. The nursing b. relief of ab pain
1/6
, Exam 4- Cirrhosis NCLEX with Verified Answers Graded A
c. decreased liver enzymes ANSWER -A, B, C, E
d. decreased ammonia levels - ANSWER -
D - small gauge minimize risk of bleeding into
tissues.
hepatic encephalopathy is associated with - avoiding strain reduces hemorrhage
elevated ammonia levels. Lactulose traps - soft bristle reduce injury to highly vascular
ammonia in the intestinal tract. It's laxative effect mucous membranes
then expels ammonia from the colon, resulting in - apply gentle but prolonged pressure to
decreased ammonia levels, correcting hepatic venipuncture
encephalopathy. - aspirin and NSAIDs should not be used in pt
with liver disease b/c they interfere w/ platelet
aggregation, increasing bleeding risk
When planning care for a pt with cirrhosis, the
nurse will give highest priority to which nursing
diagnosis? A pt with type 2 diabetes and cirrhosis asks if it
would be okay to take silymarin (milk thistle) to
a. impaired skin integrity related to edema, help minimize liver damage. The nurse responds
ascites, and pruritis based on what knowledge?
b. imbalanced nutrition: less than body
requirements related to anorexia a. milk thistle may affect liver enzymes and thus
c. excess fluid volume related to portal alter drug metabolism
hypertension and hyperaldosteronism b. milk thistle is generally safe in recommended
d. ineffective breathing pattern related to doses for up to 10 yrs
pressure on diaphragm and reduced lung volume c. there is unclear scientific evidence for the use
- ANSWER -D of milk thistle in treating cirrhosis
d. milk thislte may elevate the serum glucose
airway and breathing are always highest priority. level and is thus contraindicated in diabetes. -
ANSWER -A
When caring for a pt with liver disease, the nurse There is evidence that there is no real benefit
recognizes the need to prevent bleeding from using milk thistle to protect liver enzyme
resulting from altered clotting factors and rupture from toxic damage. Milk thistle does affect liver
of varices. Which nursing interventions would be enzyme and could alter drug metabolism. Pt will
appropriate to achieve this outcome? Select all need to be monitored for drug interactions. It is
that apply. dafe for up to 6 yrs not 10, and it may lower, not
elevate, blood glucose levels.
a. use smallest gauge needle possible when
giving injections or drawing blood.
b. teach pt to avoid straining at stool, vigorous The condition of the pt who has cirrhosis of the
blowing of nose, and coughing liver has deteriorated. Which diagnostic study
c. advise pt to use soft-bristle toothbrush and would help determine if the pt has developed liver
avoid ingestion of irritating food. cancer?
d. apply gentle pressure for the shortest possible
time period after performing venipuncture a. serum a-fetoprotein level
e. instruct pt to avoid aspirin and NSAIDs to b. ventilation/perfusion scan
prevent hemorrhage when varices are present. - c. hepatic structure ultasound
2/6
The nurse is reviewing the record of a client with teaching plan should include
a dx of cirrhosis and notes that there is
documentation of the presence of asterixis. How a. having genetic testing done
should the nurse assess for its presence? b. recommend a heart healthy diet
c. the necessity to reduce weight rapidly
Dorsiflex the foot d. avoiding alcohol until liver enzymes return to
Measure abdominal girth normal - ANSWER -B
Ask pt to extend the arms
Instruct pt to lean forward - ANSWER -Ask NAFLD can progress to cirrhosis. NO definitive
the pt to extend the arms treatment; therapy directed at reducing risk like
diabetes, body weight, and harmful medications.
Asterixis is irregular flapping movements of the
fingers and wrists when the hands and arms are
outstretched, with the palms down, wrists bent The pt with advanced cirrhosis asks why his
up, and fingers spread. It is the most common abdomen is so swollen. The nurse's best
and reliable sign that hepati encephalopathy is response is based on the knowledge that
developing.
a. a lack of clotting factors promotes the
collection of blood in the abdominal cavity
The nurse is reviewing the lab results for a pt b. portal hypertension and hypoalbuminemia
with cirrhosis and notes that the ammonia level is cause fluid shift into the peritoneal space.
elevated. Which diet does the nurse anticipate to c. decreased peristalsis in the GI tract contributes
be presribed for this pt? to gas formation and distention of the bowel
d. bile salts in the blood irritate the peritoneal
Low-protein membranes, causing edema and pocketing of
High-protein fluid. - ANSWER -B
Moderate-fat
High-carb - ANSWER -Low-protein diet Ascites is accumulation of serious fluid in
peritoneal cavity. With portal hypertension,
Protein provided by the diet is transported to the protein shifts from the blood into the lymph.
liver via the portal vein. The liver breaks down When the lymph system is unable to carry
protein, which results in the formation of excess, it leaks thru the liver into the peritoneal
ammonia. cavity. osmotic pressure of the proteins pulls
additional fluid into cavity. Second mechanism of
ascites if hypoalbuminemia from the liver unable
During assessment of a pt with obstructive to synthesize albumin, resulting in decreased
jaundice, the nurse would expect to find: colloidal oncotic pressure.
clay colored stools
dark urine and stool The health care provider orders lactulose for a
pyrexia and pruritis patient with hepatic encephalopathy. The nurse
elevated urinary urobilinogen - ANSWER - will monitor for effectiveness of this medication
clay colored stool for this pt by assessing what?
a. relief of constipation
A pt has been told she has NAFLD. The nursing b. relief of ab pain
1/6
, Exam 4- Cirrhosis NCLEX with Verified Answers Graded A
c. decreased liver enzymes ANSWER -A, B, C, E
d. decreased ammonia levels - ANSWER -
D - small gauge minimize risk of bleeding into
tissues.
hepatic encephalopathy is associated with - avoiding strain reduces hemorrhage
elevated ammonia levels. Lactulose traps - soft bristle reduce injury to highly vascular
ammonia in the intestinal tract. It's laxative effect mucous membranes
then expels ammonia from the colon, resulting in - apply gentle but prolonged pressure to
decreased ammonia levels, correcting hepatic venipuncture
encephalopathy. - aspirin and NSAIDs should not be used in pt
with liver disease b/c they interfere w/ platelet
aggregation, increasing bleeding risk
When planning care for a pt with cirrhosis, the
nurse will give highest priority to which nursing
diagnosis? A pt with type 2 diabetes and cirrhosis asks if it
would be okay to take silymarin (milk thistle) to
a. impaired skin integrity related to edema, help minimize liver damage. The nurse responds
ascites, and pruritis based on what knowledge?
b. imbalanced nutrition: less than body
requirements related to anorexia a. milk thistle may affect liver enzymes and thus
c. excess fluid volume related to portal alter drug metabolism
hypertension and hyperaldosteronism b. milk thistle is generally safe in recommended
d. ineffective breathing pattern related to doses for up to 10 yrs
pressure on diaphragm and reduced lung volume c. there is unclear scientific evidence for the use
- ANSWER -D of milk thistle in treating cirrhosis
d. milk thislte may elevate the serum glucose
airway and breathing are always highest priority. level and is thus contraindicated in diabetes. -
ANSWER -A
When caring for a pt with liver disease, the nurse There is evidence that there is no real benefit
recognizes the need to prevent bleeding from using milk thistle to protect liver enzyme
resulting from altered clotting factors and rupture from toxic damage. Milk thistle does affect liver
of varices. Which nursing interventions would be enzyme and could alter drug metabolism. Pt will
appropriate to achieve this outcome? Select all need to be monitored for drug interactions. It is
that apply. dafe for up to 6 yrs not 10, and it may lower, not
elevate, blood glucose levels.
a. use smallest gauge needle possible when
giving injections or drawing blood.
b. teach pt to avoid straining at stool, vigorous The condition of the pt who has cirrhosis of the
blowing of nose, and coughing liver has deteriorated. Which diagnostic study
c. advise pt to use soft-bristle toothbrush and would help determine if the pt has developed liver
avoid ingestion of irritating food. cancer?
d. apply gentle pressure for the shortest possible
time period after performing venipuncture a. serum a-fetoprotein level
e. instruct pt to avoid aspirin and NSAIDs to b. ventilation/perfusion scan
prevent hemorrhage when varices are present. - c. hepatic structure ultasound
2/6
