A nurse is caring for a client who was admitted with bleeding esophageal varices

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1) The nurse is caring for a male client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

1. Dyspnea and fatigue
2. Ascites and orthopnea
3. Purpura and petechiae
4. Gynecomastia and testicular atrophy

2) A man is admitted to the nursing care unit with a diagnosis of cirrhosis. He has a long history of alcohol dependence. During the late evening following his admission, he becomes increasingly disoriented and agitated. Which of the following would the client be least likely to experience?

1. Diaphoresis and tremors.
2. Increased blood pressure and heart rate.
3. Illusions.
4. Delusions of grandeur.

3) Nurse Juvy is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intension to increase the intake of:

1. Pork
2. Milk
3. Chicken
4. Broccoli

4) Which of the following terms is used to describe a chronic liver disease in which scar tissue surrounds the portal areas?

1. Alcoholic cirrhosis
2. Postnecrotic cirrhosis
3. Biliary cirrhosis
4. Compensated cirrhosis

5) A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulted to ascites. The nurse should be aware that the ascites is most likely the result of increased…

1. Pressure in the portal vein
2. Production of serum albumin
3. Secretion of bile salts
4. Interstitial osmotic pressure

6) A client with advanced cirrhosis of the liver is not tolerating protein well, as eveidenced by abnormal laboratory values. The nurse anticipates that which of the following medications will be prescribed for the client?

1. lactulose (Chronulac)
2. ethacrynic acid (Edecrin)
3. folic acid (Folvite)
4. thiamine (Vitamin B1)

7) The nurse is caring for a client with cirrhosis of the liver who has developed esophageal varices. The nurse understands that the best explanation for development of esophageal varices is which of the following?

1. Chronic low serum protein levels result in inadequate tissue repair, allowing the esophageal wall to weaken.
2. The enlarged liver presses on the diaphragm, which in turn presses on the esophageal wall, causing collapse of blood vessels into the esophageal lumen.
3. Increased portal pressure causes some of the blood that normally circulates through the liver to be shunted to the esophageal vessels, increasing their pressure and causing varicosities.
4. The enlarged liver displaces the esophagus toward the left, tearing the muscle layer of the esophageal blood vessels, which allows small aneurysms to form along the lower esophageal vessels.

8) Nurse Cynthia is providing a discharge teaching to a client with chronic cirrhosis. His wife asks her to explain why there is so much emphasis on bleeding precautions. Which of the following provides the most appropriate response?

1. “The low protein diet will result in reduced clotting.”
2. “The increased production of bile decreases clotting factors.”
3. “The liver affected by cirrhosis is unable to produce clotting factors.”
4. “The required medications reduce clotting factors.”

9) A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding esophageal varices in a patient with complicated liver cirrhosis. Upon insertion of the tube, the client complains of difficulty of breathing. The first action of the nurse is to:

1. Deflate the esophageal balloon
2. Monitor VS
3. Encourage him to take deep breaths
4. Notify the MD

10) A client with cirrhosis is at risk for developing complications. Which condition is the most serious and potentially life-threatening?

1. Esophageal varices
2. Ascites
3. Peripheral edema
4. Asterixis (liver flap)

11) Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:Which laboratory test indicates liver cirrhosis?

1. Decreased red blood cell count
2. Decreased serum acid phosphate level
3. Elevated white blood cell count
4. Elevated serum aminotransferase

12) Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of:

1. Impaired clotting mechanism
2. Varix formation
3. Inadequate nutrition
4. Trauma of invasive procedure

13) Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most common with this condition?

1. Increased urine output
2. Altered level of consciousness
3. Decreased tendon reflex
4. Hypotension

14) A nurse is completing an assessment to a client with cirrhosis. Which of the following nursing assessment is important to notify the physician?

1. Expanding ecchymosis
2. Ascites and serum albumin of 3.2 g/dl
3. Slurred speech
4. Hematocrit of 37% and hemoglobin of 12g/dl

15) A male client with cirrhosis is complaining of belly pain, itchiness and his breasts are getting larger and also the abdomen. The client is so upset because of the discomfort and asks the nurse why his breast and abdomen are getting larger. Which of the following is the appropriate nursing response?

1. “How much of a difference have you noticed”
2. “It’s part of the swelling your body is experiencing”
3. “It’s probably because you have been less physically active”
4. “Your liver is not destroying estrogen hormones that all men produce”

16) Which of the following findings would strongly indicate the possibility of cirrhosis?

1. dry skin
2. hepatomegaly
3. peripheral edema
4. pruritus

17) Which of the following is NOT a liver function?

1. conversion of excess glucose into glycogen for storage
2. conversion of conjugated bilirubin to unconjugated bilirubin
3. regulation blood coagulation
4. production of bile salts
5. conversion of ammonia to urea

18) What is the normal liver span?

1. 8-13cm
2. 2-3cm
3. 1 foot
4. 6-12cm

19) The left hepatic vein divides the left lobe into

1. A. medial and lateral lobes
2. anterior and posterior halves
3. superior and inferior halves
4. left and right parts of left lobe

20) The left lobe occupies

1. right and left hypochondrium
2. epigastrium and some left hypochondrium
3. right hypochondrium and epigastrium
4. epigastrium and umbilicus

21) The right lobe of the liver occupies epigastrium.

1. True
2. False

22) The fundus of the stomach in relationship to the liver

1. posterior and superior to right lobe
2. anterior and lateral to left lobe
3. posterior and lateral to left lobe
4. inferior to left lobe

23) Ultrasound is the best modality to differentiate a liver cyst from a solid mass

1. True
2. False

24) Right hepatic vein divides right lobe of the liver into anterior and posterior halves.

1. True
2. False

25) What separates the right lobe from the left lobe?

1. falciform ligament
2. right hepatic vein
3. ligament teres
4. portal vein

26) The right lobe of the liver is how many times larger than the left?

1. 2
2. 4
3. 6
4. 8

27) Where is Morison’s Pouch located?

1. between liver and right diaphragm
2. between liver and left diaphragm
3. between liver and right kidney
4. between liver and duodenum

28) The liver is suspended from the diaphragm and abdominal wall by

1. falciform ligament
2. ligament teres
3. ligament venosum
4. subphrenic ligaments

29) The pancreas is ____ to the ____ lobe of the liver.

1. inferior, left
2. inferior, right
3. superior, left
4. inferior, caudate

30) In a female, the liver weighs about

1. 1200 to 1400 g
2. 1400 to 1600 g
3. 1800 mg
4. 1000 g

31) Right Lobe length

1. 15-17 cm
2. 20-22 cm
3. 10-12.5 cm
4. <15 cm

32) Which diagnostic test is best to evaluate liver enlargement and ascites?

1. Ultrasound
2. X-Ray
3. CT scan
4. Nuclear Medicine
5. Arteriogram

33) CT scan of the liver

1. good for evaluating small masses <1cm
2. good for differentiating cysts vs. solid mass
3. evaluates function of liver

34) Which is the largest lobe of liver?

1. Right
2. Left
3. Quadrate
4. Caudate

1. C. Purpura and petechiae . A hepatic disorder, such as cirrhosis, may disrupt the liver’s normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.
2. D. Delusions of grandeur. Diaphoresis and tremors occur in the first phase of alcohol withdrawal. The blood pressure and heart rate increase in the first phase of alcohol withdrawal. Illusions are common in persons withdrawing from alcohol. Illusions occur most often in dim artificial lighting where the environment is not perceived accurately. Delusions of grandeur are symptomatic of manic clients, not clients withdrawing from alcohol. The symptoms and history of alcohol abuse suggest this client is in alcohol withdrawal.
3. A. Pork . The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid
4. A. Alcoholic cirrhosis. This type of cirrhosis is due to chronic alcoholism and is the most common type of cirrhosis.
5. A. Pressure in the portal vein . Enlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting to ascites.
6. A. lactulose (Chronulac) . The client with cirrhosis has impaired ability to metabolize protein because of liver dysfunction. Administration of lactulose aids in the clearance of ammonia via the gastrointestinal (GI) tract. Ethacrynic acid is a diuretic. Folic acid and thiamine are vitamins, which may be used in clients with liver disease as supplemental therapy.
7. C. Increased portal pressure causes some of the blood that normally circulates through the liver to be shunted to the esophageal vessels, increasing their pressure and causing varicosities. While low serum albumin is common with liver disease, it does not weaken the existing structures of the body. Weakness of the esophageal wall is not the problem. Since the esophageal vessels lie close to the surface, under the mucous membranes, the esophageal wall does not support them at the inner surface. The liver is located to the right of the esophagus. When it enlarges, it is more likely to compromise expansion of the right lung than to affect the esophagus. The fibrosed liver obstructs flow through portal vessels, which normally receive all blood circulating from the gastrointestinal tract. The increased pressure in portal vessels shunts some of the blood into the lower pressure veins around the lower esophagus. Since these veins are not designed to handle the high-pressure portal blood flow, they develop varicosities, which often rupture and bleed. Enlargement of the liver does not displace the esophagus.
8. C. “The liver affected by cirrhosis is unable to produce clotting factors.” When bile production is reduced, the body has reduced ability to absorb fat-soluble vitamins. Without adequate Vitamin K absorption, clotting factors II, VII, IX, and X are not produced in sufficient amounts.
9. A. Deflate the esophageal balloon. When a client with a Sengstaken-Blakemore tube develops difficulty of breathing, it means the tube is displaced and the inflated balloon is in the oropharynx causing airway obstruction
10. A. Esophageal varices . When a client has esophageal varices, the vessels become very fragile and massive hemorrhage can occur. The mortality rate is 30% – 50% after an episode of bleeding. Ascites and edema occur when liver production of albumin fails. Asterixis is a sign of hepatic encephalopathy. Focus:Prioritization
11. D. Elevated serum aminotransferase . Hepatic cell death causes release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by generalized inflammation and fibrosis of the liver tissues.
12. A. Impaired clotting mechanism. Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism.
13. B. Altered level of consciousness . Changes in behavior and level of consciousness are the first sins of hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure and develops when the liver is unable to convert protein metabolic product ammonia to urea. This results in accumulation of ammonia and other toxic in the blood that damages the cells.
14. A. Expanding ecchymosis. Clients with cirrhosis have already coagulation due to thrombocytopenia and vitamin K deficiency. This could be a sign of bleeding
15. A. “How much of a difference have you noticed” This allows the client to elaborate his concern and provides the nurse a baseline of assessment
16. B. hepatomegaly. Although option D is correct, it is not a strong indicator of cirrhosis. Pruritus can occur for many reasons. Options A and C are incorrect, fluid accumulations is usually in the form of ascites in the abdomen. Hepatomegaly is an enlarged liver, which is correct. The spleen may also be enlarged.
17. B. conversion of conjugated bili to unconjugated bilirubin
18. D. 6-12cm
19. A. medial and lateral lobes
20. B. epigastrium and some left hypochondrium
21. B. False . Right hypochondirum
22. C. posterior and lateral to left lobe
23. A. True
24. A. True
25. A. falciform ligament 
26. C. 6 
27. C. between liver and right kidney 
28. A. falciform ligament
29. A. inferior, left 
30. A. 1200 to 1400 g 
31. A. 15-17 cm 
32. B. X-Ray
33. A. good for evaluating small masses <1cm
34. A. Right