Cirrhosis case study

Which information about cirrhosis should the nurse remember when responding to Frank’s wife?
There are several types of cirrhosis with differing causes.
Which question is most important for the nurse to include when assessing the client for etiologic factors related to cirrhosis?
Have you been exposed to toxic substances where you work?
When nursing intervention is important prior to a paracentesis?
Instruct the client to empty his bladder.
Maintaining bedrest for 24 to 48 hours is an important nursing intervention following which procedure?
Angiography with portal pressure measurements.
In the client with cirrhosis, which lab value will be decreased from the normal value?
Serum albumin.
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Which clinical manifestation is likely to occur as the result of the prolonged APTT and PT/INR?
Which other clinical manifestation(s) may occur with cirrhosis? (Select all that apply)
-Fruity breath.
-Clay colored stools.
Which medication places Frank at risk for hyperkalemia?
Spironolactone (Aldactone)
Which action should the nurse perform?
Continue the albumin infusion.
What is the best approach for the nurse to use when responding to Frank?
Query Frank in a nonjudgmental manner about his use of rationalization.
What is the best response by the nurse?
The type of liver damage that you have occurs after years of drinking, and that is what makes me think you are an alcoholic.
Who should the nurse notify of Frank’s action?
Frank’s HCP.
In which situations is the use of physical restraints appropriate? (Select all that apply)
-A client who is at high risk for injury to self for whom no other safety measures have been successful.
What if Frank’s Glasgow Coma Scale rating obtained in this assessment?
What is the primary underlying cause of hepatic encephalopathy?
Increased serum ammonia.
Which outcome indicates to the nurse that the lactulose and neomycin are having the desired effect?
Increased mental alertness.
Which activity level should be initiated during the acute phase of cirrhosis?
Which intervention should be implemented related to the diagnosis of fluid volume excess?
Measure abdominal girth daily.
What intervention should the nurse implement first?
Position Frank in the bed in a side lying position.
In what order should the nurse perform the following actions? (Place in numerical order from first action through last action.)
1- Apply oxygen
2- Ensure patency of the IV
3- Notify the HCP
4- Transfer to critical care
Which lunch menu is the best choice for Frank?
Turkey sandwich and a fruit smoothie.
Which instruction has the highest priority?
Stop all alcohol consumption.
Which member of the interprofessional team is the best choice for the nurse to contact to help Frank meet this goal/
Social worker.
What is the best response by the nurse?
I really need you to find a way to help this client.
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