Cirrhosis case study – Flashcards
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Which information about cirrhosis should the nurse remember when responding to Frank's wife?
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There are several types of cirrhosis with differing causes.
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Which question is most important for the nurse to include when assessing the client for etiologic factors related to cirrhosis?
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Have you been exposed to toxic substances where you work?
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When nursing intervention is important prior to a paracentesis?
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Instruct the client to empty his bladder.
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Maintaining bedrest for 24 to 48 hours is an important nursing intervention following which procedure?
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Angiography with portal pressure measurements.
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In the client with cirrhosis, which lab value will be decreased from the normal value?
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Serum albumin.
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Which clinical manifestation is likely to occur as the result of the prolonged APTT and PT/INR?
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Epistaxis.
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Which other clinical manifestation(s) may occur with cirrhosis? (Select all that apply)
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-Fruity breath. -Clay colored stools.
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Which medication places Frank at risk for hyperkalemia?
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Spironolactone (Aldactone)
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Which action should the nurse perform?
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Continue the albumin infusion.
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What is the best approach for the nurse to use when responding to Frank?
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Query Frank in a nonjudgmental manner about his use of rationalization.
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What is the best response by the nurse?
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The type of liver damage that you have occurs after years of drinking, and that is what makes me think you are an alcoholic.
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Who should the nurse notify of Frank's action?
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Frank's HCP.
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In which situations is the use of physical restraints appropriate? (Select all that apply)
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-A client who is at high risk for injury to self for whom no other safety measures have been successful.
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What if Frank's Glasgow Coma Scale rating obtained in this assessment?
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6
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What is the primary underlying cause of hepatic encephalopathy?
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Increased serum ammonia.
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Which outcome indicates to the nurse that the lactulose and neomycin are having the desired effect?
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Increased mental alertness.
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Which activity level should be initiated during the acute phase of cirrhosis?
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Bedrest.
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Which intervention should be implemented related to the diagnosis of fluid volume excess?
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Measure abdominal girth daily.
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What intervention should the nurse implement first?
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Position Frank in the bed in a side lying position.
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In what order should the nurse perform the following actions? (Place in numerical order from first action through last action.)
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1- Apply oxygen 2- Ensure patency of the IV 3- Notify the HCP 4- Transfer to critical care
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Which lunch menu is the best choice for Frank?
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Turkey sandwich and a fruit smoothie.
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Which instruction has the highest priority?
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Stop all alcohol consumption.
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Which member of the interprofessional team is the best choice for the nurse to contact to help Frank meet this goal/
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Social worker.
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What is the best response by the nurse?
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I really need you to find a way to help this client.
