1.
The nurse is caring for a male client with cirrhosis. Which of the following assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?
Correct Answer
C. Purpura and petechiae
Explanation
Purpura and petechiae are both indicative of bleeding disorders, which can occur due to deficient vitamin K absorption caused by hepatic disease. Vitamin K is necessary for the synthesis of clotting factors in the liver, and when there is a deficiency, it can lead to easy bruising, purpura (purple discoloration of the skin), and petechiae (small red or purple spots on the skin). Dyspnea and fatigue, ascites and orthopnea, and gynecomastia and testicular atrophy are not directly related to vitamin K deficiency in cirrhosis.
2.
A man is admitted to the nursing care unit with a diagnosis of cirrhosis. He has a history of alcohol dependence. In the late evening following his admission, the patient became increasingly disoriented and agitated. What would the patient be least likely to experience?
Correct Answer
D. Delusions of grandeur.
Explanation
Delusions of grandeur are not typically associated with cirrhosis or alcohol dependence. They are more commonly seen in conditions such as schizophrenia or bipolar disorder. The patient is more likely to experience symptoms such as diaphoresis and tremors, increased blood pressure and heart rate, and illusions due to the effects of alcohol withdrawal.
3.
Nurse Juvy is taking care of a patient with cirrhosis of the liver. To lessen the effects of the disorder, the nurse teaches the patient about foods high in thiamine. The nurse determines that the patient has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of:
Correct Answer
A. Pork
Explanation
Thiamine, also known as vitamin B1, is an essential nutrient that plays a crucial role in the metabolism of carbohydrates. It is commonly found in pork, which is why increasing the intake of pork would be the best choice for a patient with cirrhosis of the liver. Milk, chicken, and broccoli are not particularly high in thiamine compared to pork, so they would not be as effective in lessening the effects of the disorder.
4.
Which term is used to describe a chronic liver disease in which scar tissue surrounds the portal areas?
Correct Answer
A. Alcoholic cirrhosis
Explanation
Alcoholic cirrhosis is the correct answer because it refers to a chronic liver disease that is caused by excessive and prolonged alcohol consumption. This disease occurs when scar tissue forms in the liver, specifically around the portal areas. The scarring disrupts the normal functioning of the liver and can lead to complications such as liver failure.
5.
A male client with a history of cirrhosis and alcoholism is admitted to the hospital with severe dyspnea resulting in ascites. The nurse must be aware that the ascites are most likely the result of increased.
Correct Answer
A. Pressure in the portal vein
Explanation
Ascites is the accumulation of fluid in the abdominal cavity and is a common complication of cirrhosis. In cirrhosis, there is increased resistance to blood flow in the liver, leading to increased pressure in the portal vein. This increased pressure causes fluid to leak out of the blood vessels and into the abdominal cavity, resulting in ascites. Therefore, the correct answer is "Pressure in the portal vein."
6.
A client with advanced cirrhosis of the liver is not tolerating protein well, as tested by abnormal laboratory values. Does the nurse anticipate what medications will be prescribed for the client?
Correct Answer
A. lactulose (Chronulac)
7.
The nurse is caring for a client with cirrhosis of the liver, which has developed esophageal varices. Does the nurse understand that the best explanation for the development of esophageal varices is which of the following?
Correct Answer
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.
Explanation
The development of esophageal varices in a client with cirrhosis of the liver is best explained by increased portal pressure causing blood to be shunted to the esophageal vessels. This increased pressure leads to the formation of varicosities in the esophagus. Chronic low serum protein levels, liver enlargement pressing on the diaphragm, and displacement of the esophagus by the enlarged liver are not the primary factors contributing to the development of esophageal varices in this case.
8.
Nurse Cynthia is providing 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?
Correct Answer
C. “The liver affected by cirrhosis is unable to produce clotting factors.”
Explanation
The liver affected by cirrhosis is unable to produce clotting factors. In chronic cirrhosis, the liver becomes scarred and loses its ability to function properly. One of the functions of the liver is to produce clotting factors that are necessary for blood to clot and prevent excessive bleeding. When the liver is damaged, it cannot produce these clotting factors, leading to a higher risk of bleeding. Therefore, emphasizing bleeding precautions is important to prevent complications and ensure the client's safety.
9.
A Sengstaken-Blakemore tube is inserted in an effort to stop the bleeding of 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:
Correct Answer
A. Deflate the esopHageal balloon.
Explanation
The correct answer is to deflate the esophageal balloon. When a Sengstaken-Blakemore tube is inserted, it has two balloons - one in the esophagus and one in the stomach. The purpose of the esophageal balloon is to apply pressure to the bleeding varices and stop the bleeding. However, if the client complains of difficulty breathing, it indicates that the esophageal balloon may be obstructing the airway. Deflating the esophageal balloon will relieve the obstruction and improve the client's breathing. Monitoring vital signs and notifying the MD are important actions, but the immediate priority is to address the client's breathing difficulty.
10.
A client with cirrhosis is at risk for developing complications. Which condition is the most serious and potentially life-threatening?
Correct Answer
A. EsopHageal varices
Explanation
Esophageal varices are the most serious and potentially life-threatening condition for a client with cirrhosis. Esophageal varices are enlarged, swollen veins in the lower part of the esophagus, and they can rupture and cause severe bleeding. This can lead to life-threatening hemorrhage and requires immediate medical intervention. Ascites, peripheral edema, and asterixis are also common complications of cirrhosis, but they are not as immediately life-threatening as esophageal varices.
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?
Correct Answer
D. Elevated serum aminotransferase levels
Explanation
Elevated serum aminotransferase levels indicate liver cirrhosis. Aminotransferases are enzymes present in liver cells, and their levels increase when there is liver damage or inflammation. In cirrhosis, the liver cells are damaged and replaced by scar tissue, leading to elevated levels of aminotransferases in the blood. This test is commonly used to assess liver function and diagnose liver diseases such as cirrhosis.
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 the following:
Correct Answer
A. Impaired clotting mechanism
Explanation
Cirrhosis of the liver can lead to impaired clotting mechanism due to decreased production of clotting factors by the damaged liver cells. This can result in a decreased ability of the blood to clot properly, leading to an increased risk of bleeding.
13.
Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most common with this condition?
Correct Answer
B. Altered level of consciousness
Explanation
Hepatic encephalopathy is a condition that occurs when the liver is unable to remove toxins from the blood, leading to a buildup of ammonia and other harmful substances. The most common clinical manifestation of hepatic encephalopathy is an altered level of consciousness. This can range from mild confusion and disorientation to severe confusion, coma, and even death. Other symptoms may include changes in behavior, personality, motor function, and sleep patterns. Increased urine output, decreased tendon reflex, and hypotension are not typically associated with hepatic encephalopathy.
14.
A nurse is completing an assessment of a client with cirrhosis. Which of the following nursing assessments is important to notify the physician?
Correct Answer
A. Expanding ecchymosis
Explanation
Expanding ecchymosis refers to the development of new or worsening bruises on the skin. This can be indicative of impaired clotting mechanisms and may suggest that the client's liver function is deteriorating further. It is important to notify the physician about this finding as it may require immediate medical intervention to prevent further complications.
15.
Which of the following findings would strongly indicate the possibility of cirrhosis?
Correct Answer
B. Hepatomegaly
Explanation
Hepatomegaly, which refers to an enlarged liver, would strongly indicate the possibility of cirrhosis. Cirrhosis is a condition characterized by the progressive scarring and damage of the liver, leading to its dysfunction. Hepatomegaly is a common symptom of cirrhosis and occurs due to the accumulation of scar tissue and fat in the liver, causing it to enlarge. Other symptoms of cirrhosis may include dry skin, peripheral edema (swelling in the legs and ankles), and pruritus (itching). However, hepatomegaly is a more specific and direct indicator of cirrhosis.
16.
Which of the following is NOT a liver function?
Correct Answer
B. Conversion of conjugated bile to unconjugated bile
Explanation
The liver performs various functions, including the conversion of excess glucose into glycogen for storage, regulation of blood coagulation, production of bile salts, and conversion of ammonia to urea. However, the liver does not convert conjugated bile to unconjugated bile. Bile is produced by the liver and stored in the gallbladder, and it plays a role in the digestion and absorption of fats. Conjugated bile refers to bile that has been modified by the liver to make it water-soluble, while unconjugated bile refers to bile that has not undergone this modification.
17.
What is the normal liver span?
Correct Answer
D. 6-12cm
Explanation
The normal liver span is typically between 6-12cm. This range represents the average size of a healthy liver in adults. The liver span can vary slightly depending on factors such as age, sex, and body size. It is important to note that liver span can be influenced by certain medical conditions or abnormalities, so individual variations may occur.
18.
The left hepatic vein divides the left lobe into
Correct Answer
A. Medial and lateral lobes
Explanation
The left hepatic vein divides the left lobe into medial and lateral lobes. This means that the left lobe of the liver is divided into two distinct sections - one closer to the middle of the body (medial lobe) and one towards the side (lateral lobe). This division allows for better anatomical understanding and surgical interventions if needed.
19.
What does the left lobe occupy?
Correct Answer
B. Epigastrium and some left hypochondrium
Explanation
The left lobe occupies the epigastrium and some left hypochondrium.
20.
The right lobe of the liver occupies the epigastrium.
Correct Answer
B. False
Explanation
The right lobe of the liver does not occupy the epigastrium. The epigastrium is the upper central region of the abdomen, while the right lobe of the liver is located on the right side of the abdomen, beneath the diaphragm. Therefore, the statement is false.
21.
The fundus of the stomach in relation to the liver
Correct Answer
C. Posterior and lateral to the left lobe
Explanation
The fundus of the stomach is located at the upper part of the stomach. It is positioned behind and to the side of the left lobe of the liver. This means that it is posterior (behind) and lateral (to the side) to the left lobe of the liver.
22.
Ultrasound is the best modality to differentiate a liver cyst from a solid mass.
Correct Answer
A. True
Explanation
Ultrasound is the best modality to differentiate a liver cyst from a solid mass because it is a non-invasive imaging technique that uses sound waves to create real-time images of the liver. It can accurately distinguish between fluid-filled cysts and solid masses based on their characteristic appearance on the ultrasound images. Cysts typically appear as well-defined, anechoic (black) lesions, while solid masses may have irregular borders and show different echogenicity (brightness) patterns. Other imaging modalities like CT or MRI may also be used, but ultrasound is often preferred as the initial imaging modality due to its high sensitivity and specificity in differentiating liver cysts from solid masses.
23.
What separates the right lobe from the left lobe?
Correct Answer
A. Falciform ligament
Explanation
The falciform ligament is a thin, crescent-shaped structure that attaches the liver to the anterior abdominal wall and separates the right and left lobes of the liver. It is located in the middle of the liver and serves as a landmark for dividing the liver into its two main lobes. The right hepatic vein, ligament teres, and portal vein are not involved in separating the right lobe from the left lobe.
24.
How many times larger is the right lobe of the liver than the left?
Correct Answer
C. 6
Explanation
The right lobe of the liver is six times larger than the left lobe. This means that the right lobe is significantly bigger in size compared to the left lobe.
25.
The liver is suspended from the diaphragm and abdominal wall by
Correct Answer
A. Falciform ligament
Explanation
The falciform ligament is a structure that attaches the liver to the diaphragm and abdominal wall. It is a thin, flat ligament that runs from the anterior surface of the liver to the anterior abdominal wall. This ligament helps to stabilize the liver and maintain its position within the abdominal cavity. The other options listed, such as the ligament teres, ligament venosum, and subphrenic ligaments, do not play a role in suspending the liver.
26.
The pancreas is ____ to the ____ lobe of the liver.
Correct Answer
A. Inferior, left
Explanation
The pancreas is located below or inferior to the left lobe of the liver.
27.
In a female, the liver weighs about
Correct Answer
A. 1200 to 1400 g
Explanation
The correct answer is 1200 to 1400 g. This is because the average weight of the liver in a female is approximately 1200 to 1400 grams.
28.
Right Lobe length
Correct Answer
A. 15-17 cm
Explanation
The right lobe length of an organ is typically measured in centimeters. In this case, the correct answer is 15-17 cm, which means that the length of the right lobe falls within this range.
29.
Which diagnostic test is best to evaluate liver enlargement and ascites?
Correct Answer
A. Ultrasound
Explanation
The best diagnostic test to evaluate liver enlargement and ascites is Ultrasound.
Ultrasound is a non-invasive imaging technique that uses sound waves to create real-time images of the liver and abdominal cavity. It is particularly effective in detecting liver enlargement, identifying the presence and extent of ascites (fluid accumulation in the abdomen), and evaluating the overall condition of the liver and surrounding structures. Ultrasound is widely used in clinical practice for this purpose due to its safety, affordability, and effectiveness in providing valuable diagnostic information.
30.
Which is the largest lobe of the liver?
Correct Answer
A. Right
Explanation
The right lobe of the liver is the largest lobe. It is located on the right side of the body and is responsible for performing many vital functions such as detoxification, metabolism, and production of bile. The right lobe is larger than the left lobe and is divided into two further lobes, the anterior and posterior lobes. This division allows for efficient functioning and distribution of blood flow within the liver. The right lobe also has a larger surface area compared to the other lobes, enabling it to carry out its functions effectively.