A client with liver cirrhosis is admitted to the hospital with hepatic encephalopathy. Which nursing intervention is essential in the care of this client?

Administering iron supplements as prescribed.

Monitoring fluid intake and output.

Implementing seizure precautions.

Encouraging high-protein diet intake.

Answer and Explanation

The Correct Answer is C

A) Iron supplements are not a priority intervention for a client with hepatic encephalopathy. In fact, administering iron supplements without proper indication can be harmful, as excessive iron can worsen liver damage in cirrhosis.

B) While monitoring fluid intake and output is important in managing various aspects of liver cirrhosis, it is not the essential intervention for hepatic encephalopathy. The priority in hepatic encephalopathy is to ensure seizure precautions and address the client's altered mental status.

C) Hepatic encephalopathy is a neuropsychiatric complication of liver cirrhosis that can lead to altered mental status, confusion, and potential seizures. Implementing seizure precautions is essential in the care of this client to ensure their safety and prevent injury during any potential seizure activity. Seizure precautions may include padding the side rails of the bed, ensuring a clear and clutter-free environment, and providing close supervision to the client. In severe cases, the healthcare provider may prescribe antiepileptic medications to manage and prevent seizures.

D) Encouraging a high-protein diet is not appropriate for a client with hepatic encephalopathy. High-protein diets can exacerbate hepatic encephalopathy by increasing ammonia production in the intestines. Instead, the client should be prescribed a controlled-protein diet and, in some cases, given lactulose to help reduce ammonia levels.

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Correct Answer is A

Explanation

A. Encouraging the client to lie on the right side after a liver biopsy is essential because this position helps to apply pressure to the biopsy site, reducing the risk of bleeding.
B. While administering pain medication may be necessary, it is not the primary nursing action following a liver biopsy compared to ensuring hemostasis and preventing complications.
C. Monitoring vital signs is important, but in this case, vital signs should be checked more frequently than every 4 hours to assess for complications like bleeding. Initial monitoring is typically every 15 minutes for the first hour and then every 30 minutes to hourly based on facility protocols.
D. Although maintaining a supine position is typically advised, the focus should be on the right side position to ensure proper hemostasis following the biopsy procedure.

A. Hematemesis B. Ascites C. Splenomegaly D. Varices

Correct Answer is D

Explanation

A) Hematemesis refers to vomiting of blood and is a symptom that can occur as a result of bleeding from esophageal varices or other gastrointestinal sources.

B) Ascites is the accumulation of fluid in the abdominal cavity, leading to abdominal distension. It is not related to the presence of visible distended veins on the abdomen and chest.

C) Splenomegaly is the enlargement of the spleen and is not related to the finding of visible distended veins.

D) Varices are dilated and tortuous veins that can develop in various locations, including the esophagus (esophageal varices) and the abdomen and chest wall (caput medusae). In liver cirrhosis, portal hypertension causes increased pressure in the portal vein, leading to the development of these enlarged veins. Esophageal varices can be life-threatening if they rupture and cause severe bleeding.

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A client with liver cirrhosis is admitted to the hospital with hepatic encephalopathy. Which nursing intervention is essential in the care of this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with suspected liver cirrhosis undergoes a liver biopsy. Which nursing action is essential following the procedure?

Correct Answer is A

Explanation

A client with liver cirrhosis is found to have visible distended veins on the abdomen and chest. Which term should the nurse use to document this finding?

Correct Answer is D

Explanation

A nurse is providing community education on the risk factors for liver cirrhosis. Which risk factor should the nurse emphasize as the leading cause of liver cirrhosis?

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A nurse is assessing a client with suspected liver cirrhosis. Which clinical manifestation should the nurse expect to find as an early sign of the condition?

A client with liver cirrhosis presents with severe ascites. Which procedure should the nurse anticipate being performed to drain the accumulated fluid from the peritoneal cavity?

A client with liver cirrhosis is prescribed lactulose to manage hepatic encephalopathy. What should the nurse instruct the client about taking this medication?

A client with liver cirrhosis is prescribed spironolactone to manage fluid retention. Which laboratory test should the nurse monitor closely while the client is on this medication?

A client with liver cirrhosis complains of difficulty sleeping at night due to frequent awakenings caused by shortness of breath. Which complication should the nurse suspect as the most likely cause of the client's symptom?