1. The complication that the nurse would monitor for after a liver biopsy is:
2. muscle cramps.
4. respiratory distress.
ANS: 3 Liver biopsy is a vascular process and, if liver disease is present, there may be an interference with clotting factors that were not noted on the workup.
2. The nurse explains that pruritus in the patient with hepatitis is related to:
1. decreased fat intake.
2. poor appetite and therefore poor protein intake.
3. accumulation of bile salts under the skin.
4. altered urinary output of bile.
ANS: 3 Bile salts accumulate under the skin, causing irritation.
3. The young woman with severe jaundice has a nursing diagnosis of altered body image related to jaundice. When the patient says, “Will I always be this horrible color?” the nurse replies:
1. “Yes, but your sclera will return to their previous white color.”
2. “No. The color will fade gradually as liver inflammation decreases.”
3. “Yes, but cosmetics can disguise the color.”
4. “No, the color will change to freckles.”
ANS: 2 Jaundice causes patients to be self-conscious and reclusive because of the change in physical appearance. Patients can be reassured that the color improves as liver function improves, usually in 2 to 4 weeks.
4. To prevent complications in a hepatitis patient on bed rest, the nurse would plan to:
1. raise the knee gatch to prevent the patient from sliding down in bed.
2. provide undisturbed periods of 6 hours to encourage rest.
3. restrict fluids.
4. encourage turning, coughing, and deep breathing every 2 hours.
ANS: 4 The nurse must encourage measures that will prevent pneumonia and impaired skin integrity because of the increased risk factors associated with bed rest.
5. The sign that would be a contraindication for the need of increased fluid intake for the patient with a hepatic disorder is:
1. low blood pressure.
2. increased urinary output.
3. signs of...