The nurse is assessing a patient with liver failure and jaundice. Which question should the nurse ...

The answer to question 1

Correct Answer: 1
Hemolytic jaundice develops when excess RBC destruction releases more bilirubin into circulation than the liver is able to process. Darkened urine and light or clay-colored stools are more commonly associated with hepatic or obstructive jaundice. Patients with gallbladder disorders are also at risk for jaundice; however, this patient's liver failure is a given.

The answer to question 2

Correct Answer: 1
Portal hypertension, increased pressure in the portal system, has several effects when it is prolonged, including dilation of veins in the gastrointestinal tract and the abdominal wall. This congestion tends to suppress (not increase) the appetite, and lead to formation of collateral vessels in the distal esophagus, stomach, and rectum. The dilated, congested vessels in the esophagus are known as esophageal varices; in the rectum, they lead to the development of hemorrhoids. In advanced liver failure, superficial varices may develop around the umbilicus (not on the arms), a feature known as caput medusae. Portal hypertension does not mean blood is leaking from the liver. It is not fast-spreading hypertension, and it is not defined as high blood pressure throughout the abdomen. Portal systemic encephalopathy (or hepatic encephalopathy), impaired consciousness and mental status, results from the accumulation of toxic waste products in the blood (ammonia in particular) as blood bypasses the congested liver. This is not caused by high abdominal blood pressure.

The answer to question 3

Correct Answer: 2
The icteric (jaundiced) phase usually begins 5 to 10 days after the onset of symptoms. It is heralded by jaundice of the sclera, skin, and mucous membranes. Inflammation of the liver and bile ducts prevents bilirubin from being excreted into the small intestine. As a result, the serum bilirubin levels are elevated, causing yellowing of the skin and mucous membranes. The stools are light brown or clay colored because bile pigment is not excreted through the normal fecal pathway. Instead, the pigment is excreted by the kidneys, causing the urine to turn brown. The liver continues to make bilirubin, even during hepatitis. The blood does not become darker when bilirubin levels are elevated. The cause of this phenomenon is known.

The answer to question 4

Correct Answer: 1, 2, 4, 5
Ascites occurs during liver failure due to low oncotic pressure related to a deficiency of serum albumin. The liver's ability to use glycogen is impaired by liver failure, leading to difficulty controlling hypoglycemia and/or hyperglycemia. Impaired metabolism of steroid hormones interferes with the menstrual cycle. Impaired ability to metabolize and excrete bilirubin leads to a buildup of bilirubin in skin, causing a jaundiced appearance. The patient is describing symptoms of a blood clot. This is not associated with liver failure. Excessive bleeding is associated with liver failure.

The answer to question 5

Correct Answer: 1
The nurse begins by assessing nutritional status, particularly diet history, height and weight, and skinfold measurements. Even though often obese, patients with gallbladder disease may have an imbalanced diet or specific vitamin deficiencies, particularly of the fat-soluble vitamins. Vitamin C is a water-soluble vitamin. Discussing strategies used to manage weight may be important in assessing causes of cholelithiasis pain, as fluctuating weight gains and losses can contribute to cholelithiasis, but this is the not the priority when assessing the patient's nutritional status. Asking if the patient has been skipping meals is important, but not as important as the diet history and typical food choices.

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