Evolve Case Study: Cirrhosis

Etiologic Factors During the nursing assessment, Frank's wife says to the nurse, "I guess it's true that cirrhosis is a disease of alcoholics." 1. Which information about cirrhosis should the nurse remember when responding to Frank's wife? A) Only alcoholics get cirrhosis. Feedback: INCORRECT The most common type of cirrhosis worldwide is actually the result of hepatotoxins, such as viral hepatitis, which cause massive liver necrosis. B) There are several types of cirrhosis with differing causes. Feedback: CORRECT There are several types of cirrhosis with differing etiologies. The most common type of cirrhosis worldwide is postnecrotic cirrhosis which is the result of massive necrosis caused by hepatotoxins such as viral hepatitis. Biliary cirrhosis is caused by inflammation resulting in biliary obstruction in the liver and common bile ducts. Laennec's cirrhosis is primarily the result of changes in the liver due to alcoholism and malnutrition. C) All alcoholics will develop cirrhosis. Feedback: INCORRECT No more than half of all alcoholics will develop Laennec's cirrhosis, which is the type of cirrhosis related to alcohol consumption. Laennec's cirrhosis is the most common form of cirrhosis in North America. D) Spouses of alcoholics are at risk for cirrhosis. Feedback: INCORRECT There is no risk for cirrhosis by association with an alcoholic. Points Earned: 1.0/1.0 Correct Answer(s): B 2. Which question is most important for the nurse to include when assessing the client for etiologic factors related to cirrhosis? A) "Have you ever been told that you have high blood pressure?" Feedback: INCORRECT Hypertension is not a risk factor for cirrhosis. B) "Do you eat a lot of high protein foods on a regular basis?" Feedback: INCORRECT Protein intake is not associated with the development of cirrhosis. Once cirrhosis develops, protein intake may need to be modified. C) "Have you been exposed to toxic substances where you work?" Feedback: CORRECT Exposure to toxic chemicals, such as pesticides, can cause cirrhosis. The long-term use of hepatotoxic medications can also cause cirrhosis.  D) "Do you smoke cigarettes or use nicotine-containing products?" Feedback: INCORRECT Nicotine use is not associated with the development of cirrhosis. Points Earned: 1.0/1.0 Correct Answer(s): C Diagnostic Tests Several tests are ordered for Frank to confirm the diagnosis of cirrhosis, and to assess the degree of liver damage and related complications. Frank is scheduled for a liver biopsy, paracentesis, and hepatic angiography. 3. Which nursing intervention is important prior to a paracentesis? A) Advise the client the dye that is injected may cause a flushing sensation. Feedback: INCORRECT There is no dye injected during a paracentesis. B) Instruct the client to empty his bladder. Feedback: CORRECT Paracentesis involves the removal of peritoneal fluid for evaluation, and it is also performed to drain excess peritoneal fluid. Prior to the procedure, the client should be instructed to void to reduce the risk for accidental rupture of the bladder during the procedure. After the procedure, the client should be assessed for signs of peritonitis or peritoneal bleeding.  C) Position the client in a fetal position. Feedback: INCORRECT This positioning is often used for a lumbar puncture, but not for a paracentesis. D) Numb the client's throat with an anesthetic spray. Feedback: INCORRECT Anesthetic spray to the throat may be used prior to an endoscopic procedure. Paracentesis does not involve the throat. Points Earned: 1.0/1.0 Correct Answer(s): B 4. Maintaining bedrest for 24 to 48 hours is an important nursing intervention following which procedure? A) Paracentesis. Feedback: INCORRECT Paracentesis involves the removal of peritoneal fluid for evaluation, and it is also performed to drain excess peritoneal fluid. Following the procedure, assessment for signs of peritoneal bleeding or infection are important nursing measures. B) Endoscopy of esophagus and stomach. Feedback: INCORRECT These endoscopic procedures are performed to visualize the esophagus and stomach to assess for varices. After the procedure, the client's gag reflex must be assessed prior to providing oral fluids to prevent aspiration. C) Percutaneous liver biopsy. Feedback: INCORRECT Percutaneous liver biopsy is performed by inserting a needle through the abdominal wall into the liver to obtain a tissue sample. Positioning the client on the right side post-procedure compresses the liver against the chest wall, decreasing the risk of bleeding or bile leakage. D) Angiography with portal pressure measurements. Feedback: CORRECT Catheterization of the hepatic vasculature allows injection of a contrast medium and visualization of the vascular supply to the liver. Vessel pressures can also be measured to assess the degree of portal hypertension. After the procedure, the client's vital signs and insertion site should be assessed frequently, and the client should be instructed to remain on bedrest for 24-48 hours. Points Earned: 0.0/1.0 Correct Answer(s): D Frank also had a number of lab tests performed. 5. In the client with cirrhosis, which lab test will reflect a decrease from the normal value? A) Total serum bilirubin. Feedback: INCORRECT The diseased liver is not able to metabolize bilirubin efficiently, resulting in an increase in total serum bilirubin. B) Serum ammonia. Feedback: INCORRECT Serum ammonia will be increased, reflecting the diseased liver's inability to metabolize and detoxify proteins. C) Serum albumin. Feedback: CORRECT Serum albumin will be decreased since the diseased liver is not able to produce albumin efficiently. D) APTT, PT/INR. Feedback: INCORRECT Tests that reflect clotting time will be prolonged, or increased, because the diseased liver produces less clotting factors. Also, the intestine absorbs less vitamin K because the liver is producing less of the bile that is necessary for vitamin K absorption. Points Earned: 0.0/1.0 Correct Answer(s): C Clinical Manifestations In addition to an increase in his total serum bilirubin and serum ammonia and his prolonged APTT, Frank also has elevated liver enzymes, which reflect his liver disease, diagnosed as Laennec's cirrhosis. Frank states to the nurse, "I have become increasingly fatigued and even though I have little appetite, my belly sure is getting big." He reports that he bruises easily and gets nosebleeds frequently. 6. Which clinical manifestation is likely to occur as the result of the prolonged APTT and PT/INR? A) Cachexia. Feedback: INCORRECT The client with cirrhosis may develop cachexia, but not as a result of altered clotting mechanisms. Cachexia, a general physical wasting of the body and malnutrition, is often associated with chronic illness. B) Ascites. Feedback: INCORRECT The client with cirrhosis will develop ascites, as well as peripheral edema, but this is not the result of altered clotting mechanisms. As the ascites increases, the client is likely to experience dyspnea because the fluid build-up puts pressure on the diaphragm. C) Jaundice. Feedback: INCORRECT The client with cirrhosis may have jaundice of the skin and sclerae. However, it occurs as the result of increased bilirubin, not prolonged APTT and PT/INR. D) Epistaxis. Feedback: CORRECT The client with cirrhosis has impaired coagulation related to a decrease in the production of clotting factors by the liver, decreased absorption of vitamin K in the intestines, and thrombocytopenia. Manifestations may include epistaxis, purpura, and petechiae. Points Earned: 1.0/1.0 Correct Answer(s): D 7. Which other clinical manifestation may occur in cirrhosis? A) Fruity breath. Feedback: CORRECT Persons with cirrhosis may experience a distinctive, sweet, musty breath odor called fetor hepaticus caused by the liver's inability to metabolize an amino acid called methionine. Another manifestation of cirrhosis is asterixis, a hand-flapping tremor caused by altered neurologic function.  B) Greenish-black stools. Feedback: INCORRECT Stools will appear clay-colored, rather than greenish-black. This is caused by a decrease in the amount of bile in the stool. In addition, the urine will appear dark in color as more bilirubin is excreted in the urine. C) Increased appetite. Feedback: INCORRECT The client with cirrhosis is more likely to experience anorexia, nausea, and vomiting, resulting in weight loss. D) Dysphagia. Feedback: INCORRECT Difficulty swallowing is not a typical manifestation of a client with cirrhosis. Points Earned: 0.0/1.0 Correct Answer(s): A Medical Management The healthcare provider prescribes the following: Spironolactone (Aldactone) 50 mg PO daily. 25% albumin 50 g IV daily via saline lock. Vitamin K (AquaMEPHYTON) 10 mg IM now. Folic acid (Folvite) 1 mg PO daily. Thiamine (Vitamin B1) 100 mg IM now. Thiamine 50 mg PO daily × 5 days.   8. Which medication places Frank at risk for hyperkalemia? A) Spironolactone (Aldactone). Feedback: CORRECT This potassium-sparing diuretic prevents potassium from being excreted, so the client should be monitored for signs of hyperkalemia.  B) Vitamin K (AquaMEPHYTON). Feedback: INCORRECT Vitamin K is used to reduce the bleeding tendencies of the client with cirrhosis. The nurse should monitor coagulation tests, such as APTT and PT/INR for improvement. C) Folic acid (Folvite). Feedback: INCORRECT The client with cirrhosis is likely to be malnourished, and will benefit from vitamin supplementation to reduce symptoms of deficiencies. The nurse should instruct the client that folic acid can cause the urine to be brighter yellow than normal. D) Thiamine (Vitamin B1). Feedback: INCORRECT The client with cirrhosis is likely to be malnourished, and will benefit from vitamin supplementation to reduce symptoms of deficiencies. The nurse should instruct the client to also eat foods high in thiamine, such as cereal products. Points Earned: 1.0/1.0 Correct Answer(s): A While administering the Albumin infusion via a vein in the right hand, the nurse notes that the peripheral edema in Frank's arms and hands has changed from 3+ to 2+. 9. Which action should the nurse perform? A) Stop the albumin infusion. Feedback: INCORRECT This finding does not necessitate stopping the albumin. B) Change the IV site. Feedback: INCORRECT There is no need to change the IV site based on this finding. C) Notify the healthcare provider that the edema is worsening. Feedback: INCORRECT The edema is improving, not worsening. The nurse does not need to notify the provider of this finding. D) Continue the albumin infusion. Feedback: CORRECT This finding reflects a decrease in edema. Since this indicates the albumin is having the desired effect, it should be continued. Albumin is administered to pull fluid from the peritoneal cavity and peripheral tissues. Excessive use of albumin without adequate diuresis may result in pulmonary edema, which is manifested by symptoms such as abnormal breath sounds and jugular vein distention.  Points Earned: 1.0/1.0 Correct Answer(s): D Therapeutic Communication: Denial When the nurse enters Frank's room, he says, "I've had about enough of this. Everybody is calling me an alcoholic. I'm not an alcoholic. Sure, I like to drink as much as the next guy, but so what? My liver will be fine if I just cut back a little on the drinking for a few weeks." 10. What is the best approach for the nurse to use when responding to Frank? A) Sympathize with Frank's feelings of frustration. Feedback: INCORRECT Expressing sympathy will not encourage further positive communication, but will instead support Frank's denial of his problem. B) Challenge Frank about his use of rationalization in a nonjudgmental manner. Feedback: CORRECT Two primary characteristics of the alcoholic are denial and rationalization. The client using denial as a defense mechanism should not be forced to face an issue with which he is not able to cope. However, the treatment of the alcoholic requires a style of more direct communication than that of a client with ineffective denial related to a grief process. C) Change the subject to provide a distraction. Feedback: INCORRECT Changing the subject is a block to further therapeutic communication. The role of the nurse is to help Frank learn effective coping strategies. D) Agree with Frank until he is ready to accept his problem. Feedback: INCORRECT Agreeing with a client in denial is not effective, because it supports the denial. Points Earned: 1.0/1.0 Correct Answer(s): B Frank asks the nurse, "What makes you think that I am an alcoholic? I just like to drink to make all my problems go away. Everyone does it." 11. What is the best response by the nurse? A) "The type of liver damage that you have occurs after years of drinking, and that is what makes me think you are an alcoholic." Feedback: CORRECT Liver enzymes are not elevated until serious damage has occurred after years (10+) of drinking alcohol. Additionally alcoholism includes at least two social complications due to excessive use of alcohol. Frank had one the nurse is aware of because of the accident and blood alcohol level that precipitated his hospitalization. B) "It sounds to me as if you are worried about being an alcoholic. Would you like to talk about what an alcoholic is?" Feedback: INCORRECT The nurse should answer Frank's question and provide factual information. C) "Everyone does not drink alcohol to make all their problems go away. What makes you think everyone deals with problems that way?" Feedback: INCORRECT This is a confrontational response and does not answer Frank's question. D) "An alcoholic is someone who has a blood alcohol level greater than 0.1, and yours was 0.12 when you were admitted." Feedback: INCORRECT A one-time incident of an elevated blood alcohol level does not make a person an alcoholic. Points Earned: 1.0/1.0 Correct Answer(s): A Ethical-Legal Considerations: Discharge Against Medical Advice (AMA) Frank becomes increasingly angry and leaves the hospital without discharge orders from the healthcare provider. 12. Who should the nurse notify of Frank's action? A) The local police department. Feedback: INCORRECT Leaving the hospital against medical advice is not illegal. Contacting the police is a breach of client confidentiality when no threat of harm or illegal action has occurred. B) A local drug abuse center. Feedback: INCORRECT This is a breach of client confidentiality. C) Frank's healthcare provider. Feedback: CORRECT The client's healthcare provider should be notified that the client has left, the relevant circumstances, and the client's condition at the time of departure. D) Frank's employer. Feedback: INCORRECT Contacting Frank's employer is a breach of client confidentiality. Points Earned: 1.0/1.0 Correct Answer(s): C The nurse discusses the situation with another nurse who states, "You should have used restraints to keep him here until we could give him a sedative to calm him down." 13. In which situation is the use of physical restraints appropriate? A) A client who has several indwelling catheters, tubes, and IV lines. Feedback: INCORRECT This information alone does not indicate the need for restraints. B) A client who verbally abuses the staff and threatens to leave the hospital Against Medical Advice (AMA). Feedback: INCORRECT These are not indicators for the use of restraints. C) A client who is at high risk for injury for whom no other safety measures have been successful. Feedback: CORRECT The nurse must be able to document not only the clear need for the use of restraints, but also the other avenues of protection that have been attempted prior to the use of restraints. D) A client who is at high risk for injury because of insufficient nursing personnel. Feedback: INCORRECT The nurse must be able to document that the use of restraints is for the client's safety, rather than for the convenience of the staff. Points Earned: 1.0/1.0 Correct Answer(s): C Hepatic Encephalopathy Two days later, Frank is transported back to the emergency department by ambulance. He is unresponsive, with a Glascow Coma Scale rating of 9. He is admitted with a diagnosis of hepatic encephalopathy. 14. What is the primary underlying cause of hepatic encephalopathy? A) Increased serum ammonia. Feedback: CORRECT Increased ammonia levels are toxic to CNS tissue, resulting in encephalopathy. Serum ammonia levels increase in cirrhosis as the liver becomes less efficient in converting ammonia to urea.  B) Increased serum pH. Feedback: INCORRECT Although alkalosis may be a contributing factor, it is not the primary cause of hepatic encephalopathy. C) Increased serum CO2. Feedback: INCORRECT This is not a causative factor in the onset of hepatic encephalopathy. D) Increased serum albumin. Feedback: INCORRECT The client with cirrhosis usually has a low serum albumin level, but it is not a causative factor in the onset of hepatic encephalopathy. Points Earned: 1.0/1.0 Correct Answer(s): A Frank's healthcare provider prescribes the following: Lactulose (Cephulac) 300 ml retention enema q6 hours. Neomycin (Mycifradin) 1 g q6 hours via nasogastric tube.   15. Which outcome indicates to the nurse that the lactulose and neomycin are having the desired effect? A) Increased mental alertness. Feedback: CORRECT One of the primary goals of treatment is to improve the client's neurologic status. Lactulose and neomycin are administered to increase the frequency of bowel movements, which increases the excretion of ammonia in the bowel, thereby reducing the elevated serum ammonia level causing the toxic effects on the CNS. B) Decreased intake of alcohol. Feedback: INCORRECT This is certainly a goal in the overall treatment of the client with cirrhosis caused by alcoholism. However, this is not a goal of treatment during the management of encephalopathy. C) Increased serum ammonia level. Feedback: INCORRECT This is the cause of hepatic encephalopathy, so increased levels indicate that the medications are not having the intended effect. D) Clay-colored bowel movements. Feedback: INCORRECT Clay-colored bowel movements are an expected manifestation of cirrhosis that is caused by the lack of bilirubin in the stool. This is not related to the medications used to treat encephalopathy. Points Earned: 1.0/1.0 Correct Answer(s): A Nursing Diagnoses and Interventions Treatment of Frank's encephalopathy is successful. He is started on a regimen of care for his cirrhosis. Frank's nurse identifies several high-priority nursing diagnoses, including: fatigue, excess fluid volume, imbalanced nutrition (less than body requirements), impaired comfort (itching).   16. Which activity level should be initiated during the acute phase of cirrhosis? A) Bedrest. Feedback: CORRECT Bedrest is an important intervention during the acute phase of cirrhosis. This allows healing time for the damaged liver and helps Frank conserve energy. Once activity is resumed, Frank should continue to take regular rest periods to conserve energy and gain strength. B) Dangle legs at bedside q2 hours. Feedback: INCORRECT When resting in bed, Frank's legs should be slightly elevated to promote venous return. Dangling the legs at the bedside is not an inappropriate intervention, since it encourages further dependent edema. C) Ambulate in halls with assistance. Feedback: INCORRECT Ambulation is contradicted for clients with acute liver disease because any increase in exercise further increases demand for liver function and decreases the liver's blood supply. D) Up ad lib. Feedback: INCORRECT Allowing Frank to be out of bed without restriction would interfere with the rest that is needed for the liver to reestablish function. Points Earned: 1.0/1.0 Correct Answer(s): A 17. Which intervention should be implemented related to the diagnosis of fluid volume excess? A) Instruct Frank to perform self-catheterization. Feedback: INCORRECT This intervention is not necessary. The client with cirrhosis does not experience urinary retention. If fatigue prevents normal voiding, an indwelling catheter may be inserted. B) Measure abdominal girth daily. Feedback: CORRECT Assessment of the effectiveness of treatment for fluid volume excess includes measuring abdominal girth and edema, auscultation of breath sounds, and daily weights. Ascites frequently returns after paracentesis. Another important intervention is to maintain fluid and sodium restrictions. Fluids may be restricted to 1 liter or less a day, and sodium may be restricted to 1 g or less a day.    C) Administer PRN antiemetics before meals. Feedback: INCORRECT The client with cirrhosis frequently experiences anorexia, nausea, and vomiting. Preventing nausea before meals will increase Frank's willingness to eat, and although it is an important intervention, it is not related to fluid volume excess. D) Encourage Frank to eat frequent high-protein snacks. Feedback: INCORRECT The client with cirrhosis should eat a well-balanced diet with a moderate protein intake. High amounts of protein increase the risk of hepatic encephalopathy. Points Earned: 1.0/1.0 Correct Answer(s): B A Complication Occurs Frank's condition remains stable. He is getting plenty of rest, alternating with periods of exercise. He is having difficulty following his diet, however, and occasionally goes to the vending machines for colas and chips. Late one afternoon, Frank calls for the nurse and reports that he feels dizzy and that he is vomiting bright red blood. When the nurse arrives, Frank is standing in the middle of the room. His color is pale, and his skin feels cold and clammy. 18. What intervention should the nurse implement first? A) Instruct Frank to remain standing while he is checked for orthostatic hypotension. Feedback: INCORRECT Frank is already dizzy and showing signs of hypotension. To leave him standing places him at high risk for injury. This is not an appropriate intervention at this time. B) Go to the med cart to obtain a dose of vitamin K (AquaMEPHYTON). Feedback: INCORRECT Frank should not be left alone because he is showing signs of hypotension, and he is at high risk for injury. C) Apply a pulse oximeter to assess Frank's oxygen saturation. Feedback: INCORRECT Assessing Frank's oxygen saturation level and vital signs are important, but another intervention should be performed first. D) Position Frank in the bed with his feet slightly elevated. Feedback: CORRECT Frank is showing evidence of impending shock, and he is at high risk for injury. He should first be placed in a shock position, and then his vital signs and oxygen saturation level should be assessed. Points Earned: 1.0/1.0 Correct Answer(s): D The nurse positions Frank in bed, calls for assistance, and assesses Frank's vital signs and oxygen saturation level. His vital signs are: T 98°F, P 138, R 28, BP 80/50. His oxygen saturation level is 86%. 19. Which action should the nurse perform first? A) Notify the healthcare provider. Feedback: INCORRECT Frank's vital signs indicate a medical emergency requiring immediate intervention. The healthcare provider should be notified of the overt bleeding and impending shock, but another action should be taken first. B) Ensure patency of the IV. Feedback: INCORRECT Frank is experiencing bleeding esophageal varices and impending shock. He will require IV fluids and possibly a blood transfusion or IV vasopressors to maintain his blood pressure, but another action should be taken first. C) Apply oxygen. Feedback: CORRECT Since Frank's oxygen saturation level is 86%, he should be started on oxygen via nasal cannula or face mask to improve his oxygenation. Frank is displaying symptoms of shock, and requires immediate intervention. D) Transfer to critical care. Feedback: INCORRECT This may become necessary, but there is a more important initial nursing intervention. Points Earned: 1.0/1.0 Correct Answer(s): C Client Teaching: Lifestyle Management Frank is experiencing bleeding esophageal varices. He is started on IV fluids of 0.9 Normal Saline at 125 ml/hour. The nurse performs gastric lavage to remove blood from the GI tract. Frank is scheduled for immediate endoscopic sclerotherapy. Following endoscopic sclerotherapy, Frank's bleeding stops and his condition stabilizes. Frank tells the nurse, "I guess you better teach me how to take care of this problem, because I'm not ready to die yet." There are several treatments for bleeding esophageal varices, including: Endoscopic sclerotherapy: This procedure involves the injection of a sclerosing agent directly into the varices through a fiber-optic endoscope. Sclerotherapy stops bleeding in 90% of clients by the second treatment. Esophageal balloon tamponade: Using a Sengstaken-Blakemore tube or Minnesota multi-lumen nasogastric tube, a balloon is inflated to compress the varices in the esophagus. While the tube is in place, the nurse must ensure that adequate pressure and traction are maintained, and that scissors are kept taped to the head of the bed in case of acute respiratory distress requiring immediate removal of the tube. Portacaval shunt: This surgical procedure lowers portal pressure by shunting blood around the liver by connecting the portal vein directly to the inferior vena cava. Clients undergoing this surgery are at high risk for postoperative hepatic encephalopathy and should be monitored carefully by the nurse. Transjugular intrahepatic portosystemic shunt (TIPS): This non-surgical procedure is used to reduce portal pressure. The hepatic vein is catheterized via the jugular vein, and a stent is inserted to maintain a tract between the hepatic and portal veins. The nurse provides Frank the information about managing his diet and fluid intake. His dietary management includes a well-balanced diet that is low in sodium, fat, and physical irritants. His diet includes only a mild fluid restriction. The nurse provides Frank several menu selections and asks him to select the best meal.     20. Which lunch menu is the best choice for Frank? A) Bologna and cheese sandwich, tomato soup, and cherry pie. Feedback: INCORRECT Processed and canned foods are high in sodium, and they should be avoided. B) Bacon, lettuce, and tomato sandwich with a chocolate milkshake. Feedback: INCORRECT Pork products such as bacon are high in sodium, and they should be avoided. In addition, bacon and lettuce may be irritating to Frank's esophageal varices. C) Meatball sandwich and a fruit smoothie. Feedback: CORRECT This is a good selection that is not excessively high in sodium and one that should not cause physical irritation to Frank's esophageal varices. D) Fried fish sandwich, coleslaw, and iced tea. Feedback: INCORRECT Deep fried foods are high in sodium and fat, and they should be avoided. Points Earned: 1.0/1.0 Correct Answer(s): C The nurse provides additional discharge teaching regarding lifestyle management. 21. Which instruction has the highest priority? A) Stop all alcohol consumption. Feedback: CORRECT The highest priority is for Frank to understand that continued alcohol consumption will result in additional liver damage.  B) Get plenty of rest and regular exercise. Feedback: INCORRECT While this is important to maintain Frank's health, it is not the highest priority. C) Schedule regular medical checkups. Feedback: INCORRECT While this is important to maintain Frank's health, it is not the highest priority. D) Take a vitamin supplement daily. Feedback: INCORRECT While this is important to maintain Frank's health, it is not the highest priority. Points Earned: 1.0/1.0 Correct Answer(s): A Management Issues: Interdisciplinary Team Collaboration Frank states he wants to change his lifestyle, return to productive employment, and regain his health. He asks the nurse how to begin the process to stop drinking. 22. Which member of the interdisciplinary team is the best choice for the nurse to contact to help Frank meet this goal? A) Occupational therapist. Feedback: INCORRECT The role of the occupational therapist focuses primarily on regaining fine motor skills necessary for daily functioning. B) Hospital nursing supervisor. Feedback: INCORRECT While the hospital nursing supervisor does serve as a resource to the staff nurse, there is a better member of the interdisciplinary team to assist Frank. C) Certified home health aide. Feedback: INCORRECT The role of the home health aide is to provide direct client care that is under the supervision of a registered nurse. D) Social worker. Feedback: CORRECT The social worker has expertise in coordinating community resources and social services, and is, therefore, the best member of the interdisciplinary team to help Frank with his lifestyle goals. Points Earned: 1.0/1.0 Correct Answer(s): D The nurse contacts the interdisciplinary team member, who states that she doesn't have time to meet with Frank. 23. What is the best response by the nurse? A) "You need to rearrange your schedule to see this client." Feedback: INCORRECT Collaboration requires assertive, not aggressive, communication skills and respect for the members of other disciplines. B) "I really need you to find a way to help this client." Feedback: CORRECT Collaboration requires assertive, not aggressive, communication skills, and respect for the members of other disciplines. This response also demonstrates client advocacy. C) "Call me back if your schedule changes." Feedback: INCORRECT Collaboration requires assertive communication skills and client advocacy. This is a passive response rather than an assertive response, and it does not demonstrate effective client advocacy. D) "Your attitude will be reported to the healthcare provider." Feedback: INCORRECT Collaboration requires assertive communication skills and respect for the members of other disciplines. This is overly aggressive and unprofessional. Points Earned: 1.0/1.0 Correct Answer(s): B Case Outcome With the assistance of the social worker, Frank is scheduled to meet with a substance abuse counselor and to attend Alcoholics Anonymous meetings with a sponsor. He is discharged from the hospital in stable condition with plans to stop drinking, and maintain a healthy lifestyle.