Question 1

What should the nurse use to accurately assess the fluid status of a patient with ascites?

Accepted Answer

1. Abdominal percussion may be difficult and inaccurate in obese patients.
2. Daily weights are accurate and objective indicators of fluid gain and loss and are directly related to sodium balance. A weight gain of 1 kg is equivalent to the retention of 1 liter of fluid.
3. The measurement of abdominal girth is subjective and often inaccurate.
4. The presence of peripheral edema is subjective and often inaccurate.

Question 2

When the CAGE questionnaire is used to guide the assessment of alcohol misuse, the nurse should ask which questions?

Accepted Answer

1. This is an example of behavior that is considered maladaptive. This type of behavior could be related to dependency but is not necessarily indicative of dependency.
2. The acronym helps the clinician to recall these four questions. Have you ever felt the need to CUT down on drinking? Have you ever felt ANNOYED by criticism of your drinking? Have you ever had GUILTY feelings about your drinking? Have you ever had an EYE opener first thing in the morning to steady your nerves or get rid of a hangover?
3. This is an example of a situational crisis and not necessarily of dependency.
4. This is not an appropriate question to ask when utilizing the CAGE questionnaire.

Question 3

What complications might a patient develop in response to portal hypertension? Select all that apply.

Accepted Answer

1. In the early stages of portal hypertension, blood collects in the sinusoids of the liver to compensate for the elevated pressure. As the pressure remains elevated, the liver enlarges.
2. The spleen is a part of the portal system, and as pressure increases, blood will back up in the system and also collect in the spleen.
3. Ascites is a marker for severe progression of liver disease. The high pressure frequently causes the esophageal and/or gastric varices to rupture and bleed. The most common site for a variceal bleed is the submucosa of the distal end of the esophagus.
4. The cardiovascular consequences related to portal hypertension and hepatic failure include hypotension, peripheral edema, arrhythmias, and heart failure.
5. This is a normal range of portal pressure. Portal hypertension is defined as portal pressure of 20 mm Hg.

Question 4

Which finding suggests to the nurse that a patient is experiencing early physiologic clinical manifestations of alcohol withdrawal?

Accepted Answer

1. Yelling and acting belligerent is a behavioral and neuropsychiatric manifestation of alcohol withdrawal syndrome.
2. Vital signs including temperature and pulse oximetry are evaluated. Early indications of alcohol withdrawal tend to be mild increases in heart rate, temperature, and blood pressure with more severe symptoms, such as hallucinations, developing as the patient progresses through the continuum.
3. Being a repeat offender and demanding a drink is a behavioral manifestation of alcohol withdrawal syndrome.
4. Lethargy and decreased responsiveness is a later manifestation of alcohol withdrawal syndrome.

Question 5

An adolescent patient is admitted after ingesting 20 500-mg acetaminophen (Tylenol) tablets as a suicide attempt. The patient is currently nauseated, vomiting, and diaphoretic with a BP of 96/52 What should be the priority in this patient's care?

Accepted Answer

1. The predicted risk of toxicity from a single acute overdose relies on the time of ingestion and serum acetaminophen level. Whether a level is toxic or nontoxic can only be interpreted when the time of ingestion is accurately accounted for. The Rumack-Matthew nomogram can be used to predict hepatic toxicity between 4 and 24 hours after an acute ingestion.
2. These symptoms are side effects of intravenous administration of N-acetylcysteine NAC (Mucomyst).
3. This medication is administered after the initial acetaminophen level is drawn. It must be administered between 4 and 24 hours after acetaminophen.
4. This will depend upon the patient's status.

Question 6

A patient who misuses alcohol finished drinking at noon. At 6 p.m., which autonomic manifestations of alcohol withdrawal should the nurse assess in the patient?

Accepted Answer

1. These are not autonomic manifestations of alcohol withdrawal.
2. Because alcohol is short acting, the nurse anticipates that signs and symptoms of minor withdrawal commonly appear within 6 to 12 hours of the last ingestion. Autonomic manifestations that occur during the first hours of alcohol withdrawal include hyperventilation, tachycardia, palpitations, hypertension, increased body temperature, hyperreflexia, insomnia, restlessness, diaphoresis, tremors, mydriasis, and seizures.
3. Anorexia and diarrhea are nonspecific gastrointestinal symptoms that are not associated with either drug or alcohol abuse.
4. Auditory and visual hallucinations are later manifestations associated with alcohol withdrawal syndrome.

Question 7

A patient with ascites is recovering from a paracentesis where 8 liters of fluid have been removed. What should the nurse monitor in order to detect a common complication after this procedure?

Accepted Answer

1. Postprocedure responsibilities include monitoring hemodynamic status to detect the potential complications of hypovolemic shock.
2. A paracentesis does not change serum ammonia levels.
3. A postprocedure chest film is not indicated following a paracentesis.
4. The patient's temperature should be routinely monitored every 4, not 2, hours.

Question 8

A patient is in the late stages of liver failure with cirrhosis and progressive, irreversible damage. What should the nurse explain to the family?

Accepted Answer

1. Evaluation for a liver transplant needs to be done during the early stages of liver failure in order for this therapy to be successful.
2. In alcoholic cirrhosis, abstinence from alcohol may decrease liver cell injury and improve portal hypertension.
3. All body systems are affected with hepatic dysfunction. It is a multisystem dysfunction-fluid and electrolyte, renal, integument, hematologic, cardiac, pulmonary, and gastrointestinal.
4. Late stage liver dysfunction may develop varices as a result of portal hypertension. Even if this patient does not develop varices, this patient will not survive for years.

Question 9

A patient who has been drinking heavily for 3 years seeks medical care. What should the nurse realize about alcohol withdrawal syndrome when caring for this patient?

Accepted Answer

1. Alcohol suppresses the production of GABA. When alcohol is withdrawn, GABA may resume normal function, which is to inhibit transmission of impulses.
2. Neurotransmitters are usually balanced between inhibitory and stimulatory. In the presence of alcohol, transmitters are inhibited. With the absence of alcohol, the transmitters become stimulated.
3. When exposed to repeated doses of alcohol, the central nervous system (CNS) becomes accustomed to the depressant effects of the alcohol and produces adaptive changes in an attempt to function normally. In the absence of or with a significant decrease in the amount of alcohol, chaos erupts within the CNS. When alcohol is no longer acting as a depressant, the compensatory actions cause excessive CNS excitability.
4. With the withdrawal of alcohol, neuroreceptors do not regain normalcy. Instead they are prone to become overstimulated due to the depressant effect of alcohol.

Question 10

The nurse prepares to administer the third dose of aldactone (Spironolactone) to a patient with cirrhosis and ascites. What should cause the nurse to question the administration of this medication?

Accepted Answer

1. The serum creatinine of 1.6 mmol/L is within normal limits.
2. The serum sodium of 130 mEq/l, even though it is low, does not meet the criteria to hold the medication.
3. The nurse anticipates this potassium-sparing diuretic may be discontinued if the potassium level is greater than 5.3 mEq/L. This medication needs to be held or discontinued as this patient's potassium level is 5.7 mEq/L.
4. A weight gain of 0.2 kg is not an indication to hold diuretics. The objective of diuretics is to reduce the ascites and peripheral edema.

Question 11

A patient with a myocardial infarction is withdrawing from alcohol. The patient is nauseated and having tremors despite receiving medications for withdrawal. The nurse suspects the patient is experiencing which electrolyte imbalance?

Accepted Answer

1. This is a normal magnesium level (1.2-2.0).
2. This is a normal phosphate level (1.8-3.0).
3. A low serum potassium (hypokalemia less than 3.5 mEq/L) is a frequent finding in alcohol withdrawal syndrome related to inadequate intake, excessive diuresis, vomiting, and diarrhea.
4. This is a normal calcium level.

Question 12

A patient with esophageal varices is treated with an esophageal tamponade (Sengstaken-Blakemore) tube. What should be the nurse's priority when caring for this patient?

Accepted Answer

1. This is important, but airway always takes priority.
2. Accidental migration of the tube can result in airway obstruction. This requires immediate intervention by cutting all the lumens of the tube to rapidly deflate them and removing the tube. Maintenance of the airway is the priority.
3. Although this is important to keep the patient from pulling out the tube, airway takes priority.
4. Although it is important to maintain this pressure against the varices to prevent bleeding, maintaining the airway is the priority.

Question 13

A patient who ingests several alcoholic beverages each day has been taking 1 gm of acetaminophen (Tylenol) six times a day and Percocet for pain relief following knee surgery. The patient is currently complaining of nausea with right upper quadrant pain and has an AST of 60 units/L and ALT of 45 units/L. Which additional laboratory studies should the nurse use when assessing this patient? Select all that apply.

Accepted Answer

1. The PT/PTT and INR are the most important levels to obtain because elevation of these levels is indicative of liver dysfunction and puts the patient at risk for bleeding.
2. A more accurate assessment of renal function would be creatinine and blood urea nitrogen in addition to potassium.
3. The amount of acetaminophen this patient consumes is 6,000 mg/day. This exceeds the safe level of 4,000 mg/day. The patient needs to be assessed for acetaminophen toxicity.
4. An ethanol level and opiate level would also be appropriate for this patient, given the patient's history.
5. Urine myoglobin is only used for those patients with tissue trauma, such as those with severe orthopedic injury and burns.

Question 14

A patient is recovering from an endoscopy with banding of esophageal varices. Which intervention should have the highest priority immediately following the procedure and until the patient is fully awake?

Accepted Answer

1. During endoscopy, patients may have a topical anesthetic sprayed to the throat area, which may impair swallowing. The nurse waits until the patient is awake to assess swallowing.
2. Irrigation is done as needed to maintain patency.
3. If the patient is not intubated, the nurse should position the patient in the left lateral decubitus position to protect the airway until the patient is fully awake. Airway protection is always top priority.
4. The nurse monitors vital signs, including temperature and oxygen saturation and level of pain and consciousness, until the patient returns to baseline (typically every 10 to 15 minutes for 30 minutes to an hour, then per ICU protocol, or more frequently depending on acuity).

Question 15

When using the Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-A), what should the nurse realize that the use of medication for clinically significant symptoms is based upon?

Accepted Answer

1. Vital signs are monitored and treated with appropriate medications and fluids to maintain hemodynamic stability.
2. Response to treatment is an evaluation of therapy given. Treatment with further medication would be based on that evaluation and the patient's level of consciousness. Medication should not be automatically administered without further assessment.
3. Patients are medicated with benzodiazepines when they cross a designated threshold of severity. Frequency of assessments will be determined by the severity, treatment, response to treatment, and overall acuity.
4. Physiologic and behavioral symptoms determine intervention as opposed to the amount of observation time required to monitor the patient.

Question 16

A patient with portal hypertension and hepatic encephalopathy is surprised that he is permitted to eat meat for dinner. What should the nurse explain to the patient about protein intake?

Accepted Answer

1. The patient does not have an alteration in the metabolism of protein.
2. Patients with HE should be managed with medications and should not have a protein restriction. They actually have an increased need for protein, and limiting it will accelerate PCM.
3. Protein will prevent the development of complications and not necessarily directly impact liver healing.
4. Ingesting protein does not prevent fluid from leaking into the abdomen.

Question 17

The nurse plans to use the Clinical Institute Withdrawal Assessment (CIWA-Ar) scale with a patient who has been recently admitted with pancreatitis. What should the nurse realize when using this measurement tool?

Accepted Answer

1. The higher the score, the greater the patient's risk for severe withdrawal symptoms.
2. The higher the score, the greater the patient's risk for severe withdrawal symptoms.
3. Best practice utilizes the CIWA-Ar to guide pharmacologic therapy and direct the level of care required. The nurse assesses and scores 10 specific symptoms: nausea and vomiting, tremor, sweating, anxiety, agitation, headache, disorientation, tactile disturbances, visual disturbances, and auditory disturbances. Concurrently, vital signs including temperature and pulse oximetry are evaluated.
4. There are 10 specific areas that are assessed in the patient at risk for developing alcohol withdrawal syndrome.

Question 18

A patient with a history of alcohol misuse has been admitted for treatment. What should the nurse include in the assessment of this patient?

Accepted Answer

1. The actual standard for the interview is the CIWA-Ar, which is a standardized interview tool that is used for assessment.
2. It is important to consider a patient's nonverbal responses, anxiety, and presence or absence of eye contact for clues. The nurse questions the patient and/or family related to current and past alcohol use and family history of alcohol problems.
3. Patients typically either deny alcohol use or admit to consumption of a significantly lower amount of alcohol.
4. This is not a part of the nursing assessment for alcohol use.

Question 19

In anticipation of a patient's alcohol withdrawal symptoms, the nurse should perform which action? Select all that apply.

Accepted Answer

1. The nurse will assess for hallucinations and orient the patient to reality as needed during alcohol withdrawal syndrome.
2. Alcohol withdrawal seizures commonly occur, and the nurse should prepare for this within 6 to 48 hours of the last intake of alcohol.
3. The nurse will continually monitor the patient's vital signs during alcohol withdrawal syndrome.
4. This is not appropriate in the critical care environment because the nurse-to-patient ratio in this environment is usually one or two patients per nurse. This ratio allows for close assessment and monitoring of the patient experiencing alcohol withdrawal syndrome.
5. The goals of management for alcohol withdrawal include preventing, recognizing, and treating symptoms while providing a safe environment for the patient.

Question 20

The nurse suspects that a patient is dependent on alcohol rather than abusing alcohol when what is assessed?

Accepted Answer

1. This defines dependence. Alcohol dependency (also known as alcoholism) is a pattern of maladaptive behavior associated with one or more of the following: withdrawal symptoms; proof of tolerance; relentless desire to cut down or control use; occupational, social, and recreational tasks are given up; alcohol is taken in a larger amount than planned; time is spent obtaining, using, and recovering from the alcohol; and alcohol use continues regardless of physical and psychological troubles.
2. Recurrent legal problems are associated with alcohol abuse and not dependency.
3. Social and interpersonal problems are associated with alcohol abuse and not dependency.
4. Using alcohol in physically hazardous situations is associated with alcohol abuse and not dependency.

Quiz 12: Care of the Critically Ill Patient Experiencing Alcohol Withdrawal Andor Liver Failure