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

Question 1

What should the nurse use to accurately assess the fluid status of a patient with ascites?
1) Abdominal percussion
2) Daily weights
3) Measurement of abdominal girth
4) Presence of peripheral edema

Answer 1

2
Explanation: 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?
1) Have you ever crashed overnight in an unfamiliar area, arrived late for work, given up family and friends, or escaped arrest by the law?
2) Have you ever felt the need to cut down on drinking, felt annoyed by criticism of your drinking, had guilty feelings about your drinking, or had an eye opener first thing in the morning to get rid of a hangover?
3) Have you ever had a big crisis that led to arrest and grief from your family and friends and tried to explain away your actions?
4) Have you called off or were absent from work because you had too much to drink and needed to sleep it off?

Answer 2

2
Explanation: 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. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Hepatomegaly
2) Splenomegaly
3) Ascites and variceal hemorrhage
4) Atherosclerotic plaques
5) Portal system pressure 5 to 10 mm Hg

Answer 3

1, 2, 3
Explanation: 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?
1) Yelling at the nurse and demanding to go home
2) BP of 160/90, HR of 110, and T of 100
3) Well-known repeat offender and is demanding a drink
4) Cannot sit up straight or respond appropriately to questions

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 96/5
1) Have a serum acetaminophen level drawn.
2) Observe for possible urticaria and bronchospasms.
2) What should be the priority in this patient's care?
3) Provide the first oral dose of N-acetylcysteine (Mucomyst) in orange juice.
4) Start an intravenous access line for rehydration.

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?
1) Nausea and abdominal cramps
2) Diaphoresis and tremors
3) Anorexia and diarrhea
4) Auditory-visual hallucinations and global confusion

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?
1) Blood pressure at least every half hour until the patient is stable
2) Serum ammonia every 4 hours for the next 24 hours
3) Chest film for evidence of a pneumothorax
4) Temperature every 2 hours to detect bacterial peritonitis

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?
1) Liver transplantation is the only feasible treatment.
2) Abstinence from alcohol may decrease further liver cell injury and improve portal hypertension.
3) The liver is the only organ affected so that the patient and family need not worry about other body systems.
4) If the patient does not have any variceal hemorrhages, he will probably live 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?
1) Alcohol is a stimulant that increases gamma-aminobutyric acid (GABA).
2) The neurotransmitters inhibit impulses on the neurons.
3) The CNS has become accustomed to the depressant effects of the alcohol, and CNS excitability develops when alcohol is no longer present.
4) The neuroreceptors in the brain can begin to initiate a chemical reaction of normalcy.

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?
1) Serum creatinine of 1.6 mg/dL
2) Serum sodium of 130 mEq/L
3) Serum potassium of 5.7 mEq/L
4) Weight gain of 0.2 kg

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?
1) Serum magnesium 2.5 mEq/dL
2) Serum phosphate 2.7 mEq/dL
3) Serum potassium 3.1 mEq/dL
4) Total calcium 9.0 mg/dL

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?
1) Ensuring that the gastric balloon remains inflated
2) Keeping a pair of scissors at the bedside at all times
3) Keeping the patient sedated and quiet
4) Maintaining the esophageal balloon pressure between 15 and 20 mm Hg

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. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Prothrombin time and INR to identify coagulation abnormalities
2) Serum potassium to evaluate kidney function
3) Serum acetaminophen level plotted on a Rumack-Matthew nomogram
4) Toxicology screen to identify other substances ingested
5) Urine screen for myoglobin to detect tissue damage

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?
1) Determining if the patient is able to swallow
2) Irrigating the NG tube with saline to detect any additional bleeding
3) Maintaining the patient in the left lateral decubitus position
4) Monitoring the patient's vital signs every hour

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?
1) Temperature, pulse oximetry, and urine output
2) Response to treatment
3) Designated threshold of severity
4) Amount of one-to-one attention needed

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?
1) Protein cannot be metabolized because of the patient's health problem.
2) Protein prevents the development of other health problems.
3) It encourages the liver to heal faster.
4) It prevents 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?
1) The lower the score, the greater the patient's risk for severe withdrawal symptoms.
2) The higher the score, the lower the patient's risk for severe withdrawal symptoms.
3) Pharmacologic therapy is matched with the score to direct the level of care required.
4) Sixteen specific areas are scored and assessed with this tool.

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?
1) The use of addiction standards to assess for drinking patterns
2) The inclusion of objective and subjective input from the patient, including signs of anxiety and patterns of usage
3) The amount of denial that the patient is exhibiting
4) The amount of time spent obtaining, using, and recovering from alcohol

Question 19

In anticipation of a patient's alcohol withdrawal symptoms, the nurse should perform which action? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Recognize that hallucinations are common, and reorient the patient.
2) Prepare for seizures that might occur within the first 12 hours of admission.
3) Frequently assess vital signs.
4) Have a sitter present to monitor any attempt by the patient to escape.
5) Prevent, recognize, and treat symptoms while providing a safe environment.

Question 20

The nurse suspects that a patient is dependent on alcohol rather than abusing alcohol when what is assessed?
1) Alcohol is taken in larger amounts than planned, and there is proof of tolerance.
2) Recurrent legal problems related to substance abuse are present.
3) Despite social and interpersonal problems, the person continues to use alcohol.
4) The person uses alcohol in physically hazardous situations.

Question 21

What should the nurse expect to assess in a patient with acute liver failure? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Jaundice
2) Sudden severe nose bleed
3) Ascites
4) Peripheral edema
5) Asterixis

Question 22

A patient who ingests five alcoholic drinks per day demonstrates neuropsychiatric effects of alcohol withdrawal. What should the nurse expect to assess in this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Anger
2) Argumentative behavior
3) Disorientation
4) Confusion
5) Hyperreflexia

Question 23

What should the nurse include when planning care for a patient experiencing pruritus associated with decompensated liver disease? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Provide cholestyramine as prescribed.
2) Provide colestipol as prescribed.
3) Provide diphenhydramine at hour of sleep.
4) Encourage the patient to keep the nails short.
5) Restrict fluids.

Question 24

A patient with esophageal varices received octreotide (Sandostatin) 100 microgram intravenous bolus, and the nurse prepares to start a continuous infusion of the medication. The drug is diluted 500 micrograms in 250 mL of 0.9% normal saline to be administered at 50 mcg/hour. How many milliliters per hour should the intravenous infusion pump be set to in order to deliver the correct dose?
1) 100 mL
2) 50 mL
3) 12.5 mL
4) 25 mL

Question 25

A patient with chronic alcohol use demonstrates confusion, abnormal gait, and visual disturbances. What should the nurse expect to be prescribed for this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Thiamine
2) A benzodiazepine
3) Anticoagulant medication
4) Anticonvulsant medication
5) Intravenous dextrose infusion

Question 26

A patient with a history of alcohol dependency is demonstrating signs of a thiamine deficiency. What did the nurse assess in this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Ataxia
2) Nystagmus
3) Peripheral neuropathy
4) Fatigue
5) Muscle wasting

Question 27

A patient comes into the emergency department after ingesting 50 650-mg tablets of arthritis-strength acetaminophen (Tylenol) 2 hours ago. What intervention should the nurse prepare to implement at this time? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Provide medication to induce vomiting.
2) Prepare to insert a nasogastric tube for gastric lavage.
3) Contact the pharmacy for activated charcoal.
4) Draw a serum acetaminophen level.
5) Administer N-acetylcysteine (NAC) (Mucomyst).

Question 28

A patient with bleeding esophageal varices is scheduled to receive a bolus followed by a continuous infusion of octreotide (Sandostatin). What care should the nurse expect when providing this medication?
1) Anticipate that the medication will stop the bleeding immediately.
2) Notify the physician if the patient has cardiac disease because the medication is contraindicated.
3) Recognize that doses of 100 mcg/hour and higher are associated with better outcomes.
4) Review serial hematocrit levels to determine if the patient is continuing to bleed.

Question 29

The nurse plans care for a patient with alcohol withdrawal syndrome. Which criteria should the nurse use to determine the severity of the patient's symptoms from this syndrome? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Current blood alcohol level
2) Concurrent illnesses
3) History of previous withdrawals
4) History of substance abuse
5) Current vital signs

Question 30

A nurse cares for a patient during a transjugular intrahepatic portosystemic shunt (TIPS) procedure. For which complication should the nurse assess during the procedure?
1) Alcohol withdrawal symptoms, because minimal sedation will be used
2) Dysrhythmias as the catheter moves through the heart
3) Hypotension as the liver is decompressed
4) Vagal responses as the catheter is inserted

Question 31

Which manifestation experienced by a patient having vasopressin (Pitressin) therapy for bleeding esophageal varices indicates a serious adverse effect of the medication?
1) A pounding frontal headache
2) Midsternal chest pain
3) Abdominal cramping
4) Vertigo

Question 32

A patient with a history of taking acetaminophen (Tylenol) for osteoarthritis pain is surprised to learn the diagnosis of liver failure. What should the nurse explain to the patient about this diagnosis? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) "Liver damage can occur when the maximum daily dose of acetaminophen is taken repeatedly."
2) "If your body cannot remove the toxins from acetaminophen, liver damage occurs."
3) "Liver damage from acetaminophen can occur from taking as little as 4 grams of the medication a day."
4) "Liver damage from acetaminophen only occurs when taking 10 grams or more of the medication per dose."
5) "Liver damage from acetaminophen only occurs when it is taken with alcoholic beverages."

Question 33

During a focused assessment, the nurse learns that a patient consumes one 1,000-mL box of wine each day. If the patient is using a 5-ounce glass, how many drinks should the nurse document that this patient consumes daily? Round your number to the nearest whole number.

Question 34

A patient with hepatic encephalopathy has an increased ammonia level. Which should the nurse expect to be prescribed for this patient?
1) Lactulose
2) Rifaximin
3) Carvedilol
4) N-acetylcysteine

Question 35

A patient with a history of alcohol use arrives at the clinic for a routine physical examination. What finding should indicate to the nurse that the patient has an alcohol use disorder (AUD)? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Fatigue
2) Red palms
3) Blurred vision
4) Peripheral edema
5) Yellow-tinged skin

Question 36

The nurse assesses a patient with chronic liver disease. What information should the nurse use from the patient's medical record to complete the Child-Pugh classification system? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Bowel sounds
2) Albumin level
3) Bilirubin level
4) Intake and output
5) Prothrombin time