A client with liver cirrhosis is admitted to the hospital with hepatic encephalopathy. Which nursing intervention is essential in the care of this client?

Administering iron supplements as prescribed.

Monitoring fluid intake and output.

Implementing seizure precautions.

Encouraging high-protein diet intake.

Answer and Explanation

The Correct Answer is C

A) Iron supplements are not a priority intervention for a client with hepatic encephalopathy. In fact, administering iron supplements without proper indication can be harmful, as excessive iron can worsen liver damage in cirrhosis.

B) While monitoring fluid intake and output is important in managing various aspects of liver cirrhosis, it is not the essential intervention for hepatic encephalopathy. The priority in hepatic encephalopathy is to ensure seizure precautions and address the client's altered mental status.

C) Hepatic encephalopathy is a neuropsychiatric complication of liver cirrhosis that can lead to altered mental status, confusion, and potential seizures. Implementing seizure precautions is essential in the care of this client to ensure their safety and prevent injury during any potential seizure activity. Seizure precautions may include padding the side rails of the bed, ensuring a clear and clutter-free environment, and providing close supervision to the client. In severe cases, the healthcare provider may prescribe antiepileptic medications to manage and prevent seizures.

D) Encouraging a high-protein diet is not appropriate for a client with hepatic encephalopathy. High-protein diets can exacerbate hepatic encephalopathy by increasing ammonia production in the intestines. Instead, the client should be prescribed a controlled-protein diet and, in some cases, given lactulose to help reduce ammonia levels.

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Correct Answer is D

Explanation

A) This statement is incorrect. Chronic hepatitis C infection is a significant risk factor for liver cirrhosis, and individuals with this infection require regular monitoring and appropriate medical management to prevent or delay the progression of cirrhosis.

B) While hepatitis D co-infection can worsen the course of chronic hepatitis B or C infection, it does not diminish the significance of hepatitis C infection as a risk factor for liver cirrhosis.

C) While chronic hepatitis B infection is also a known risk factor for liver cirrhosis, the client's history of hepatitis C infection is more relevant to the risk of developing cirrhosis in this case.

D) Chronic hepatitis C infection is a well-established risk factor for liver cirrhosis. The hepatitis C virus causes persistent inflammation in the liver, leading to liver cell damage and scarring (fibrosis). Over time, this fibrosis can progress to cirrhosis, which is the advanced stage of liver damage.

A. Portal hypertension B. Ascites C. Hepatocellular carcinoma D. Splenomegaly

Correct Answer is A

Explanation

A) In liver cirrhosis, portal hypertension occurs due to increased pressure in the portal vein, which carries blood from the intestines to the liver. The increased pressure leads to the development of portosystemic collaterals (collateral circulation) to divert blood flow. This can cause hypersplenism, a condition where the spleen becomes enlarged and traps platelets, leading to a decreased platelet count (thrombocytopenia).

B) Ascites is the accumulation of fluid in the abdominal cavity and is not directly related to a decreased platelet count.

C) Hepatocellular carcinoma is a type of liver cancer and can be a complication of liver cirrhosis. However, it is not the likely cause of the client's decreased platelet count.

D) Splenomegaly (enlargement of the spleen) can occur in liver cirrhosis due to portal hypertension. However, splenomegaly itself is not the cause of the decreased platelet count; it is the hypersplenism resulting from the splenomegaly that causes thrombocytopenia.

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A client with liver cirrhosis is admitted to the hospital with hepatic encephalopathy. Which nursing intervention is essential in the care of this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of chronic hepatitis C infection asks the nurse about the risk of developing liver cirrhosis. Which response by the nurse is accurate?

Correct Answer is D

Explanation

A nurse is caring for a client with liver cirrhosis and notices that the client's platelet count is significantly decreased. Which complication of liver cirrhosis is the likely cause of this finding?

Correct Answer is A

Explanation

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