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HESI Case Study: Cirrhosis Questions And
Correct Detailed Answers (Verified Answers) Already Graded A+
- Question: What is the best approach for the nurse to use when responding to the client?
Correct Answer: Ask the client why he feels people are judging them.
- Question: While administering the albumin infusion via a vein in the right hand, the
nurse notes that the peripheral edema in the client's arms and hands has changed from 3+ to 2+. It is most important for the nurse to implement which intervention?
Correct Answer: Continue the albumin infusion.
3. Question: Which medication places the client at risk for hyperkalemia?
Correct Answer: Spironolactone.
- Question: With a confirmed diagnosis of Laennec's cirrhosis, which assessment finding
warrants immediate intervention? (Select all that apply.)
Correct Answer:
• Hematemesis • Melena
- Question: Based on the prolonged APTT and PT/INR what clinical manifestation would
the nurse anticipate visualizing upon assessment?
Correct Answer: Petechiae
- Question: In the client with cirrhosis, which lab values does the nurse anticipate will be
increased from the normal value? (Select all that apply.)
Correct Answer:
• Total serum bilirubin
• AST/ALT
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• APTT, PT/INR
- Question: After the client undergoes the paracentesis, which nursing assessment
warrants immediate intervention?
Correct Answer: Increasing abdominal pain
- Question: Which nursing interventions are important prior to a paracentesis? (Select all
that apply.)
Correct Answer:
• Ensure the client has signed a consent.• Instruct the client to empty their bladder.• Position the client in an upright position.• Apply sphygmomanometer to monitor blood pressure.
- Question: The nurse continues the focused risk assessment by asking about etiologic
factors related to cirrhosis. Which assessment finding provides the most likely indication that the client is at high risk for cirrhosis?
Correct Answer: Previous diagnosis of Hepatitis C.
10. Question: Which nursing intervention best promotes accurate and effective
communication?
Correct Answer: Explain that there are several types of cirrhosis.
- Question: The client asks the nurse what makes everyone think that they are an
- Question: Who should the nurse notify of the client's action? (Select all that apply.)
alcoholic. The client states when they drink, they don't have to think about problems and that others must feel the same way. How should the nurse respond to the client?Correct Answer: Explain that their lab values are consistent with alcohol abuse.
Correct Answer:
• The charge nurse.• The client's HCP.
- Question: The nurse discusses the situation with another nurse who states that the
client should have been sedated and restrained to keep them from leaving. In which situations is the use of physical restraints appropriate? (Select all that apply.)
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Correct Answer:
• A combative and agitated client who is pulling at the indwelling catheters and IV lines.• A client who is at high risk for injury to self for whom no other safety measures have been successful.• A disoriented client who is trying to dislodge a tracheotomy tube.
- Question: What is client's Glasgow Coma Scale rating obtained in this assessment?
(Enter numerical value only. If rounding is necessary, round to the nearest whole number.)
Correct Answer: 8
- Question: The client is minimally responsive and has a Glasgow Coma Scale rating of
- The client is admitted with a diagnosis of hepatic encephalopathy. Which of the client's
serum laboratory values requires intervention by the nurse?
Correct Answer: Serum ammonia 157 mcg/dL (112.1 mcmol/L)
- Question: Which outcome indicates to the nurse that the lactulose and rifaximin are
having the desired effect?
Correct Answer: Increased mental alertness.
- Question: The treatment goal for cirrhosis is to slow the progression, prevent and treat
any complications. Which interventions are most important for the nurses to include in the client's plan of care? (Select all that apply.)
Correct Answer:
• Stress the importance of following a low sodium diet.• Empasize the need for B-complex vitamins.• Use moisturizing lotion to the skin to minimize scratching.
- Question: Management of ascites is focused on sodium restriction diet, diuretic
therapy, and fluid removal. While monitoring the client's fluid volume, what action should the nurse take?
Correct Answer: Measure abdominal girth daily.
- Question: Nursing care for the client focuses on conserving strength while maintaining
muscle strength and tone. Which interventions should the RN/PN include in the client's plan of care? (Select all that apply.)
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Correct Answer:
• Assess pressure areas while turning every 2 hours.• Space nursing care to provide uninterrupted periods of rest.• Increase activity as tolerated.
20. Question: What intervention is a priority for the nurse?
Correct Answer: Assist the client to bed and position them side lying.
- Question: The nurse positions the client in bed, calls for assistance, and assesses the
client's vital signs and oxygen saturation level. Vital signs are: temperature 98.6° F (37° C), heart rate 148 beats/min, respirations 32 breaths/min, and blood pressure 70/36 mmHg and oxygen saturation level is 82%. In what order should the nurse perform the following actions? (Place in numerical order from first action through last action.)
Correct Answer:
- Apply oxygen.
- Ensure patency of the IV.
- Notify the Rapid Response Team.
- Transfer to critical care.
- Question: The nurse provides additional discharge teaching regarding lifestyle
management. Which information should the nurse provide to the client? (Select all that apply.)
Correct Answer:
• Get plenty of rest and regular exercise.• Avoid the consumption of raw shellfish.• Consider joining an Alcoholic Anonymous (AA) group.
- Question: Which member of the inter-professional team is the best choice for the
nurse to contact to help the client meet this goal?
Correct Answer: Social worker
- Question: The nurse contacts the social worker who states they are too busy and
unable to meet with the client. What is the best response by the nurse?
