Frank Hershey (Cirrhosis) Hesi Case Study (September 2019) Quiz

Which nursing interventions should be implemented related to the diagnosis of fluid volume excess? (Select all that apply).

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C: "have you been exposed to toxic substances where you work?"
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A: ensure the client has signed a consent.B: instruct the client to empty his bladderC: position the client in an upright positionE: apply a sphygmomanometer to monitor the blood pressure
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A: maintain a diet low in sodium intakeB: measure abdominal girth dailyC: administer PRN antiemetics before meals
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A: bed restB: increased intake of vitamin A, D, E and folic acidE: use moisturizing lotion to the skin to minimize scratching

What intervention is a priority for the nurse?

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B: "Tell me why you feel people are judging you."
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D: assist Frank to bed an position him side lying
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B: "I would really appreciate it if you could find some time to meet with this client"
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B: measure abdominal girth daily

What information should the nurse provide to Frank? (Select all that apply).

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B: get plenty of rest and regular exerciseC: avoid the consumption of raw shellfishE: consider joining the alcoholic anonymous (AA) group
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A: increased mental alertness
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B: there are several types of cirrhosis
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A: fruity breathC: decreased appetiteE: ascites

Which intervention should be implemented related to the diagnosis of fluid volume excess?

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A: ensure the client has signed a consent.B: instruct the client to empty his bladderC: position the client in an upright positionE: apply a sphygmomanometer to monitor the blood pressure
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B: "Tell me why you feel people are judging you."
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B: measure abdominal girth daily
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A: bed restB: increased intake of vitamin A, D, E and folic acidE: use moisturizing lotion to the skin to minimize scratching

In the client with cirrhosis, what lab values does the nurse anticipate will be increased from the normal value? (Select all that apply).

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B: "Tell me why you feel people are judging you."
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C: "have you been exposed to toxic substances where you work?"
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D: angiography with portal pressure measurements
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A: total serum bilirubinB: serum ammoniaD: APTT, PT/INR

Which assessment would the nurse expect to find in the client with cirrhosis? (Select all that apply).

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B: there are several types of cirrhosis
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B: get plenty of rest and regular exerciseC: avoid the consumption of raw shellfishE: consider joining the alcoholic anonymous (AA) group
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A: fruity breathC: decreased appetiteE: ascites
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A: increased mental alertness

Which information provided by the nurse is most accurate?

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A: fruity breathC: decreased appetiteE: ascites
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B: there are several types of cirrhosis
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A: increased mental alertness
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B: get plenty of rest and regular exerciseC: avoid the consumption of raw shellfishE: consider joining the alcoholic anonymous (AA) group

What is Frank's Glasgow Come Scale rating obtained in this assessment?

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B: "Tell me why you feel people are judging you."
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8
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B: Mr. Hershey's vital signs will be checked frequently for the next few hours.
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A: increased serum ammonia

Which member of the inter professional team is the best choice for the nurse to contact to help Frank meet his goal?

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D: social worker
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D: petechiae
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C: "have you been exposed to toxic substances where you work?"
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B: measure abdominal girth daily

Which medication places Frank at risk for hyperkalemia?

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A: spironolactone (aldactone)
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A: increased serum ammonia
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D: continue the albumin infusion
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B: measure abdominal girth daily

Which question is most important for the nurse to include when assessing the client for etiologic factors related to cirrhosis?

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C: "have you been exposed to toxic substances where you work?"
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A: total serum bilirubinB: serum ammoniaD: APTT, PT/INR
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B: Mr. Hershey's vital signs will be checked frequently for the next few hours.
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A: maintain a diet low in sodium intakeB: measure abdominal girth dailyC: administer PRN antiemetics before meals

What is the primary underlying cause of hepatic encephalopathy?

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D: continue the albumin infusion
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A: spironolactone (aldactone)
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B: "Tell me why you feel people are judging you."
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A: increased serum ammonia

What education should be provided to Mr. Hershey after his paracentesis?

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C: "have you been exposed to toxic substances where you work?"
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B: "Tell me why you feel people are judging you."
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B: Mr. Hershey's vital signs will be checked frequently for the next few hours.
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A: ensure the client has signed a consent.B: instruct the client to empty his bladderC: position the client in an upright positionE: apply a sphygmomanometer to monitor the blood pressure

Maintaining bedrest for 24 to 48 hours is an important nursing intervention following which procedure?

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A: total serum bilirubinB: serum ammoniaD: APTT, PT/INR
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D: angiography with portal pressure measurements
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D: assist Frank to bed an position him side lying
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B: "Tell me why you feel people are judging you."

Which nursing interventions are important prior to a paracentesis? (Select all that apply)

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A: maintain a diet low in sodium intakeB: measure abdominal girth dailyC: administer PRN antiemetics before meals
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A: bed restB: increased intake of vitamin A, D, E and folic acidE: use moisturizing lotion to the skin to minimize scratching
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A: ensure the client has signed a consent.B: instruct the client to empty his bladderC: position the client in an upright positionE: apply a sphygmomanometer to monitor the blood pressure
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A: a combative and agitated client who is pulling at the indwelling catheters and IV lines. C: A client who is at high risk for injury to self for whom no other safety measures have been successful. E: a disoriented client who is trying to dislodge a tracheostomy tube.

It is most important for the nurse to implement which intervention?

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B: "Tell me why you feel people are judging you."
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D: continue the albumin infusion
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A: increased serum ammonia
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A: spironolactone (aldactone)

What is the best response for the nurse to use when responding to Frank?

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B: "Tell me why you feel people are judging you."
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B: Mr. Hershey's vital signs will be checked frequently for the next few hours.
0%
A: increased serum ammonia
0%
B: "I would really appreciate it if you could find some time to meet with this client"

Which nursing interventions should be implemented related to the diagnosis of fluid volume excess? (Select all that apply).

What intervention is a priority for the nurse?

What information should the nurse provide to Frank? (Select all that apply).

Which intervention should be implemented related to the diagnosis of fluid volume excess?

In the client with cirrhosis, what lab values does the nurse anticipate will be increased from the normal value? (Select all that apply).

Which assessment would the nurse expect to find in the client with cirrhosis? (Select all that apply).

Which information provided by the nurse is most accurate?

What is Frank's Glasgow Come Scale rating obtained in this assessment?

Which member of the inter professional team is the best choice for the nurse to contact to help Frank meet his goal?

Which medication places Frank at risk for hyperkalemia?

Which question is most important for the nurse to include when assessing the client for etiologic factors related to cirrhosis?

What is the primary underlying cause of hepatic encephalopathy?

What education should be provided to Mr. Hershey after his paracentesis?

Maintaining bedrest for 24 to 48 hours is an important nursing intervention following which procedure?

Which nursing interventions are important prior to a paracentesis? (Select all that apply)

It is most important for the nurse to implement which intervention?

What is the best response for the nurse to use when responding to Frank?

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