The nurse is assessing a patient with liver failure and jaundice. ...

[amal]

The nurse is assessing a patient with liver failure and jaundice. Which question should the nurse ask to determine if the cause of the jaundice is hemolytic?
 
  1. Have you been diagnosed with a disorder of red blood cell destruction?
  2. What color is your urine?
  3. What color are your stools?
  4. Do you have any gallbladder problems?

Question 2

The nurse, teaching a patient about portal hypertension, knows teaching has been effective when the patient makes which statement?
 
  1. In portal hypertension, blood backs up in the liver. It causes enlarged blood vessels in my esophagus.
  2. In portal hypertension, blood leaks from my liver. It causes me to feel hungry frequently.
  3. Portal hypertension means fast-spreading high blood pressure. It causes red veins on my arms.
  4. Portal hypertension means high blood pressure throughout my abdomen. It causes me to feel confused.

[SeanoH09]

Answer to Question 1

Correct Answer: 1
Hemolytic jaundice develops when excess RBC destruction releases more bilirubin into circulation than the liver is able to process. Darkened urine and light or clay-colored stools are more commonly associated with hepatic or obstructive jaundice. Patients with gallbladder disorders are also at risk for jaundice; however, this patient's liver failure is a given.

Answer to Question 2

Correct Answer: 1
Portal hypertension, increased pressure in the portal system, has several effects when it is prolonged, including dilation of veins in the gastrointestinal tract and the abdominal wall. This congestion tends to suppress (not increase) the appetite, and lead to formation of collateral vessels in the distal esophagus, stomach, and rectum. The dilated, congested vessels in the esophagus are known as esophageal varices; in the rectum, they lead to the development of hemorrhoids. In advanced liver failure, superficial varices may develop around the umbilicus (not on the arms), a feature known as caput medusae. Portal hypertension does not mean blood is leaking from the liver. It is not fast-spreading hypertension, and it is not defined as high blood pressure throughout the abdomen. Portal systemic encephalopathy (or hepatic encephalopathy), impaired consciousness and mental status, results from the accumulation of toxic waste products in the blood (ammonia in particular) as blood bypasses the congested liver. This is not caused by high abdominal blood pressure.