A nurse is caring for a patient diagnosed with acute hepatitis B. Which nursing intervention should be the highest priority?
A 28-year-old patient presents with jaundice, dark urine, clay-colored stools, and elevated liver enzymes. The patient has been diagnosed with acute hepatitis B and reports severe fatigue and nausea.
1Administer antiviral medications as prescribed
2Monitor for signs of fulminant hepatic failure✓ 정답
3Provide high-protein, high-calorie diet
4Encourage increased fluid intake to prevent dehydration
해설
Monitoring for signs of fulminant hepatic failure is the highest priority because it is a life-threatening complication requiring immediate intervention. Other interventions like antiviral therapy, diet, and hydration are important but secondary.
Clinical Judgment
This question tests Prioritization and Anticipating Risk. Most patients with acute hepatitis B recover naturally, but a small number develop Fulminant Hepatic Failure, a life-threatening emergency. The nurse's top priority is early detection and prevention of the most dangerous complication. The patient's symptoms (jaundice, dark urine, clay-colored stools) are typical findings of hepatitis, but if altered mental status, severe bleeding tendency, or rapidly worsening jaundice appear, immediate medical intervention is needed. Therefore, risk surveillance takes higher priority than treatment or symptom relief.
Memory Tip: First, Find Failure (Fulminant). In acute hepatitis, the first (F) thing to find (F) is signs of fulminant (F) hepatic failure. Or remember: "Acute hepatitis? Always Assess for the worst first."
KR vs US
In Korea, hepatitis patient management traditionally tends to focus on rest and nutritional support (high-protein diet). In contrast, the US NGN/CJMM emphasizes a 'risk anticipation' model that prioritizes patient safety. Systematic monitoring to avoid missing the most fatal yet rare complication is considered a core nursing responsibility.
임상 시나리오
Clinical Practice Guide
To monitor for early signs of fulminant hepatic failure:
1. Neurological status: Check level of consciousness (GCS), orientation, personality changes, and asterixis every 4-8 hours.
2. Laboratory values: Watch for rapid prolongation of PT/INR (coagulation time), hypoglycemia, and elevated ammonia.
3. Bleeding signs: Observe for gum bleeding, nosebleeds, subcutaneous hemorrhage (ecchymosis, purpura), and blood in stool/urine.
Caution
In SATA (Select All That Apply) questions asking for the "highest priority," interventions related to 'monitoring' or 'risk assessment' are very likely to be the correct answer, rather than treatment or education. Options starting with "Administer..." or "Teach..." are often lower priority.
핵심 개념
Fulminant Hepatic Failure (전격성 간부전) — A life-threatening condition in which liver function rapidly deteriorates with hepatic encephalopathy within 8 weeks after acute liver injury in a patient with no previous liver disease. It is characterized by massive hepatocyte necrosis.
Hepatitis B — Inflammatory liver disease caused by the hepatitis B virus (HBV). It is divided into acute and chronic forms and is transmitted through blood and body fluids.
Asterixis (날개짓 떨림) — Irregular, intermittent "flapping" tremor that occurs when the wrist is extended and fingers are spread apart. It is a classic neurological sign of hepatic encephalopathy.
Clay-Colored Stools (백토변) — Grayish-white stool caused by reduced or absent excretion of bile into the intestine. It is observed in bile duct obstruction or severe hepatocellular damage (decreased bile production).
Prioritization (우선순위 설정) — Ranking the patient's various problems or needs in the nursing process according to their urgency and importance. Life-threatening issues, ABC (airway, breathing, circulation) problems, and high-risk assessments take top priority.