# A nurse is assessing a patient with active pulmonary tuberculosis who has been on anti-tuberculosis therapy for 6 weeks. The patient reports persistent fatigue, nausea, and yellowing of the eyes. Laboratory results show elevated liver enzymes (ALT 180 U/L, AST 200 U/L). What is the most appropriate nursing intervention?

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## 문제

A nurse is assessing a patient with active pulmonary tuberculosis who has been on anti-tuberculosis therapy for 6 weeks. The patient reports persistent fatigue, nausea, and yellowing of the eyes. Laboratory results show elevated liver enzymes (ALT 180 U/L, AST 200 U/L). What is the most appropriate nursing intervention?

## 보기

1. Continue current medications and monitor liver function weekly
2. Reduce the dosage of all anti-tuberculosis medications by half
3. Hold all hepatotoxic anti-tuberculosis medications and notify the physician immediately **✔ 정답**
4. Add hepatoprotective supplements while continuing current therapy

**정답: 3**

## 해설

The patient shows signs of drug-induced hepatotoxicity from anti-tuberculosis medications. Immediate discontinuation of hepatotoxic drugs and physician notification are critical, while other options delay necessary intervention.

## 심화 해설

Clinical Scenario Analysis

This patient is exhibiting classic signs and symptoms of drug-induced liver injury (DILI), specifically anti-tuberculosis drug-induced liver injury (ATLI). The subjective reports of persistent fatigue, nausea, and scleral icterus ("yellowing of the eyes") combined with objective laboratory data showing markedly elevated liver enzymes (ALT 180 U/L, AST 200 U/L) indicate hepatocellular damage. In the context of standard anti-tuberculosis therapy containing isoniazid, rifampicin, and pyrazinamide, all of which are known hepatotoxins, this presentation is a medical red flag requiring immediate action [1][2].

Pathophysiology and Clinical Reasoning

The mechanism of ATLI involves the production of toxic metabolites. Isoniazid is metabolized in the liver via N-acetyltransferase 2 (NAT2), producing hepatotoxic hydrazine intermediates. Rifampicin is a potent inducer of cytochrome P450 enzymes, which can accelerate the metabolism of isoniazid into its toxic byproducts, increasing the risk of a synergistic hepatotoxic effect. Pyrazinamide also contributes independently to liver injury. The resulting hepatocellular necrosis causes the release of intracellular enzymes like alanine aminotransferase (ALT) and aspartate aminotransferase (AST) into the bloodstream. The elevation of bilirubin, manifesting clinically as jaundice and scleral icterus, indicates a more severe injury pattern where the liver's ability to conjugate and excrete bilirubin is compromised. A systematic review and meta-analysis confirms that a combination of these drugs significantly elevates the risk of liver injury compared to individual agents [1].

Rationale for the Correct Intervention

The most appropriate nursing intervention is to **hold all hepatotoxic anti-tuberculosis medications and notify the physician immediately**. The severity of the patient's presentation—symptomatic hepatitis with jaundice and transaminase levels exceeding 3-5 times the upper limit of normal—is a universally accepted criterion for immediate cessation of therapy. Continuing medications, even with monitoring, risks progression to acute liver failure. A study on ATLI prevalence highlights that prompt recognition and drug withdrawal are the cornerstones of management to prevent severe outcomes [2]. Dose reduction is not a safe strategy, as the injury is often idiosyncratic and not strictly dose-dependent. Adding hepatoprotective supplements without stopping the offending agents has no evidence of reversing ongoing, significant hepatocellular injury and delays definitive management. The nurse's priority is patient safety through advocacy, which involves stopping the potential cause of harm and securing a new medical order from the prescriber. A validated nomogram for predicting ATLI risk underscores the importance of pre-treatment risk assessment, but once injury occurs, the clinical response must be decisive and immediate .

Analysis of Incorrect Options

- **Option 1 (Continue current medications and monitor liver function weekly):** This is inappropriate for symptomatic, icteric hepatitis with transaminase levels this high. Monitoring alone without intervention exposes the patient to an unacceptable risk of irreversible liver damage. The presence of jaundice signals a more advanced and dangerous stage of injury [2].

- **Option 2 (Reduce the dosage of all anti-tuberculosis medications by half):** This is a dangerous and ineffective approach. It risks creating drug resistance in Mycobacterium tuberculosis while not guaranteeing cessation of the hepatotoxic reaction. The liver injury is not a simple, predictable dose-response curve for all patients [1].

- **Option 4 (Add hepatoprotective supplements while continuing current therapy):** There is no high-level evidence that supplements can counteract the severe hepatotoxic effects of these drugs once significant injury has begun. This action would only delay the critical, life-saving step of discontinuing the offending medications. The focus must be on removing the causative agents, not masking the damage .

NCLEX-RN Testing Concept

This question tests the critical nursing competency of recognizing and managing a serious adverse drug reaction. It integrates knowledge of pharmacology (hepatotoxic drug metabolism), pathophysiology (mechanisms of hepatocellular injury), and clinical judgment (interpreting lab values and symptoms to prioritize a safety intervention). The NCLEX-RN exam frequently assesses the nurse's ability to identify when a patient's condition necessitates immediate communication with the physician and a change in the treatment plan, rather than ongoing monitoring or independent, unproven interventions. The presence of jaundice in a patient on multi-drug therapy is a pivotal cue that distinguishes a mild, asymptomatic transaminase elevation from a clinically significant, potentially life-threatening event requiring immediate drug cessation [2].

References (research sources)

- [1]Risk factors for drug-induced liver injury in tuberculosis patients: a meta-analysis and systematic review.Meta-analysis/systematic reviewLiu X, Liu C, Yao R, Wan B, Fu L, Yang X, Zhang Y, Du J, Long X. (2026) · DOI: 10.3389/fmed.2026.1834524

- [2]Anti-tuberculosis drug-induced hepatotoxicity among patients undergoing tuberculosis treatment at the Antituberculosis Center of Brazzaville, Republic of Congo.Research articleEbata-Mboussa EF, Assiana DOE, Moyen N, Mouzinga FH, Bonsi ST, Elenga EB, Okemba-Okombi FH, Ondzia FRO. (2026) · DOI: 10.1016/j.ijregi.2026.100869

## 임상 시나리오

Anti-TB Drug-Induced Liver Injury (ATLI) ManagementImmediate Cessation of Hepatotoxic Drugs
When a patient on anti-TB therapy develops jaundice or scleral icterus with ALT or AST elevated 3–5 times the upper limit of normal, all potentially hepatotoxic drugs (isoniazid, rifampicin, pyrazinamide) must be held immediately.

Notify the physician promptly to initiate a liver-sparing regimen, often using non-hepatotoxic agents like ethambutol and a fluoroquinolone while liver function recovers.

CautionNever reduce the dose or add supplements as a substitute for stopping the offending drugs; this does not halt the immune-mediated or toxic metabolite injury and risks acute liver failure.

## 핵심 개념

- **Drug-Induced Liver Injury (DILI)** — Liver damage caused by medications, ranging from asymptomatic enzyme elevation to acute liver failure, commonly associated with anti-tuberculosis drugs like isoniazid.
- **Hepatotoxicity** — Chemical-driven liver damage; in ATT, it presents with fatigue, nausea, jaundice, and markedly elevated ALT/AST, necessitating immediate drug cessation.
- **Scleral Icterus** — Yellowing of the whites of the eyes due to hyperbilirubinemia, a key physical sign of significant liver dysfunction or hepatitis.
- **Alanine Aminotransferase (ALT)** — A liver enzyme released into the bloodstream upon hepatocellular injury; levels above 3-5 times the upper limit of normal with symptoms indicate severe DILI.

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