Ch 44: Assessment and Management of Patients with Biliary Disorders

b) Pancreatitis Pg. 1431 Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity. The other conditions are less likely to exhibit fluid volume deficit.

29. Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit? a) Peptic ulcer b) Pancreatitis c) Appendicitis d) Cholecystitis

c) Measure blood glucose concentration every 4 to 6 hours Pg. 1432 Enteral or parenteral nutrition may be prescribed. In addition to administering enteral or parenteral nutrition, the nurse monitors the serum glucose concentration every 4 to 6 hours.

25. A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN? a) Auscultate the abdomen for bowel sounds every 4 hours b) Measure abdominal girth every shift c) Measure blood glucose concentration every 4 to 6 hours d) Monitor for reports of nausea and vomiting

c) Increase respiratory effectiveness Pg. 1426 The nurse must teach the client about using an incentive spirometer to promote lung expansion. The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis. The client will need to use incentive spirometry to promote lung expansion, increase alveolar inflation, and strengthen respiratory muscles. Most clients don't have a nasogastric tube in place after a cholecystectomy. It isn't appropriate to teach improved nutritional status before surgery. It isn't important for the client to be aware of how to decrease the amount of postoperative analgesia, because this is the responsibility of the health care team.

72. A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan? a) Decrease the amount of postoperative analgesia needed b) Eliminate the need for nasogastric intubation c) Increase respiratory effectiveness d) Improve nutritional status during recovery

b) Coffee Pg. 1435 Post-acute management of the client with acute pancreatitis includes the introduction of solid food. Oral feedings that are low in fat and protein are gradually initiated. Caffeine is eliminated from the diet and therefore coffee, which contains caffeine, should be removed from the client's breakfast tray. Even decaffeinated coffee has a small amount of caffeine but could serve as a compromise for chronic coffee drinkers. The other food items are appropriate for the client.

60. The nurse is caring for a client recovering from acute pancreatitis. Which menu item should the nurse remove from the client's breakfast tray? a) Oatmeal b) Coffee c) Toast d) Orange slices

a) Pruritus b) Dark urine d) Clay-colored stools e) Jaundice Pg. 1441 The obstructed flow of bile produces jaundice, clay-colored stools, and dark urine. Malabsorption of nutrients and fat-soluble vitamins may result if the tumor obstructs the entry of bile to the gastrointestinal tract. Abdominal discomfort or pain and pruritus may be noted, along with anorexia, weight loss, and malaise. If these signs and symptoms are present, cancer of the head of the pancreas is suspected.

59. Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region obstruct the common bile duct. Which of the following clinical manifestations would indicate a common bile duct obstruction associated with a tumor in the head of the pancreas? Select all that apply. a) Pruritus b) Dark urine c) Weight gain d) Clay-colored stools e) Jaundice

b) Female gender c) Multiparous d) Obese e) Eating a high fat diet Pg. 1419 Cholelithiasis affects approximately 50% of women by the age of 70 years. Two to three times more women than men develop cholesterol stones and gallbladder disease, particularly those who are multiparous, eat a high fat diet, and obese. Wealth is not associated with cholelithiasis.

67. A nurse admits a wealthy client who is 8 weeks postpartum after her third child and overweight. The client reports severe right upper quadrant pain that radiates to the back after eating Thanksgiving dinner with turkey and gravy earlier in the evening. What factors lead the nurse to suspect gallbladder disease? Select all that apply. a) Wealthy b) Female gender c) Multiparous d) Obese e) Eating a high fat diet

b) 6 to 12 Pg. 1422 Ursodeoxycholic acid (UDCA [URSO, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. Six to 12 months of therapy are required in many clients to dissolve stones, and monitoring of the client for recurrence of symptoms or occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required during this time.

33. Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve? a) 3 to 5 b) 6 to 12 c) 1 to 2 d) 13 to 18

a) Administering morphine I.V. as ordered Pg. 1432 The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

57. A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client? a) Administering morphine I.V. as ordered b) Placing the client in a semi-Fowler's position c) Providing mouth care d) Maintaining nothing-by-mouth (NPO) status

b) Reserving a site for a peripherally inserted central catheter (PICC) Pg. 1433 Pancreatitis treatment typically involves resting the GI tract by maintaining nothing-by-mouth status. The nurse should reserve a site for placement of a PICC, which enables the client to receive long-term total parenteral nutrition. Clients in the acute stages of pancreatitis also require large volumes of I.V. fluids to compensate for fluid loss.

70. A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate? a) Providing generous servings at mealtime b) Reserving a site for a peripherally inserted central catheter (PICC) c) Limiting I.V. fluid intake according to the physician's order d) Providing the client with plenty of P.O. fluids

c) Vitamin K Pg. 1441 Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.

26. A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery? a) Potassium b) Oral bile acids c) Vitamin K d) Vitamin B

d) Pancreatitis can elevate the diaphragm and alter the breathing pattern Pg. 1431 Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. Appendicitis, cholecystitis, and gastric ulcer are less likely to exhibit fluid volume deficit.

38. The nurse is caring for a client with acute pancreatitis who is admitted to the intensive care unit to monitor for pulmonary complications. What is the nurse's understanding of the pathophysiology of pulmonary complications related to pancreatitis? a) Pancreatitis causes alterations to hemoglobin, impairing oxygenation b) Pancreatitis causes thickening of pulmonary secretions, impairing oxygenation c) Pancreatitis can atrophy the diaphragm and alter the breathing pattern d) Pancreatitis can elevate the diaphragm and alter the breathing pattern

c) "I should wash the site with mild soap and water" Pg. 1428 After a laparoscopic cholecystectomy, the client should be instructed about pain management, activity and exercise, wound care, nutrition, and follow-up care. The client should be directed to wash the puncture site with mild soap and water when caring for the wound. When resuming activity, the client should be instructed to drive after 3 or 4 days, take a shower or bath after 1 or 2 days, and begin light exercise such as walking immediately.

66. The nurse instructs a client on care at home after a laparoscopic cholecystectomy. Which client statement indicates that teaching has been effective? a) "I can drive after 2 weeks" b) "I can take a shower in a week" c) "I should wash the site with mild soap and water" d) "I should remain on bed rest for several days"

d) "Maintain a high-carbohydrate, low-fat diet" Pg. 1435 A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake isn't necessary because chronic pancreatitis isn't associated with hyponatremia or fluid loss.

55. A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct? a) "Maintain a high-fat diet and drink at least 3 L of fluid a day" b) "Maintain a high-fat, high-carbohydrate diet" c) "Maintain a high-sodium, high-calorie diet" d) "Maintain a high-carbohydrate, low-fat diet"

c) Place the client in semi-Fowler's position Pg. 1432 A client with severe biliary colic is in extreme pain and has a very difficult time taking a deep breath due to severe pain on inspiration. Placing the client in upright or semi-Fowler's position best promotes adequate breathing and best supports the client's function. Ambulation, deep breathing and coughing, and incentive spirometry may be too difficult or impossible for the client with severe biliary colic symptoms.

69. The nurse cares for a client with cholecystitis with severe biliary colic symptoms. Which nursing intervention best promotes adequate respirations in a client with these symptoms? a) Instruct the client on the proper use of an incentive spirometer b) Encourage the client to ambulate frequently c) Place the client in semi-Fowler's position d) Encourage the client to deep breathe and cough

b) Frequent vomiting, leading to loss of fluid volume Pg. 1431 Fluid and electrolyte disturbances are common complications because of nausea, vomiting, movement of fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever, and the use of gastric suction. The nurse assesses the client's fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the client daily and carefully measures fluid intake and output, including urine output, nasogastric secretions, and diarrhea.

46. Which condition in a client with pancreatitis makes it necessary for the nurse to check fluid intake and output, check hourly urine output, and monitor electrolyte levels? a) Acetone in the urine b) Frequent vomiting, leading to loss of fluid volume c) High glucose concentration in the blood d) Dry mouth, which makes the client thirsty

a) Full liquid diet as tolerated d) Initiate enteral feedings if tolerated e) Nasogastric tube to intermittent wall suction for removal of gastric secretions Pg. 1431 The nurse should question any order for clear liquid diet because oral intake should be held to inhibit pancreatic enzyme secretion. However, enteral feedings should be initiated as soon as possible, as the client tolerates them. The placement of a nasogastric tube to wall suction is recommended for the treatment of nausea, vomiting, or abdominal distention only; routine use of a nasogastric tube for removal of gastric secretions in order to limit pancreatic enzymes is not recommended. Enteral feedings should be tried first before parenteral feedings.

63. A nurse is caring for a client with mild acute pancreatitis. Which health care provider prescriptions will the nurse question as it relates to evidence-based practices in the treatment of acute pancreatitis? Select all that apply. a) Full liquid diet as tolerated b) Nasogastric tube to intermittent wall suction for relief of nausea c) No feedings per registered dietitian recommendations d) Initiate enteral feedings if tolerated e) Nasogastric tube to intermittent wall suction for removal of gastric secretions

a) Roasted chicken, mashed potatoes, and green beans c) Marinated lean steak, steamed rice, and roasted zucchini e) Oatmeal with a cooked fruit compote and hot tea Pg. 1422 Many individuals recover from an acute attack of gallbladder inflammation. After tolerating a low-fat liquid diet, the diet is usually advanced to allow cooked fruits, rice or tapioca, lean meats, mashed potatoes, and non-gas-forming vegetables. Bread, coffee, or tea may be added as tolerated. The client should avoid eggs, fatty dressings or mayonnaise, cheese, or gas-forming vegetables.

65. A client recovers from an episode of gallbladder inflammation and the client's diet is advanced from a low-fat liquid diet. Which meals will the nurse recommend to the client? Select all that apply. a) Roasted chicken, mashed potatoes, and green beans b) Egg salad sandwich with low fat mayonnaise and a side salad with ranch dressing c) Marinated lean steak, steamed rice, and roasted zucchini d) Vegetable lasagna, bread sticks, and steamed broccoli e) Oatmeal with a cooked fruit compote and hot tea

d) High-carbohydrate, low-protein, low-fat diet Pg. 1435 The nurse should provide a high-carbohydrate, low-protein, low-fat diet when tolerated. These foods increase caloric intake without stimulating pancreatic secretions beyond the ability of the pancreas to respond.

10. The patient admitted with acute pancreatitis has passed the acute stage and is now able to tolerate solid foods. What type of diet will increase caloric intake without stimulating pancreatic enzymes beyond the ability of the pancreas to respond? a) High-carbohydrate, high-protein, low-fat diet b) Low-sodium, high-potassium, low-fat diet c) Low-carbohydrate, high-potassium diet d) High-carbohydrate, low-protein, low-fat diet

a) Frequent changes of positions Pg. 1432 Frequent changes of position are necessary to prevent atelectasis and pooling of respiratory secretions.

11. When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions? a) Frequent changes of positions b) Placing the patient in the prone position c) Perform chest physiotherapy d) Suction the patient every 4 hours

d) Relieving abdominal pain Pg. 1431 The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can't help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

12. A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client? a) Preventing fluid volume overload b) Maintaining adequate nutritional status c) Teaching about the disease and its treatment d) Relieving abdominal pain

d) Regular insulin infusion for blood glucose level greater than 126 mg/dL Pg. 51 The client with acute pancreatitis is acutely ill and monitored in the intensive care unit. Insulin may be required if hyperglycemia occurs; however, best practice recommendations include targeting a blood glucose level of 140 to 200 mg/dL. Clinicians are also advised to avoid glucose targets less than 140 mg/dL because adverse effects are likely to increase with lower blood glucose targets. Respiratory care may include the use of humidified oxygen. Opioids are used to treat the pain associated with acute pancreatitis. The client's arterial blood gas will be monitored while in the intensive care unit.

17. The nurse is caring for a client with acute pancreatitis. Which prescription will the nurse question before implementing? a) Apply oxygen at 2 liters via nasal cannula b) Give intravenous morphine sulfate 2 mg every 4 hours PRN c) Obtain an arterial blood gas analysis now and every hour d) Regular insulin infusion for blood glucose level greater than 126 mg/dL

d) "How much alcohol do you consume in a day?" Pg. 1433 Chronic pancreatitis is an inflammatory disorder characterized by progressive destruction of the pancreas. Alcohol consumption in Western societies is the major cause of chronic pancreatitis. Excessive and prolonged consumption of alcohol accounts for approximately 70% to 80% of all cases of chronic pancreatitis. The incidence of pancreatitis is 50 times greater in people with alcoholism than in those who do not abuse alcohol. The type of food (like fried or heavily processed foods) rather than the number of meals eaten each day may contribute to pancreatitis and subsequent flare-ups of the condition. The prescibed use of acetaminophen is not a typical risk factor in pancreatitis and is rare with cases of overdose. The amount and/or lack of exercise is not directly linked to pancreatitis. Risk factors do include obesity.

20. The nurse is assessing a client admitted with suspected pancreatitis. Which question will the nurse prioritize when assessing this client? a) "When was the last time you took acetaminophen?" b) "How many meals do you eat every day?" c) "How often and how long do you exercise each day? d) "How much alcohol do you consume in a day?"

c) Vitamin A Pg. 1420 Obstruction of bile flow interferes with absorption of the fat-soluble vitamins A, D, E, and K. Clients may exhibit deficiencies of these vitamins if biliary obstruction has been prolonged. Vitamins B6, B12, and C are not fat soluble.

22. The nurse knows that the client with cholelithiasis can have a nutritional deficiency. The obstruction of bile flow due to cholelithiasis can interfere with the absorption of a) Vitamin B12 b) Vitamin C c) Vitamin A d) Vitamin B6

b) Severe abdominal pain Pg. 1430 Severe abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas.

30. The nurse is admitting a patient to the intensive care unit with a diagnosis of acute pancreatitis. What does the nurse expect was the reason the patient came to the hospital? a) Fever b) Severe abdominal pain c) Jaundice d) Mental agitation

c) Clay-colored stools Pg. 1427 The client with gallstones has clay-colored stools and excruciating upper right quadrant pain that radiates to the back or right shoulder. The excretion of bile pigments by the kidneys makes urine very dark. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. The client develops a fever and may have a palpable abdominal mass.

34. Which is a clinical manifestation of cholelithiasis? a) Nonpalpable abdominal mass b) Abdominal pain in the upper left quadrant c) Clay-colored stools d) Epigastric distress before a meal

b) Severe, radiating abdominal pain Pg. 1430 Clients with pancreatitis most commonly report severe mid- to upper-abdominal pain, radiating to both sides and straight to the back. The client may describe the stools as being frothy and foul smelling, not black or tarry. The client's urine may be dark. The client will not experience increased or painful urination, increased appetite, or weight gain.

35. Which is the most common report by clients with pancreatitis? a) Increased and painful urination b) Severe, radiating abdominal pain c) Increased appetite and weight gain d) Tarry, black stools and dark urine

c) Deficient fluid volume Pg. 1436 Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.

45. What is the most appropriate nursing diagnosis for the client with acute pancreatitis? a) Excess fluid volume b) Ineffective gastrointestinal tissue perfusion c) Deficient fluid volume d) Decreased cardiac output

a) Gray Pg. 1420 A gray-white stool color is common with a biliary obstruction because the stool is no longer colored with bile pigments.

48. A client with suspected biliary obstruction due to gallstones reports changes to the color of his stools. Which stool color does the nurse recognize as common to biliary obstruction? a) Gray b) Green c) Red d) Black

c) Impaired nutrition: less than body requirements Pg. 1437 While each diagnosis may be applicable to this client, the priority nursing diagnosis is impaired nutrition: less than body requirements. The physician, nurse, and dietitian emphasize to the client and family the importance of avoiding alcohol and foods that have produced abdominal pain and discomfort in the past. Oral food or fluid intake is not permitted during the acute phase.

54. A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority? a) Disturbed body image b) Anxiety c) Impaired nutrition: less than body requirements d) Nausea

d) To reduce gastric and pancreatic secretions Pg. 1431 Anticholinergic medications reduce gastric and pancreatic secretion.

56. The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason? a) To decrease metabolism b) To depress the central nervous system and increase the pain threshold c) To relieve nausea and vomiting d) To reduce gastric and pancreatic secretions

a) Cholelithiasis Pg. 1418 Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition. Cholecystitis is acute inflammation of the gallbladder. Choledocholithiasis is a gallstone in the common bile duct. Choledochotomy is an incision into the common bile duct.

62. A client with calculi in the gallbladder is said to have a) Cholelithiasis b) Cholecystitis c) Choledochotomy d) Choledocholithiasis

d) Edema and inflammation Pg. 1429 Mild acute pancreatitis is characterized by edema and inflammation confined to the pancreas. Minimal organ dysfunction is present, and return to normal function usually occurs within 6 months.

8. A patient is diagnosed with mild acute pancreatitis. What does the nurse understand is characteristic of this disorder? a) Pleural effusion b) Disseminated intravascular coagulopathy c) Sepsis d) Edema and inflammation

c) It visualizes the gallbladder and bile duct Pg. 1420 The cholecystogram is a diagnostic imaging test used to visualize the gallbladder and bile duct. The celiac axis arteriography visualizes the liver and pancreas. Ultrasonography shows the sizes of the abdominal organs and detects any masses. The endoscopic retrograde cholangiopancreatography (ERCP) visualizes the biliary structures and pancreas via endoscopy.

18. A client is scheduled for a cholecystogram for later in the day. What is the nurse's understanding on the diagnostic use of this exam? a) It visualizes the liver and pancreas b) It shows the sizes of the abdominal organs and detects any masses c) It visualizes the gallbladder and bile duct d) It visualizes the biliary structures and pancreas via endoscopy

b) Elevated urine amylase levels Pg. 1430 Elevated serum and urine amylase, lipase, and liver enzyme levels accompany significant pancreatitis. If the common bile duct is obstructed, the bilirubin level is above normal. Blood glucose levels and white blood cell counts can be elevated. Serum electrolyte levels (calcium, potassium, and magnesium) are low.

21. A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find? a) Decreased liver enzyme levels b) Elevated urine amylase levels c) Increased serum calcium levels d) Decreased white blood cell count

c) Yellow sclerae Pg. 1427 Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

19. A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: a) Circumoral pallor b) Light amber urine c) Yellow sclerae d) Black, tarry stools

a) Assessing the color of the sclera every shift Pg. 1427 If bile is not draining properly, an obstruction is probably causing bile to be forced back into the liver and bloodstream. Because jaundice may result, the nurse should assess the color of the sclerae.

50. Which intervention should be included in the plan of care for a client who has undergone a cholecystectomy? a) Assessing the color of the sclera every shift b) Clamping the T-tube immediately after surgery c) Placing the client on NPO (nothing by mouth) status for 2 days after surgery d) Placing the client in the semi-Fowler position immediately after surgery

a) "The tube allows the gastrointestinal tract to rest" Pg. 1441 Postoperative management of clients who have undergone a pancreatectomy or a pancreaticoduodenectomy is similar to the management of clients after extensive gastrointestinal or biliary surgery. An NG tube with suction and parenteral nutrition allow the gastrointestinal tract to rest while promoting adequate nutrition.

61. A client has a nasogastric (NG) tube for suction and is NPO after a pancreaticoduodenectomy. Which explanation made by the nurse is the major purpose of this treatment? a) "The tube allows the gastrointestinal tract to rest" b) "The tube provides relief from nausea and vomiting" c) "The tube helps control fluid and electrolyte imbalance" d) "The tube allows toxins to be removed"

c) Dysfunction of the pancreatic islet cells Pg. 1437 Diabetes mellitus resulting from dysfunction of the pancreatic islet cells is treated with diet, insulin, or oral antidiabetic agents. The hazard of severe hypoglycemia with alcohol consumption is stressed to the client and family. When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. A standard treatment with pancreatitis is to make the client NPO. The dysfunction is related to the pancreas, not the liver.

9. Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes mellitus. Which of the following explains the cause of this secondary diabetes? a) Renal failure b) Ingestion of foods high in sugar c) Dysfunction of the pancreatic islet cells d) Inability for the liver to reabsorb serum glucose

c) Gallbladder Pg. 1417 The gallbladder functions as a storage depot for bile.

13. A nurse is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the: a) Duodenum b) Common bile duct c) Gallbladder d) Cystic duct

b) Cheese Pg. 1422 The client should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the client that fatty foods may induce an episode of cholecystitis. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea may be consumed as tolerated.

14. Which foods should be avoided following acute gallbladder inflammation? a) Cooked fruits b) Cheese c) Coffee d) Mashed potatoes

c) Serum amylase Pg. 1430 Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.

23. A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test? a) Serum potassium b) Serum bilirubin c) Serum amylase d) Serum calcium

a) Bile-stained vomiting Pg. 1430 Nausea and vomiting are common in acute pancreatitis. The emesis is usually gastric in origin but may also be bile stained. Fever, jaundice, mental confusion, and agitation may also occur.

71. A client who had developed jaundice 2 months earlier is brought to the ED after attending a party and developing excruciating pain that radiated over the abdomen and into the back. Upon assessment, which additional symptom would the nurse expect this client to have? a) Bile-stained vomiting b) Warm, dry skin c) Hypertension d) Weight loss

b) Lipase Pg. 1440 Lipase is a pancreatic enzyme that aids in the digestion of fats. Amylase aids in the digestion of carbohydrates. Secretin is responsible for stimulating secretion of pancreatic juice. Trypsin aids in the digestion of protein.

7. Which enzyme aids in the digestion of fats? a) Trypsin b) Lipase c) Secretin d) Amylase

c) 6 to 12 months Pg. 1422 Six to 12 months of therapy with UDCA is recommended in clients to dissolve the stones.

44. Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones? a) 1 to 4 months b) 4 to 6 months c) 6 to 12 months d) Over 1 year

b) Hot roast beef sandwich with gravy Pg. 1422 The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated. The client should avoid fried foods such as roast beef because fatty foods may bring on an episode of cholecystitis.

49. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? a) Vanilla pudding b) Hot roast beef sandwich with gravy c) Mashed potatoes d) White rice

b) Pain with abdominal distention and hypotension Pg. 1430 Assessment findings associated with pancreatitis include pain with abdominal distention and hypotension. Blood in stools and recent hypertension aren't associated with pancreatitis; fatty diarrhea and hypotension are usually present. Presence of easy bruising and bradycardia aren't found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Adventitious breath sounds and hypertension aren't associated with pancreatitis.

24. A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm the diagnosis of acute pancreatitis? a) Presence of easy bruising and bradycardia b) Pain with abdominal distention and hypotension c) Presence of blood in the client's stool and recent hypertension d) Adventitious breath sounds and hypertension

a) Cannot tolerate high-glucose concentration Pg. 1437 Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.

32. Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients: a) Cannot tolerate high-glucose concentration b) Are at risk for gallbladder contraction c) Are at risk for hepatic encephalopathy d) Can digest high-fat foods

c) Acute pain related to biliary spasms Pg. The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

4. A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? a) Imbalanced nutrition: Less than body requirements related to biliary inflammation b) Anxiety related to unknown outcome of hospitalization c) Acute pain related to biliary spasms d) Deficient knowledge related to prevention of disease recurrence

c) Positioning the client on the side with the knees flexed Pg. The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

1. When caring for a client with acute pancreatitis, the nurse should use which comfort measure? a) Administering frequent oral feedings b) Administering an analgesic once per shift, as ordered, to prevent drug addiction c) Positioning the client on the side with the knees flexed d) Encouraging frequent visits from family and friends

d) Providing intensive insulin therapy Pg. 1431 Intensive insulin therapy (continuous infusion) in the critically ill client has undergone much study and has shown promise in terms of positive client outcomes when compared with intermittent insulin dosing. Glycemic control with normal or near normal blood glucose levels improves client outcomes. Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration, even with insulin coverage. Clients with pancreatitis should not be given high-fat foods because they are difficult to digest. The current recommendation for pain management in this population is parenteral opioids. The nurse should maintain the client in a semi-Fowler's position to reduce pressure on the diaphragm.

41. Because clients with pancreatitis cannot tolerate high-glucose concentrations, total parental nutrition (TPN) should be used cautiously with them. Which of the following interventions has shown great promise in the prognosis of clients with severe acute pancreatitis? a) Administering oral analgesics around the clock b) Maintaining a high-Fowler's position c) Allowing a clear liquid diet during the acute phase d) Providing intensive insulin therapy

c) Increased amount of fibrous material Pg. 1418 An increase in fibrous material and some fatty deposition occurs in the normal pancreas of people older than 70 years of age. There is a decreased rate of pancreatic secretion and decreased bicarbonate output in older adults. Decreased calcium absorption may also occur.

42. Which is a gerontological consideration associated with the pancreas? a) Increased calcium absorption b) Increased bicarbonate output c) Increased amount of fibrous material d) Increased rate of pancreatic secretion

a) Light-colored urine Pg. 1420 The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish, like putty, or clay-colored. The symptoms may be acute or chronic. Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen, may occur. If it goes untreated jaundice and pruritus can occur.

28. Clinical manifestations of common bile duct obstruction include all of the following except: a) Light-colored urine b) Jaundice c) Pruritus d) Clay-colored feces

b) Amylase Pg. 1430 Amylase is secreted by the exocrine pancreas. Lipase aids in the digestion of fats. Trypsin aids in the digestion of proteins. Secretin is the major stimulus for increased bicarbonate secretion from the pancreas.

2. The digestion of carbohydrates is aided by a) Trypsin b) Amylase c) Lipase d) Secretin

a) Decreases in the physiologic function of major organs Pg. 1429 Acute pancreatitis affects people of all ages, but the mortality rate associated with acute pancreatitis increases with advancing age. The pattern of complications changes with age. Younger clients tend to develop local complications; the incidence of multiple organ failure increases with age, possibly as a result of progressive decreases in physiologic function of major organs with increasing age.

3. A 70-year-old client is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which gerontologic consideration associated with the pancreas? a) Decreases in the physiologic function of major organs b) Increases in the bicarbonate output by the kidneys c) Development of local complications d) Increases in the rate of pancreatic secretion

b) Weight loss Pg. 1437 Weight loss is most common in the client with chronic pancreatitis due to decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack. The other answer choices are not the most common complications related to chronic pancreatitis.

36. A client with chronic pancreatitis is treated for uncontrolled pain. Which complication does the nurse recognize is most common in the client with chronic pancreatitis? a) Fatigue b) Weight loss c) Hypertension d) Diarrhea

a) Choledocholithotomy Pg. 1418 Choledocholithotomy refers to incision of the common bile duct for the removal of stones. Cholecystostomy refers to opening and draining the gallbladder. Choledochotomy refers to opening into the common duct. Choledochoduodenostomy refers to anastomosis of the common duct to the duodenum.

37. Which term most precisely refers to the incision of the common bile duct for removal of stones? a) Choledocholithotomy b) Cholecystostomy c) Choledochotomy d) Choledochoduodenostomy

b) Age Pg. 1438 Incidence of pancreatic cancer increases with age, peaking in the seventh and eighth decades for both men and women. It is very rare before 45 years, and most patients present in or beyond the sixth decade of life. Cigarette smoking, exposure to industrial chemicals or toxins in the environment, and a diet high in fat, meat, or both are associated with pancreatic cancer, although their roles are not completely clear. Diabetes mellitus, chronic pancreatitis, and hereditary pancreatitis are also associated with pancreatic cancer.

39. A nursing student has been assigned to care for a client with pancreatic cancer. The student is aware that the risk for pancreatic cancer is most directly proportional to a) Presence of diabetes mellitus b) Age c) Cigarette smoking d) Dietary intake of fat

a) 6 to 12 months Pg. 1422 Ursodeoxycholic acid (UDCA [Urso, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol (Karch, 2012). Six to 12 months of therapy is required in many patients to dissolve stones, and monitoring of the patient for recurrence of symptoms or the occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required during this time.

43. A patient is receiving pharmacologic therapy with ursodeoxycholic acid or chenodeoxycholic-cholic acid for treatment of small gallstones. The patient asks the nurse how long the therapy will take to dissolve the stones. What is the best answer the nurse can give? a) 6 to 12 months b) 3 to 5 months c) 6 to 8 months d) 1 to 2 months

d) The patient has developed peritonitis Pg. 1430 Abdominal guarding is present. A rigid or board-like abdomen may develop and is generally an ominous sign, usually indicating peritonitis.

52. A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is board-like and no bowel sounds are detected. What is the major concern for this patient? a) The patient has developed renal failure b) The patient is developing a paralytic ileus c) The patient requires more pain medication d) The patient has developed peritonitis

a) Use incentive spirometry every hour Pg. 1427 The nurse instructs the client in techniques of coughing and deep breathing and in the use of incentive spirometry to improve respiratory function. The nurse assists the client to perform these activities every hour. Repositioning the client every 2 hours minimizes the risk of atelectasis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring pulse oximetry helps show changes in respiratory status and promotes early intervention, but it would do little to minimize the risk of atelectasis. Withholding analgesics is not an appropriate intervention due to the severe pain associated with pancreatitis.

15. A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? a) Use incentive spirometry every hour b) Instruct the client to cough only when necessary c) Monitor pulse oximetry every hour d) Withhold analgesics unless necessary

d) Assisting the client to turn, cough, and deep breathe every 2 hours Pg. 1435 Assessment should focus on the client's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation.

16. The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client? a) Performing range-of-motion (ROM) leg exercises hourly while the client is awake b) Assisting the client to ambulate the evening of the operative day c) Teaching the client to choose low-fat foods from the menu d) Assisting the client to turn, cough, and deep breathe every 2 hours

b) Withholding all oral intake, as ordered, to decrease pancreatic secretions Pg. 1431 The nurse should withhold all oral intake to suppress pancreatic secretions, which may worsen pancreatitis. Pain relief may require parenteral opioids such as morphine, fentanyl (Sublimaze), or hydromorphone (Dilaudid). No clinical evidence supports the use of meperidine for pain relief in pancreatitis, and, in fact, accumulation of its metabolites can cause CNS irritability and possibly seizures. Pancreatitis places the client at risk for fluid volume deficit from fluid loss caused by increased capillary permeability. Therefore, this client needs fluid resuscitation, not fluid restriction. A client with pancreatitis is most comfortable lying on the side with knees flexed.

27. A nurse is caring for a client admitted with acute pancreatitis. Which nursing action is most appropriate for a client with this diagnosis? a) Limiting I.V. fluids, as ordered, to decrease cardiac workload b) Withholding all oral intake, as ordered, to decrease pancreatic secretions c) Keeping the client supine to increase comfort d) Administering meperidine, as ordered, to relieve severe pain

b) "This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort" Pg. 1424-1425 If pain occurs in the right shoulder or scapular area (from migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure), the nurse may recommend using a heating pad for 15 to 20 minutes hourly, sitting up in a bed or chair, or walking.

31. A client discharged after a laparoscopic cholecystectomy calls the surgeon's office reporting severe right shoulder pain 24 hours after surgery. Which statement is the correct information for the nurse to provide to this client? a) "This pain may be caused by a bile duct injury. You will need to go to the hospital immediately to have this evaluated" b) "This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort" c) "This pain is caused from your incision. Take analgesics as needed and as prescribed and report to the surgeon if pain is unrelieved even with analgesic use" d) "This may be the initial symptoms of an infection. You need to come to see the surgeon today for an evaluation"

d) Alcohol consumption and smoking Pg. 1436 Alcohol consumption in Western societies is a major factor in the development of chronic pancreatitis, as is smoking. Because heavy drinkers usually smoke, it is difficult to separate the effects of the alcohol abuse and smoking. Malnutrition is a major cause of chronic pancreatitis worldwide, but alcohol consumption is more commonly the cause in Western societies. Caffeine consumption is not related to acute pancreatitis. Acute hepatitis does not usually lead to chronic pancreatitis unless complications develop.

40. A nurse is teaching a client and the client's family about chronic pancreatitis. Which are the major causes of chronic pancreatitis? a) Malnutrition and acute pancreatitis b) Acute hepatitis and alcohol consumption c) Caffeine consumption and acute pancreatitis d) Alcohol consumption and smoking

c) Pancreatic carcinoma Pg. 1439 Pain, jaundice, and weight loss are considered classic signs of pancreatic carcinoma. Other signs include rapid, profound, and progressive weight loss as well as vague upper or midabdominal pain or discomfort unrelated to any gastrointestinal function that is often difficult to describe. It is often more severe at night and is accentuated when lying supine. The formation of ascites is common. An important sign is the onset of symptoms of insulin deficiency: glucosuria, hyperglycemia, and abnormal glucose tolerance. Therefore, diabetes may be an early sign of carcinoma of the pancreas.

47. A client is admitted to the health care center with hyperglycemia, a 15-pound weight loss, and reports of vague upper and midabdominal pain that increases in intensity at night. The client' health history indicates alcoholism, smoking of a pack of cigarettes daily, and diabetes for the past 20 years. Upon examination the nurse finds swelling in the feet and abdominal ascites. Based on the clinical manifestations, which condition is the most likely diagnosis? a) Acute pancreatitis with edema b) Cholecystitis c) Pancreatic carcinoma d) Pancreatic pseudocysts

c) 30 mg/dL Pg. 1442 Hyperinsulinism is caused by overproduction of insulin by the pancreatic islets. Occasionally, tumors of nonpancreatic origin produce an insulin-like material that can cause severe hypoglycemia and may be responsible for seizures coinciding with blood glucose levels that are too low to sustain normal brain function (i.e., lower than 30 mg/dL [1.6 mmol/L]) (Goldman & Schafer, 2012; McPherson & Pincus, 2011).

5. A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood glucose level does the nurse recognize as inadequate to sustain normal brain function? a) 90 mg/dL b) 70 mg/dL c) 30 mg/dL d) 50 mg/dL

d) Decompression Pg. 1424 Negative pressure exerted through a tube inserted in the stomach removes secretions and gaseous substances from the stomach, preventing abdominal distention, nausea, and vomiting. Instillations in a nasogastric tube after surgery are done when necessary to promote patency; this is not the most common purpose of a nasogastric tube after surgery. Gavage is contraindicated after abdominal surgery until peristalsis returns. Lavage after surgery may be done to promote hemostasis in the presence of gastric bleeding, but this is not the most common purpose of a nasogastric tube after surgery.

51. A preoperative client scheduled to have an open cholecystectomy says to the nurse, "The doctor said that after surgery, I will have a tube in my nose that goes into my stomach. Why do I need that?" What most common reason for a client having a nasogastric tube in place after abdominal surgery should the nurse include in a response? a) Gavage b) Lavage c) Instillation d) Decompression

b) Use a pain scale throughout treatment d) Administer pain relief measures f) Maintain nothing by mouth (NPO) diet Pg. 1430 The diagnosis of acute pancreatitis is based on the fulfillment of two out of the three criteria to include upper abdominal pain, serum lipase level greater than 3 times the upper limit of normal, serum amylase level greater than 3 times the upper limit of normal, and an increase in the diameter of the pancreas upon computed tomography (CT) scan.The nursing diagnosis priority for acute pain relies on using a pain scale at baseline, before and after administration of pain relieving medications. Controlling pain is important because restlessness increases the body's metabolism, which stimulates the secretion of pancreatic and gastric enzymes. Pancreatic secretion is increased by food and fluid intake, so maintaining an NPO status decreases inflammation and pain. Bed rest decreases body metabolism and thus reduces pancreatric and gastric secretions. Assessing the client current nutrtional is important, since alteration in pancreatic secretions interferes with normal digestive processes, but is not a priority initial intervention. Providing oral hygiene assists with nutrtiional intake, but is not the first priority in care for this client.

53. A client with severe abdominal pain and an abnormal computed tomography (CT) scan, which shows an enlarged pancreas, has been andmitted to a medical unit today. The nurse anticipates including which actions in the client's plan of care? Select all that apply. a) Provide oral hygiene and gargling solutions b) Use a pain scale throughout treatment c) Encourage ambulation as tolerated d) Administer pain relief measures e) Assess current nutritional status f) Maintain nothing by mouth (NPO) diet

a) Reposition the client every 2 hours Pg. 1432 Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.

58. A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? a) Reposition the client every 2 hours b) Monitor pulse oximetry every hour c) Withhold oral feedings for the client d) Instruct the client to avoid coughing

b) Pigment Pg. 1419 There are two major types of gallstones: those composed predominantly of pigment and those composed primarily of cholesterol. Pigment stones probably form when unconjugated pigments in the bile precipitate to form stones; these stones account for 10% to 25% of cases in the United States. There are no gallstones with the names of pearl, patterned, or pixelated.

6. One difference between cholesterol stones (left) and the stones on the right are that the ones on the right account for only 10% to 25% of cases of stones in the United States. What is the name of the stones on the right? a) Pixelated b) Pigment c) Pearl d) Patterned

a) "Apply a heating pad to your shoulder for 15 minutes hourly as needed" Pg. 1425 Pain in the right shoulder may occur after laparoscopic cholecystectomy due to migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure. The nurse should instruct the client to apply a heating pad to the shoulder for 15 to 20 minutes every hour as needed for pain relief. The nurse should not instruct the client to take analgesic medication-this is a medical order performed by the health care provider only. This scenario is not life threatening and the client does not need to go to the emergency department. It is also not necessary for the client to place the shoulder in a sling as this is not an injury-related condition.

64. A client who is 24 hours post op from laparoscopic cholecystectomy calls the nurse and reports pain in the right shoulder. How should the nurse respond to the client's report of symptoms? a) "Apply a heating pad to your shoulder for 15 minutes hourly as needed" b) "Take an over the counter analgesic as needed" c) "Come into the emergency room as soon as possible" d) "Place your shoulder in a sling to avoid moving it"

d) ERCP Pg. 1437 The ERCP is the most useful study in the diagnosis of chronic pancreatitis. The other answer choices may be used; however, these are not the most useful in the diagnosis of chronic pancreatitis.

68. The nurse is caring for a client with suspected chronic pancreatitis. Which diagnostic test or imaging does the nurse recognize as the most useful in diagnosing this condition? a) MRI b) CT c) Ultrasound d) ERCP