Ch. 50: Assessment and Management of Patients with Biliary Disorders

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) Impaired nutrition: less than body requirements b) Nausea c) Anxiety d) Disturbed body image

Impaired nutrition: less than body requirements 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.

When caring for the patient with acute pancreatitis, the nurse must consider pain relief measures. What nursing interventions could the nurse provide? (Select all that apply.) a) Withholding oral feedings to limit the release of secretin b) Administering parenteral opioid analgesics as ordered c) Administering prophylactic antibiotics d) Encouraging bed rest to decrease the metabolic rate e) Assisting the patient into the prone position

• Withholding oral feedings to limit the release of secretin • Administering parenteral opioid analgesics as ordered • Encouraging bed rest to decrease the metabolic rate The current recommendation for pain management is the use of opioids, with assessment for their effectiveness and altering therapy if pain is not controlled or increased (Marx, 2009). Nonpharmacologic interventions such as proper positioning (not prone), music, distraction, and imagery may be effective in reducing pain when used along with medications. In addition, oral feedings are withheld to decrease the secretion of secretin.

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) White rice d) Mashed potatoes

Hot roast beef sandwich with gravy 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 fried chicken, because fatty foods may bring on an episode of cholecystitis.

Which of the following would be included as a postoperative intervention for the patient undergoing a laparoscopic cholecystectomy? a) Semi-Fowler's position b) Observe color of sclera c) Low-carbohydrate, low-protein diet immediately after surgery d) NPO status postop for 2 days

Observe color of sclera The nurse should be particularly observant of the color of the sclera. After recovery from anesthesia, the patient is placed in the low Fowler's position. Water and other fluids may be administered within hours after laparoscopic procedures. A soft diet is started after bowel sounds return.

A patient is admitted to the health care center with hyperglycemia, a 15-pound weight loss, and complaints of vague upper and midabdominal pain that increases in intensity at night. His health history record indicates that he is an alcoholic, smokes a pack of cigarettes daily, and has had diabetes for the past 20 years. On examination, the nurse finds swelling in his feet and abdominal ascites. Based on the clinical manifestations, which of the following is most likely to be the diagnosis? a) Cholecystitis b) Pancreatic pseudocysts c) Pancreatic carcinoma d) Acute pancreatitis with edema

Pancreatic carcinoma 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 and it 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.

The nursing student has just reviewed material in the course textbook regarding pancreatitis. The student knows that a major symptom of pancreatitis that causes the client to seek medical care is: a) Jaundice b) Mental agitation c) Severe abdominal pain d) Fever

Severe abdominal pain The pain of acute pancreatitis is often very severe, necessitating the liberal use of analgesics. Jaundice is indicative of a bile duct obstruction. Fever and mental agitation are not indicative of pancreatitis.

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

Assisting the patient to turn, cough, and deep breathe every 2 hours Assessment should focus on the patient'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.

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

Dysfunction of the pancreatic islet cells 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.

Which of the following enzymes aids in the digestion of fats? a) Secretin b) Trypsin c) Lipase d) Amylase

Lipase 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.

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) Instruct the client to avoid coughing. b) Withhold oral feedings for the client. c) Monitor pulse oximetry every hour. d) Reposition the client every 2 hours.

Reposition the client every 2 hours. 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.

The physician has written the following orders: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) for a new patient admitted with pancreatitis. The nurse attributes which of the following as the cause for NPO status? a) To aid opening up of pancreatic duct b) To prevent the occurrence of fibrosis c) To drain the pancreatic bed d) To avoid inflammation of the pancreas

To avoid inflammation of the pancreas Pancreatic secretion is increased by food and fluid intake and may cause inflammation of the pancreas.

A 70-year-old patient 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 of the following gerontologic considerations associated with the pancreas? a) Decreases in the physiologic function of major organs b) Increases in the rate of pancreatic secretion c) Development of local complications d) Increases in the bicarbonate output by the kidneys

Decreases in the physiologic function of major organs 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 patients 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.

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

Frequent vomiting leading to loss of fluid volume 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 patient's fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the patient daily and carefully measures fluid intake and output, including urine output, nasogastric secretions, and diarrhea.

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 boardlike 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.

The patient has developed peritonitis. Abdominal guarding is present. A rigid or boardlike abdomen may develop and is generally an ominous sign, usually indicating peritonitis

Total parental nutrition (TPN) should be used cautiously in patients with pancreatitis due to which of the following? a) They are at risk for gallbladder contraction. b) They can digest high-fat foods. c) They cannot tolerate high-glucose concentration. d) They are at risk for hepatic encephalopathy.

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

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 depress the central nervous system and increase the pain threshold b) To relieve nausea and vomiting c) To decrease metabolism d) To reduce gastric and pancreatic secretions

To reduce gastric and pancreatic secretions Anticholinergic medications reduce gastric and pancreatic secretion.

A patient is admitted to the hospital with possible cholelithiasis. What diagnostic test of choice will the nurse prepare the patient for? a) Cholecystography b) Ultrasonography c) Oral cholecystography d) X-ray

Ultrasonography Ultrasonography has replaced cholecystography (discussed later) as the diagnostic procedure of choice because it is rapid and accurate and can be used in patients with liver dysfunction and jaundice. It does not expose patients to ionizing radiation.

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

"Maintain a high-carbohydrate, low-fat diet." 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.

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

30 mg/dL Hyperinsulinism is caused by overproduction of insulin by the pancreatic islets. Occasionally, tumors of nonpancreatic origin produce an insulinlike 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

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) Acute pain related to biliary spasms b) Imbalanced nutrition: Less than body requirements related to biliary inflammation c) Anxiety related to unknown outcome of hospitalization d) Deficient knowledge related to prevention of disease recurrence

Acute pain related to biliary spasms 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

A patient with acute pancreatitis has been started on total parenteral nutrition (TPN). Following the administration of the TPN, which of the following should the nurse plan to monitor? a) Auscultate the abdomen for bowel sounds every 4 hours b) Measure the abdominal girth every shift c) Blood glucose levels every 4 to 6 hours d) Complaints of nausea and vomiting

Blood glucose levels every 4 to 6 hours Enteral or parenteral nutrition may be prescribed. In addition to administering enteral or parenteral nutrition, the nurse monitors serum glucose levels every 4 to 6 hours.

Which of the following is clinical manifestation of cholelithiasis? a) Clay-colored stools b) Epigastric distress prior to a meal c) Nonpalpable abdominal mass d) Upper left quadrant abdominal pain

Clay-colored stools The patient 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 patient develops a fever and may have a palpable abdominal mass.

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

Edema and inflammation 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.

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) Increased serum calcium levels b) Decreased white blood cell count c) Elevated urine amylase levels d) Decreased liver enzyme levels

Elevated urine amylase levels 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.

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) Gallbladder b) Duodenum c) Cystic duct d) Common bile duct

Gallbladder The gallbladder functions as a storage depot for bile.

A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system? a) Maintain the client in a semi-Fowler's position. b) Administer enteral or parenteral nutrition. c) Withhold oral feedings. d) Carry out wound care as prescribed.

Maintain the client in a semi-Fowler's position. The nurse maintains the client in the semi-Fowler's position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. Respiratory distress and hypoxia are common, and the client may develop diffuse pulmonary infiltrates, dyspnea, tachypnea, and abnormal blood gas values. The client who has undergone surgery may have multiple drains or an open surgical incision and is at risk for skin breakdown and infection. Oral food or fluid intake is not permitted; therefore, enteral or parenteral feedings may be prescribed.

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) Maintaining adequate nutritional status b) Preventing fluid volume overload c) Teaching about the disease and its treatment d) Relieving abdominal pain

Relieving abdominal pain 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.

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

Withholding all oral intake, as ordered, to decrease pancreatic secretions The nurse should withhold all oral intake to suppress pancreatic secretions, which may worsen pancreatitis.

The digestion of carbohydrates is aided by a) trypsin. b) secretin. c) amylase. d) lipase.

amylase. 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.

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) yellow sclerae. c) black, tarry stools. d) light amber urine.

yellow sclerae. 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.

The nurse admits a woman who is 8 weeks postpartum. The client presents with reports of severe right upper quadrant pain that radiates to her back. She states she just finished eating Thanksgiving dinner earlier that evening. The nurse suspects gallbladder disease. Statistics show that incidence of gallbladder disease is greater for women who are which of the following? Select all that apply. a) Multiparous b) Obese c) Thin d) Wealthy e) Older than 60 years

• Multiparous • Obese Two to three times more women than men develop cholesterol stones and gallbladder disease; affected women are usually older than 40 years, multiparous, and obese.