Chapter 44 Assessment and Management of Patients with Biliary Disorders

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

Ans: D

A client's assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment question(s) addresses likely etiologic factors? Select all that apply. A. "How many alcoholic drinks do you typically consume in a week?" B. "Have you ever been tested for diabetes?" C. "Have you ever been diagnosed with gallstones?" D. "Would you say that you eat a particularly high-fat diet?" E. "Does anyone in your family have cystic fibrosis?"

A, B, C, D

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? - Maintaining nothing-by-mouth (NPO) status - Providing mouth care - Administering morphine I.V. as ordered - Placing the client in a semi-Fowler's position

Administering morphine I.V. as ordered Explanation: 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.

Reason behind an increased serum lipase level in acute pancreatitis

Increased lipase appears in the blood stream following damage to the pancreas

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? - Presence of easy bruising and bradycardia - Presence of blood in the client's stool and recent hypertension - Adventitious breath sounds and hypertension - Pain with abdominal distention and hypotension

Pain with abdominal distention and hypotension Explanation: 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.

Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit? - Appendicitis - Pancreatitis - Peptic ulcer - Cholecystitis

Pancreatitis Explanation: 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.

The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of: - Serum bilirubin - Serum amylase - Serum calcium - Serum lipase

Serum lipase Explanation: In most cases, serum amylase and lipase levels are elevated within 24 hours of the onset of the symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated for a longer period, often days longer than amylase.

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? - The patient is developing a paralytic ileus. - The patient has developed peritonitis. - The patient requires more pain medication. - The patient has developed renal failure.

The patient has developed peritonitis. Explanation: Abdominal guarding is present. A rigid or board-like abdomen may develop and is generally an ominous sign, usually indicating peritonitis (Privette et al., 2011).

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? - Fatigue - Hypertension - Diarrhea - Weight loss

Weight loss Explanation: 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.

A client with acute pancreatitis is prescribed hydromorphone 2 mg intranvenously every 4 hours as needed for severe pain. Which assessment will the nurse prioritize for this client? - Bleeding tendency - Development of nausea - Bowel sounds - Heart sounds

Bowel sounds Explanation: Adequate administration of analgesia is essential during the course of acute pancreatitis to provide sufficient pain relief and to minimize restlessness, which may further stimulate pancreatic secretion. Pain relief may require parenteral opioids such as morphine, fentanyl, or hydromorphone. Gastrointestinal paralysis and ileus are common problems in early acute pancreatitis that can be potentiated and aggravated by the use of high-dose opioids. Although opioids can affect heart rate, assessing the effect on heart sounds would not be the priority over assessing for bowel sounds in acute pancreatitis. Bleeding tendency would be a priority if the client is taking nonsteroidal anti-inflammatory drugs. Nausea is not identified as a potential adverse effect when a client with acute pancreatitis receives opioids for pain management.

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

Coffee Explanation: 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.

A nurse is assessing a client who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the client's pain, the nurse should anticipate that it may radiate to what region? A. Left upper chest B. Inguinal region C. Neck or jaw D. Right shoulder

D. Right shoulder Rationale: The client may have biliary colic with excruciating upper-right abdominal pain that radiates to the back or right shoulder. Pain from cholecystitis does not typically radiate to the left upper chest, inguinal area, neck, or jaw.

A client is being treated for acute pain from an episode of pancreatitis. The nurse has identified a nursing diagnosis of Ineffective Breathing Pattern related to pain secondary to effects of surgery. Which intervention should the nurse perform in order to best address this diagnosis? A. Position the client supine to facilitate diaphragm movement. B. Administer corticosteroids by nebulizer as prescribed. C. Perform oral suctioning as needed to remove secretions. D. Administer analgesic per orders.

D. Administer analgesic per orders. Rationale: The client has ineffective breathing patterns due to pain. To increase the likelihood of the client being able to perform interventions for his/her respiratory status, it would be important to treat acute pain first.

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: - Gallbladder - Duodenum - Cystic duct - Common bile duct

Gallbladder

Which of the organs involve amylase?

Liver, pancreas, and salivary glands

A client has been diagnosed with pancreatic cancer and has been admitted for care. Following initial treatment, the nurse should be aware that the client is most likely to require which of the following situations? A. Inpatient rehabilitation B. Rehabilitation in the home setting C. Intensive physical therapy D. Hospice care

D. Hospice care Rationale: Pancreatic carcinoma has only a low survival rate regardless of the stage of disease at diagnosis or treatment. As a result, there is a higher likelihood that the client will require hospice care than physical therapy and rehabilitation.

A nurse who provides care in a community clinic assesses a wide range of individuals. The nurse should identify which client as having the highest risk for chronic pancreatitis? A. A 45-year-old obese woman with a high-fat diet B. An 18-year-old man who is a weekend binge drinker C. A 39-year-old man with chronic alcoholism D. A 51-year-old woman who smokes one-and-a-half packs of cigarettes per day

C. A 39-year-old man with chronic alcoholism Rationale: Excessive and prolonged consumption of alcohol accounts for most cases of chronic pancreatitis in Western societies.

The most common risk factor for development of acute pancreatitis in women?

Gallstones

An adult client has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this client's plan of care? A. Measure the client's abdominal girth daily. B. Limit the use of opioid analgesics. C. Monitor the client for signs of dysphagia. D. Encourage activity as tolerated.

A. Measure the client's abdominal girth daily. Rationale: Due to the risk of ascites, the nurse should monitor the client's abdominal girth. There is no specific need to avoid the use of opioids or to monitor for dysphagia, and activity is usually limited.

A nurse is providing discharge education to a client who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods? A. High-fiber foods B. Low-purine, nutrient-dense foods C. Low-fat foods high in proteins and carbohydrates D. Foods that are low-residue and low in fat

Ans: C Rationale: The nurse encourages the client to eat a diet that is low in fats and high in carbohydrates and proteins immediately after surgery. There is no specific need to increase fiber or avoid purines. A low-residue diet is not indicated.

The nurse is caring for a client who has just returned from the ERCP removal of gallstones. The nurse should monitor the client for signs of what complications? A. Pain and peritonitis B. Bleeding and perforation C. Acidosis and hypoglycemia D. Gangrene of the gallbladder and hyperglycemia

B. Bleeding and perforation Rationale: Following ERCP removal of gallstones, the client is observed closely for bleeding, perforation, and the development of pancreatitis or sepsis. Blood sugar alterations, gangrene, peritonitis, and acidosis are less likely complications.

A student nurse is caring for a client who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments? A. Fluid output B. Oral intake C. Blood glucose levels D. BUN and creatinine levels

C. Blood glucose levels Rationale: In addition to administering enteral or parenteral nutrition, the nurse monitors serum glucose levels every 4 to 6 hours. Output should be monitored but in most cases it is not more important than serum glucose levels. A client on parenteral nutrition would have no oral intake to monitor. Blood sugar levels are more likely to be unstable than indicators of renal function.

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? - To decrease metabolism - To relieve nausea and vomiting - To reduce gastric and pancreatic secretions - To depress the central nervous system and increase the pain threshold

To reduce gastric and pancreatic secretions

A client is admitted to the ICU with acute pancreatitis. The client's family asks what causes acute pancreatitis. The critical care nurse knows that a majority of clients with acute pancreatitis have what health issue? A. Type 1 diabetes B. An impaired immune system C. Undiagnosed chronic pancreatitis D. An amylase deficiency

C. Undiagnosed chronic pancreatitis Rationale: Eighty percent of clients with acute pancreatitis have biliary tract disease or a history of long-term alcohol abuse. These clients usually have had undiagnosed chronic pancreatitis before their first episode of acute pancreatitis. Diabetes, an impaired immune function, and amylase deficiency are not specific precursors to acute pancreatitis.

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

Clay-colored stools Explanation: 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.

A nurse is assessing an older adult client with gallstones. The nurse is aware that the client may not exhibit typical symptoms, and that particular symptoms that may be exhibited in the elderly client may include what examples? A. Fever and pain B. Chills and jaundice C. Nausea and vomiting D. Signs and symptoms of septic shock

D. Signs and symptoms of septic shock Rationale: The elderly client may not exhibit the typical symptoms of fever, pain, chills jaundice, and nausea and vomiting. Symptoms of biliary tract disease in the elderly may be accompanied or preceded by those of septic shock, which include oliguria, hypotension, change in mental status, tachycardia, and tachypnea.

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 - Vitamin A - Vitamin B12 - Vitamin C - Vitamin B6

Vitamin A Explanation: 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.

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

Alcohol consumption and smoking Explanation: 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.

A client has been admitted to the hospital for the treatment of chronic pancreatitis. The client has been stabilized and the nurse is now planning health promotion and educational interventions. Which of the following should the nurse prioritize? A. Educating the client about expectations and care following surgery B. Educating the client about the management of blood glucose after discharge C. Educating the client about post discharge lifestyle modifications D. Educating the client about the potential benefits of pancreatic transplantation

Ans: C

A client has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize what topic? A. Management of fluid balance in the home setting B. The need for blood glucose monitoring for the next week C. Signs and symptoms of intra-abdominal complications D. Appropriate use of prescribed pancreatic enzymes

C. Signs and symptoms of intra-abdominal complications Rationale: Because of the early discharge following laparoscopic cholecystectomy, the client needs thorough education in the signs and symptoms of complications. Fluid balance is not typically a problem in the recovery period after laparoscopic cholecystectomy. There is no need for blood glucose monitoring or pancreatic enzymes.

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? - Vanilla pudding - White rice - Mashed potatoes - Hot roast beef sandwich with gravy

Hot roast beef sandwich with gravy Explanation: 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.

A client is admitted to the health care center with severe abdominal pain rated 10 on a 1-to-10 scale, tachycardia, hypertension, and muscle spasms. The nurse immediately administers morphine sulfate 4 mg slow intravenous pyelogram (IVP), as ordered. The nurse plans for which goal after administration of this mediation? - To diagnose the cause of abdominal pain - To control muscle spasms - To increase the client's pain threshold - To control blood pressure

To increase the client's pain threshold Explanation: Morphine, fentanyl, and hydromorphone act by depressing the central nervous system, thereby increasing the client's pain threshold.

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? - Decreased white blood cell count - Elevated urine amylase levels - Decreased liver enzyme levels - Increased serum calcium levels

Elevated urine amylase levels Explanation: 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 patient is diagnosed with mild acute pancreatitis. What does the nurse understand is characteristic of this disorder? - Edema and inflammation - Disseminated intravascular coagulopathy - Sepsis - Pleural effusion

Edema and inflammation Explanation: 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 nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan? - Improve nutritional status during recovery. - Decrease the amount of postoperative analgesia needed. - Increase respiratory effectiveness. - Eliminate the need for nasogastric intubation.

Increase respiratory effectiveness. Explanation: 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.

A nurse cares for an older adult client and teaches the client about age-related changes of the biliary tract. What statements will the nurse include when discussing age-related changes that occur in the pancreas of the older adult? Select all that apply. a. "The pancreas develops fibrous material with age." b. "The pancreas enlarges and atrophies with age." c. "The pancreas decreases bicarbonate secretion with age." d. "The pancreas develops fatty deposits with age." e. "The pancreas decreases secretion of enzymes with age."

a. "The pancreas develops fibrous material with age." c. "The pancreas decreases bicarbonate secretion with age." d. "The pancreas develops fatty deposits with age." e. "The pancreas decreases secretion of enzymes with age."

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? - Preventing fluid volume overload - Teaching about the disease and its treatment - Maintaining adequate nutritional status - Relieving abdominal pain

Relieving abdominal pain Explanation: 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 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? - Dry mouth, which makes the client thirsty - Acetone in the urine - High glucose concentration in the blood - Frequent vomiting, leading to loss of fluid volume

Frequent vomiting, leading to loss of fluid volume Explanation: 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.

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

I should wash the site with mild soap and water." Explanation: 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.

Clinical manifestations of common bile duct obstruction include all of the following except: - Pruritus - Jaundice - Light-colored urine - Clay-colored feces

Light-colored urine Explanation: 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.

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? - instillation - decompression - lavage - gavage

decompression Explanation: 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.

Management of a patient with ascites includes nutritional modifications and diuretic therapy. Which of the following interventions would a nurse expect to be part of patient care? Select all that apply. a. Zaroxolyn would be the thiazide diuretic of choice. b. A daily weight change of 0.5 pounds would require health care provider notification. c. Aldactone, an aldosterone-blocking agent would be used. d. Daily salt intake would be restricted to 2 grams or less. e. The diuretic will be held if the serum sodium level decreases to <134 m Eq/L.

c. Aldactone, an aldosterone-blocking agent would be used. d. Daily salt intake would be restricted to 2 grams or less. e. The diuretic will be held if the serum sodium level decreases to <134 m Eq/L. Explanation: Lasix, a loop diuretic, combined with Aldactone is the most effective regimen to control ascites. The serum sodium level should not drop below 134 mEq/L. A daily weight change of 1.1 lb (those without peripheral edema) or 2.2 lbs (those with peripheral edema) should be reported.

A nurse discusses risk factors of cholelithiasis with a client. Which risk factors will the nurse include in the teaching? Select all that apply. a. Cystic fibrosis b. Changes in weight c. Sickle cell disease d. Obesity e. Diabetes

a. Cystic fibrosis b. Changes in weight d. Obesity e. Diabetes Explanation: Risk factors for the development of gallstones (cholelithiasis) may include: changes in weight, obesity, cystic fibrosis, and diabetes. All of these conditions impact fat metabolism, increasing the risk of developing cholesterol gallstones. Sickle cell disease does not impact the development of gallstones.

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

"How much alcohol do you consume in a day?" Explanation: 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.

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? - "The tube allows toxins to be removed." - "The tube provides relief from nausea and vomiting." - "The tube allows the gastrointestinal tract to rest." - "The tube helps control fluid and electrolyte imbalance."

"The tube allows the gastrointestinal tract to rest." Explanation: 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.

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? - "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." - "This pain may be caused by a bile duct injury. You will need to go to the hospital immediately to have this evaluated." - "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." - "This may be the initial symptoms of an infection. You need to come to see the surgeon today for an evaluation."

"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." Explanation: 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.

Trademark sign of an acute onset of pancreatitis

- severe epigastric abdominal pain that may radiate to the back - It may occur after a heavy meal or with a meal that may stimulate the early release of pancreatic enzymes, such as spicy foods.

A client has a recent diagnosis of chronic pancreatitis and is undergoing diagnostic testing to determine pancreatic islet cell function. The nurse should anticipate what diagnostic test? A. Glucose tolerance test B. ERCP C. Pancreatic biopsy D. Abdominal ultrasonography

A. Glucose tolerance test Rationale: A glucose tolerance test evaluates pancreatic islet cell function and provides necessary information for making decisions about surgical resection of the pancreas. This specific clinical information is not provided by ERCP, biopsy, or ultrasound.

A client has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? A. Have the client refrain from food and fluids after midnight. B. Administer the contrast agent orally 10 to 12 hours before the study. C. Administer the radioactive agent intravenously the evening before the study. D. Encourage the intake of 64 ounces of water 8 hours before the study.

A. Have the client refrain from food and fluids after midnight. Rationale: An ultrasound of the gallbladder is most accurate if the client fasts overnight, so that the gallbladder is distended. Contrast and radioactive agents are not used when performing ultrasonography of the gallbladder, as an ultrasound is based on reflected sound waves.

A client's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the client's laboratory studies, what finding is most closely associated with this diagnosis? A. Increased bilirubin B. Decreased serum cholesterol C. Increased blood urea nitrogen (BUN) D. Decreased serum alkaline phosphatase level

A. Increased bilirubin Rationale: If the flow of blood is impeded, bilirubin, a pigment derived from the breakdown of red blood cells, does not enter the intestines. As a result, bilirubin levels in the blood increase. Cholesterol, BUN, and alkaline phosphatase levels are not typically affected.

A 37-year-old client presents at the emergency department (ED) reporting nausea and vomiting and severe abdominal pain. The client's abdomen is rigid, and there is bruising to the client's flank. The client's spouse states that the client was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the client for what health problem? A. Severe pancreatitis with possible peritonitis B. Acute cholecystitis C. Chronic pancreatitis D. Acute appendicitis with possible perforation

A. Severe pancreatitis with possible peritonitis Rationale: Severe abdominal pain is the major symptom of pancreatitis that causes the client to seek medical care. Pain in pancreatitis is accompanied by nausea and vomiting that does not relieve the pain or nausea. Abdominal guarding is present and a rigid or board-like abdomen may be a sign of peritonitis. Ecchymosis (bruising) to the flank or around the umbilicus may indicate severe peritonitis. Pain generally occurs 24 to 48 hours after a heavy meal or alcohol ingestion. The link with alcohol intake makes pancreatitis a more likely possibility than appendicitis or cholecystitis.

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

Acute pain related to biliary spasms Explanation: 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 client with chronic pancreatitis had a pancreaticojejunostomy created 3 months ago for relief of pain and to restore drainage of pancreatic secretions. The client has come to the office for a routine postsurgical appointment. The client is frustrated that the pain has not decreased. What is the most appropriate initial response by the nurse? A. "The majority of clients who have a pancreaticojejunostomy have their normal digestion restored but do not achieve pain relief." B. "Pain relief occurs by 6 months in most clients who undergo this procedure, but some people experience a recurrence of their pain." C. "Your health care provider will likely want to discuss the removal of your gallbladder to achieve pain relief." D. "You are probably not appropriately taking the medications for your pancreatitis and pain, so we will need to discuss your medication regimen in detail."

Ans: B Rationale: Pain relief from a pancreaticojejunostomy often occurs by 6 months in more than 85% of the clients who undergo this procedure, but pain returns in a substantial number of clients as the disease progresses. This client had surgery 3 months ago; the client has 3 months before optimal benefits of the procedure may be experienced. There is no obvious indication for gallbladder removal and nonadherence is not the most likely factor underlying the pain.

A client has just been diagnosed with chronic pancreatitis. The client is underweight and in severe pain and diagnostic testing indicates that over 80% of the client's pancreas has been destroyed. The client asks the nurse why the diagnosis was not made earlier in the disease process. What would be the nurse's best response? A. "The symptoms of pancreatitis mimic those of much less serious illnesses." B. "Your body doesn't require pancreatic function until it is under great stress, so it is easy to go unnoticed." C. "Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost." D. "It's likely that your other organs were compensating for your decreased pancreatic function."

Ans: C

The family of a patient in the ICU diagnosed with acute pancreatitis asks the nurse why the patient has been moved to an air bed. What would be the nurses best response? A) Air beds allow the care team to reposition her more easily while she's on bed rest. B) Air beds are far more comfortable than regular beds and she'll likely have to be on bed rest a long time. C) The bed automatically moves, so she's less likely to develop pressure sores while she's in bed. D) The bed automatically moves, so she is likely to have less pain.

Ans: C Feedback: It is important to turn the patient every 2 hours; use of specialty beds may be indicated to prevent skin breakdown. The rationale for a specialty bed is not related to repositioning, comfort, or ease of movement.

A community health nurse is caring for a client whose multiple health problems include chronic pancreatitis. During the most recent home visit, the nurse learns that the client is experiencing severe abdominal pain and has vomited 3 times in the past several hours. What is the nurse's most appropriate action? A. Administer a PRN dose of pancreatic enzymes as prescribed. B. Teach the client about the importance of abstaining from alcohol. C. Arrange for the client to be transported to the hospital. D. Insert an NG tube, if available, and stay with the client.

Ans: C Rationale: Chronic pancreatitis is characterized by recurring attacks of severe upper abdominal and back pain, accompanied by vomiting. The onset of these acute symptoms warrants hospital treatment. Pancreatic enzymes are not indicated and an NG tube would not be inserted in the home setting. Client education is a later priority that may or may not be relevant.

A client is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication? A. Sudden increase in random blood glucose readings B. Increased abdominal girth accompanied by decreased level of consciousness C. Fever, increased heart rate and decreased blood pressure D. Abdominal pain unresponsive to analgesics

Ans: C Rationale: Pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis because of resulting hemorrhage, septic shock, and multiple organ dysfunction syndrome (MODS). Signs of shock would include hypotension, tachycardia and fever. Each of the other listed changes in status warrants intervention, but none is clearly suggestive of an onset of pancreatic necrosis.

A nurse is creating a care plan for a client with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan? A. Bed rest reduces the client's metabolism and reduces the risk of metabolic acidosis. B. Reduced activity protects the physical integrity of pancreatic cells. C. Bed rest lowers the metabolic rate and reduces enzyme production. D. Inactivity reduces caloric need and gastrointestinal motility.

Ans: C Rationale: The acutely ill client is maintained on bed rest to decrease the metabolic rate and reduce the secretion of pancreatic and gastric enzymes. Staying in bed does not release energy from the body to fight the disease.

A client has been treated in the hospital for an episode of acute pancreatitis. The client has acknowledged the role that his alcohol use played in the development of his health problem, but has not expressed specific plans for lifestyle changes. What is the nurse's most appropriate response? A. Educate the client about the link between alcohol use and pancreatitis. B. Ensure that the client knows the importance of attending follow-up appointments. C. Refer the client to social work or spiritual care. D. Encourage the client to connect with a community-based support group.

Ans: D Rationale: After the acute attack has subsided, some clients may be inclined to return to their previous drinking habits. The nurse provides specific information about resources and support groups that may be of assistance in avoiding alcohol in the future. Referral to Alcoholics Anonymous as appropriate or other support groups is essential. The client already has an understanding of the effects of alcohol, and follow-up appointments will not necessarily result in lifestyle changes. Social work and spiritual care may or may not be beneficial.

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

Assisting the client to turn, cough, and deep breathe every 2 hours Explanation: 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.

A client has had a laparoscopic cholecystectomy. The client is now reporting right shoulder pain. What should the nurse suggest to relieve the pain? A. Aspirin every 4 to 6 hours as prescribed B. Application of heat 15 to 20 minutes each hour C. Application of an ice pack for no more than 15 minutes D. Application of liniment rub to affected area

B. Application of heat 15 to 20 minutes each hour Rationale: If pain occurs in the right shoulder or scapular area (from migration of the CO2 used to insufflate the abdominal cavity during the procedure), the nurse may recommend use of a heating pad for 15 to 20 minutes hourly, walking, and sitting up when in bed. Aspirin would constitute a risk for bleeding.

A nurse is preparing a plan of care for a client with pancreatic cysts that have necessitated drainage through the abdominal wall. What nursing diagnosis should the nurse prioritize? A. Disturbed body image B. Impaired skin integrity C. Nausea D. Risk for deficient fluid volume

B. Impaired skin integrity Rationale: While each of the diagnoses may be applicable to a client with pancreatic drainage, the priority nursing diagnosis is Impaired Skin Integrity. The drainage is often perfuse and destructive to tissue because of the enzyme contents. Nursing measures must focus on steps to protect the skin near the drainage site from excoriation. The application of ointments or the use of a suction apparatus protects the skin from excoriation.

A nurse is caring for a client who has been scheduled for endoscopic retrograde cholangiopancreatography (ERCP) the following day. When providing anticipatory guidance for this client, the nurse should describe what aspect of this diagnostic procedure?A. The need to protect the incision postprocedure B. The use of moderate sedation C. The need to infuse 50% dextrose during the procedure D. The use of general anesthesia

B. The use of moderate sedation Rationale: Moderate sedation, not general anesthesia, is used during ERCP. D50 is not given and the procedure does not involve the creation of an incision.

A client who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this client knows to immediately report what assessment finding to the health care provider? A. Decreased breath sounds B. Drainage of bile-colored fluid onto the abdominal dressing C. Rigidity of the abdomen D. Acute pain with movement

C. Rigidity of the abdomen Rationale: The location of the subcostal incision will likely cause the client to take shallow breaths to prevent pain, which may result in decreased breath sounds. The nurse should remind clients to take deep breaths and cough to expand the lungs fully and prevent atelectasis. Acute pain is an expected assessment finding following surgery; analgesics should be given for pain relief. Abdominal splinting or application of an abdominal binder may assist in reducing the pain. Bile may continue to drain from the drainage tract after surgery, which will require frequent changes of the abdominal dressing. Increased abdominal tenderness and rigidity should be reported immediately to the health care provider, as it may indicate bleeding from an inadvertent puncture or nicking of a major blood vessel during the surgical procedure.

A client presents to the emergency department (ED) reporting severe right upper quadrant pain. The client states that the family doctor said the pain was caused by gallstones. The ED nurse should recognize what possible complication of gallstones? A. Acute pancreatitis B. Atrophy of the gallbladder C. Gallbladder cancer D. Gangrene of the gallbladder

D. Gangrene of the gallbladder Rationale: In calculous cholecystitis, a gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur; and the blood vessels in the gallbladder are compressed, compromising its vascular supply. Gangrene of the gallbladder with perforation may result. Pancreatitis, atrophy, and cancer of the gallbladder are not plausible complications.

A home health nurse is caring for a client discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the client who has had pancreatic surgery? A. Proteinuria and hyperkalemia B. Hemorrhage and hypercalcemia C. Weight loss and hypoglycemia D. Malabsorption and hyperglycemia

D. Malabsorption and hyperglycemia Rationale: The nurse arrives at this diagnosis based on the complications of malabsorption and hyperglycemia. These complications often lead to the need for dietary modifications. Pancreatic enzyme replacement, a low-fat diet, and vitamin supplementation often are also required to meet the client's nutritional needs and restrictions. Electrolyte imbalances often accompany pancreatic disorders and surgery, but the electrolyte levels are more often deficient than excessive. Hemorrhage is a complication related to surgery, but not specific to the nutritionally based nursing diagnosis. Weight loss is a common complication, but hypoglycemia is less likely.

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? - Increases in the rate of pancreatic secretion - Increases in the bicarbonate output by the kidneys - Decreases in the physiologic function of major organs - Development of local complications

Decreases in the physiologic function of major organs Explanation: 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.

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? - Ingestion of foods high in sugar - Renal failure - Dysfunction of the pancreatic islet cells - Inability for the liver to reabsorb serum glucose

Dysfunction of the pancreatic islet cells Explanation: 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.

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? - Frequent changes of positions - Perform chest physiotherapy - Placing the patient in the prone position - Suction the patient every 4 hours

Frequent changes of positions Explanation: Frequent changes of position are necessary to prevent atelectasis and pooling of respiratory secretions.

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? - Black - Gray - Green - Red

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

A client with gallstones is diagnosed with acute pancreatitis and is requesting information about the physiology of the gallbladder. Which information will the nurse include about the function of this organ? - Digests carbohydrates in the jejunum - Serves as a storage unit for glucagon - Controls the flow of trypsin to digest proteins - Releases bile in response to cholecystokinin

Releases bile in response to cholecystokinin Explanation: The gallbladder is a pear-shaped, hollow, saclike organ that lies in a shallow depression on the inferior surface of the liver. When food enters the duodenum, the gallbladder contracts and the sphincter of Oddi relaxes. Relaxation of this sphincter allows the bile to enter the intestine. This response is mediated by secretion of the hormone cholecystokinin (CCK) from the intestinal wall. Gallstones can block the bile duct and digestive juices to the pancreas causing acute pancreatitis. The gallbladder functions as a storage depot for bile. Bile does not digest carbohydrates in the jejunum. The liver controls the flow of trypsin to digest proteins.

The medical management for pancreatitis comprises different types of tasks, each undertaken to fulfill a specific goal. Which is a reason for keeping a patient on NPO status?

To decrease the release of pancreatic enzymes

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? - Monitor pulse oximetry every hour. - Withhold analgesics unless necessary. - Instruct the client to cough only when necessary. - Use incentive spirometry every hour.

Use incentive spirometry every hour. Explanation: 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.

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. Nasogastric tube to intermittent wall suction for relief of nausea. b. Full liquid diet as tolerated. 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. Nasogastric tube to intermittent wall suction for relief of nausea. b. Full liquid diet as tolerated. d. Initiate enteral feedings if tolerated. Explanation: 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.

A client telephones the medical clinic to ask for help with pruritus and a change in stool color. Which additional symptom(s) indicates to the nurse that the client is experiencing gallbladder stones? Select all that apply. a. Yellow sclera b. Right shoulder pain c. Dark-colored urine d. Diarrhea e. Epigastric pain

a. Yellow sclera b. Right shoulder pain c. Dark-colored urine Explanation: The client with gallbladder disease resulting from gallstones may develop two types of symptoms: those due to disease of the gallbladder itself and those due to obstruction of the bile passages by a gallstone. Jaundice occurs in a few clients with gallbladder disease, usually with obstruction of the common bile duct. The bile, which is no longer carried to the duodenum, is absorbed by the blood and gives the skin and mucous membranes a yellow color. This is frequently accompanied by marked pruritus (itching) of the skin. The excretion of the bile pigments by the kidneys gives the urine a very dark color. The client may have biliary colic with excruciating upper right abdominal pain that radiates to the back or right shoulder. Diarrhea is not associated with gallbladder stones. Abdominal pain occurs in the right upper quadrant in gallbladder disease.

A client is diagnosed with a tumor on the head of the pancreas. Which treatment(s) will the nurse anticipate being prescribed to prepare the client for surgery? Select all that apply. a. Heparin intravenously b. Blood component therapy c. Pancrelipase d. High protein diet e. Vitamin K supplements

b. Blood component therapy c. Pancrelipase d. High protein diet e. Vitamin K supplements Explanation: Before extensive surgery can be performed, a period of preparation is necessary because the client's nutritional status and physical condition are quite often compromised. A high-protein diet is often prescribed. Blood component therapy is frequently required. Pancreatic enzymes (such as pancrelipase) which aid in digestion are often prescribed. Preoperative preparation also includes vitamin K to minimize postoperative complications. Anticoagulants like heparin are not prescribed prior to surgery for a tumor on the head of the pancreas as they could increase the risk of bleeding.

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients: - can digest high-fat foods. - are at risk for gallbladder contraction. - cannot tolerate high-glucose concentration. - are at risk for hepatic encephalopathy.

cannot tolerate high-glucose concentration. Explanation: 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.