Chapter 50

A patient with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the patient will undergo what intervention? A) Laparoscopic cholecystectomy B) Methyl tertiary butyl ether (MTBE) infusion C) Intracorporeal lithotripsy D) Extracorporeal shock wave therapy (ESWL)

A Most of the nonsurgical approaches, including lithotripsy and dissolution of gallstones, provide only temporary solutions to gallstone problems and are infrequently used in the United States. Cholecystectomy is the preferred treatment.

A patient with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure? A) Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. B) Laparoscopic cholecystectomy can be performed in a clinic setting, while an open procedure requires an OR. C) A laparoscopic approach allows for the removal of the entire gallbladder. D) A laparoscopic approach can be performed under conscious sedation.

A Open surgery has largely been replaced by laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus). As a result, surgical risks have decreased, along with the length of hospital stay and the long recovery period required after standard surgical cholecystectomy. Both approaches allow for removal of the entire gallbladder and must be performed under general anesthetic in an operating theater.

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

A Due to the risk of ascites, the nurse should monitor the patient'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 patient's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the patient'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 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 nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A)Fried chicken B)Mashed potatoes C)Dinner roll D)Tapioca pudding

A 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 patient should avoid fried foods such as fried chicken, as fatty foods may bring on an episode of cholecystitis.

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

A Severe abdominal pain is the major symptom of pancreatitis that causes the patient 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 patient's assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment questions address 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,C Eighty percent of patients with acute pancreatitis have biliary tract disease such as gallstones or a history of long-term alcohol abuse. Diabetes, high-fat consumption, and cystic fibrosis are not noted etiologic factors.

A nurse is caring for a patient with gallstones who has been prescribed ursodeoxycholic acid (UDCA). The patient askshow this medicine is going to help his symptoms. The nurse should be aware of what aspect of this drug's pharmacodynamics? A) It inhibits the synthesis of bile. B) It inhibits the synthesis and secretion of cholesterol. C) It inhibits the secretion of bile. D) It inhibits the synthesis and secretion of amylase.

B UDCA acts by inhibiting the synthesis and secretion of cholesterol, thereby desaturating bile. UDCA does not directly inhibit either the synthesis or secretion of bile or amylase.

A patient has had a laparoscopic cholecystectomy. The patient is now complaining of right shoulder pain. What should the nurse suggest to relieve the pain? A)Aspirin every 4 to 6 hours as ordered 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 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 caring for a patient who has been scheduled for endoscopic retrograde cholangiopancreatography (ERCP) the following day. When providing anticipatory guidance for this patient, 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 Moderate sedation, not general anesthesia, is used during ERCP. D50 is not administered and the procedure does not involve the creation of an incision.

A patient with chronic pancreatitis had a pancreaticojejunostomy created 3 months ago for relief of pain and to restore drainage of pancreatic secretions. The patient has come to the office for a routine postsurgical appointment. The patient is frustrated that the pain has not decreased. What is the most appropriate initial response by the nurse? A)"The majority of patients who have a pancreaticojejunostomy have their normal digestion restored but do not achieve pain relief." B)"Pain relief occurs by 6 months in most patients who undergo this procedure, but some people experience a recurrence of their pain." C)"Your physician 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."

B Pain relief from a pancreaticojejunostomy often occurs by 6 months in more than 85% of the patients who undergo this procedure, but pain returns in a substantial number of patients as the disease progresses. This patient had surgery 3 months ago; the patient 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 patient has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this patient? A)Oral oxycodone B)IV hydromorphone (Dilaudid) C)IM meperidine (Demerol) D)Oral naproxen (Aleve)

B The pain of acute pancreatitis is often very severe and pain relief may require parenteral opioids such as morphine, fentanyl (Sublimaze), or hydromorphone (Dilaudid). There is no clinical evidence to support the use of meperidine for pain relief in pancreatitis. Opioids are preferred over NSAIDs.

A patient is admitted to the unit with acute cholecystitis. The physician has noted that surgery will be scheduled in 4 days. The patient asks why the surgery is being put off for a week when he has a "sick gallbladder." What rationale would underlie the nurse's response? A) Surgery is delayed until the patient can eat a regular diet without vomiting. B) Surgery is delayed until the acute symptoms subside. C) The patient requires aggressive nutritional support prior to surgery. D) Time is needed to determine whether a laparoscopic procedure can be used.

B Unless the patient's condition deteriorates, surgical intervention is delayed just until the acute symptoms subside (usually within a few days). There is no need to delay surgery pending an improvement in nutritional status, and deciding on a laparoscopic approach is not a lengthy process.

A patient with gallstones has been prescribed ursodeoxycholic acid (UDCA). The nurse understands that additional teaching is needed regarding this medication when the patient states: A)"It is important that I see my physician for scheduled follow-up appointments while taking this medication." B)"I will take this medication for 2 weeks and then gradually stop taking it." C)"If I lose weight, the dose of the medication may need to be changed." D)"This medication will help dissolve small gallstones made of cholesterol."

B Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. This drug can reduce the size of existing stones, dissolve small stones, and prevent new stones from forming. Six to 12 months of therapy is required in many patients to dissolve stones, and monitoring of the patient is required during this time. The effective dose of medication depends on body weight.

A nurse is preparing a plan of care for a patient 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 While each of the diagnoses may be applicable to a patient 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 providing discharge education to a patient 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

C The nurse encourages the patient 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.

A patient has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize which of the following topics? 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 Because of the early discharge following laparoscopic cholecystectomy, the patient 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.

A patient has just been diagnosed with chronic pancreatitis. The patient is underweight and in severe pain and diagnostic testing indicates that over 80% of the patient's pancreas has been destroyed. The patient 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."

C By the time symptoms occur in chronic pancreatitis, approximately 90% of normal acinar cell function (exocrine function) has been lost. Late detection is not usually attributable to the vagueness of symptoms. The pancreas contributes continually to homeostasis and other organs are unable to perform its physiologic functions.

A community health nurse is caring for a patient whose multiple health problems include chronic pancreatitis. During the most recent visit, the nurse notes that the patient 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 ordered. B)Teach the patient about the importance of abstaining from alcohol. C)Arrange for the patient to be transported to the hospital. D)Insert an NG tube, if available, and stay with the patient.

C 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. Patient education is a later priority that may or may not be relevant.

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

C Eighty percent of patients with acute pancreatitis have biliary tract disease or a history of long-term alcohol abuse. These patients 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.

A nurse who provides care in a walk-in clinic assesses a wide range of individuals. The nurse should identify which of the following patients 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 Excessive and prolonged consumption of alcohol accounts for approximately 70% to 80% of all cases of chronic pancreatitis.

A student nurse is caring for a patient 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 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 patient on parenteral nutrition would have no oral intake to monitor. Blood sugar levels are more likely to be unstable than indicators of renal function.

A patient 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 patients 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

C Pancreatic necrosis is a major cause of morbidity and mortality in patients 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 patient 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 patient'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.

C The acutely ill patient 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 patient who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this patient knows to immediately report what assessment finding to the physician? 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 The location of the subcostal incision will likely cause the patient to take shallow breaths to prevent pain, which may result in decreased breath sounds. The nurse should remind patients 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 administered 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 physician, as it may indicate bleeding from an inadvertent puncture or nicking of a major blood vessel during the surgical procedure.

A patient has been admitted to the hospital for the treatment of chronic pancreatitis. The patient 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 patient about expectations and care following surgery B)Educating the patient about the management of blood glucose after discharge C)Educating the patient about postdischarge lifestyle modifications D)Educating the patient about the potential benefits of pancreatic transplantation

C The patient's lifestyle (especially regarding alcohol use) is a major determinant of the course of chronic pancreatitis. The disease is not often managed by surgery and blood sugar monitoring is not necessarily indicated for every patient after hospital treatment. Transplantation is not an option.

A patient has been treated in the hospital for an episode of acute pancreatitis. The patient 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 after discharge. What is the nurse's most appropriate response? A)Educate the patient about the link between alcohol use and pancreatitis. B)Ensure that the patient knows the importance of attending follow-up appointments. C)Refer the patient to social work or spiritual care. D)Encourage the patient to connect with a community-based support group.

D After the acute attack has subsided, some patients 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 patient 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.

A 55-year-old man has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this patient's health problem? A)"Toxins have accumulated and inflamed your pancreas." B)"Bacteria likely migrated from your intestines and became lodged in your pancreas." C)"A virus that was likely already present in your body has begun to attack your pancreatic cells." D)"The enzymes that your pancreas produces have damaged the pancreas itself."

D Although the mechanisms causing pancreatitis are unknown, pancreatitis is commonly described as the autodigestion of the pancreas. Less commonly, toxic substances and microorganisms are implicated as the cause of pancreatitis.

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

D Pancreatic carcinoma has only a 5% survival rate at 5 years regardless of the stage of disease at diagnosis or treatment. As a result, there is a higher likelihood that the patient will require hospice care than physical therapy and rehabilitation.

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

D The elderly patient 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.

A patient returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the patient for signs and symptoms of what serious potential complication of this surgery? A)Diabetic coma B)Decubitus ulcer C)Wound evisceration D)Bile duct injury

D The most serious complication after laparoscopic cholecystectomy is a bile duct injury. Patients do not face a risk of diabetic coma. A decubitus ulcer is unlikely because immobility is not expected. Evisceration is highly unlikely, due to the laparoscopic approach.

A patient is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention should the nurse perform in order to best address this diagnosis? A)Position the patient supine to facilitate diaphragm movement. B)Administer corticosteroids by nebulizer as ordered. C)Perform oral suctioning as needed to remove secretions. D)Maintain the patient in a semi-Fowler's position whenever possible.

D The nurse maintains the patient in a semi-Fowler's position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. A supine position will result in increased pressure on the diaphragm and potentially decreased respiratory expansion. Steroids and oral suctioning are not indicated.

A nurse is assessing a patient who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the patient'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 The patient 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.