Exam 4

The nurse is caring for a client with common bile duct obstruction. The nurse should anticipate that the health care provider (HCP) will prescribe which diet for this client? a. Low fat b. High protein c. High carbohydrate d. Low in water-soluble vitamins

A Rationale: Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum. Bile acids or bile salts are produced by the liver to emulsify or break down fats. The diets listed in the remaining options are incorrect.

The nurse is assigned to care for a client with a Sengstaken-Blakemore tube. Which laboratory result is most focused on evaluating the effectiveness of this tube? a. Sodium b. Creatinine c. Hemoglobin d. Ammonia

C Rationale: A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis with ruptured esophageal varices if other treatment measures are unsuccessful. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. Evaluation of the client's hemoglobin level trends will determine if the tube is effective. Sodium, creatinine, and ammonia levels are not related to monitoring for blood loss.

The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels? a. Evaluating for asterixis b. Inspecting for petechiae c. Palpating for peripheral edema d. Evaluating for decreased level of consciousness

C Rationale: Albumin is responsible for maintaining the osmolality of the blood. When there is a low albumin level, there is decreased osmotic pressure, which in turn can lead to peripheral edema. The remaining options are incorrect and are not associated with a low albumin level.

The nurse has taught the client with chronic pancreatitis about risk factor modification to reduce the incidence of recurrences. The nurse determines that teaching was effective if the client states that it will be necessary to control which factor? a. Alcohol intake b. Duodenal ulcer c. Crohn's disease d. Diabetes mellitus

A Rationale: Chronic pancreatitis is aggravated by continued alcohol intake. Each of the other options is not specifically associated with pancreatitis.

The nurse is performing an assessment on a client with suspected acute pancreatitis. Which complaint made by the client supports the diagnosis? a. "I have epigastric pain radiating to my neck." b. "I have severe abdominal pain that is relieved after vomiting." c. "My temperature has been running between 96°F (35.5°C) and 97°F (36.1°C)." d. "I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."

D Rationale: Nausea and vomiting are common presenting manifestations of acute pancreatitis. A hallmark symptom is severe abdominal pain that is not relieved by vomiting. The vomitus characteristically consists of gastric and duodenal contents. Fever also is a common sign. Epigastric pain radiating to the neck area is not a characteristic symptom.

The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? a. "I need to limit my intake of dietary fiber." b. "I need to drink plenty, at least 8 to 10 cups daily." c. "I need to eat regular meals and chew my food well." d. "I will take the prescribed medications because they will regulate my bowel patterns."

A Rationale: IBS is a functional gastrointestinal disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. Dietary fiber and bulk help to produce bulky, soft stools and establish regular bowel elimination habits. Therefore, the client should consume a high-fiber diet. Eating regular meals, drinking 8 to 10 cups of liquid a day, and chewing food slowly help to promote normal bowel function. Medication therapy depends on the main symptoms of IBS. Bulk-forming laxatives or antidiarrheal agents or other agents may be prescribed.

The nurse has been caring for a client who required a Sengstaken-Blakemore tube because other treatment measures for esophageal varices were unsuccessful. The health care provider (HCP) arrives on the nursing unit and deflates the esophageal balloon. Which assessment finding by the nurse is the most important and should be reported to the HCP immediately? a. Hematemesis b. Bloody diarrhea c. Swelling of the abdomen d. An elevated temperature and a rise in blood pressure

A Rationale: A Sengstaken-Blakemore tube may be inserted in a client with a diagnosis of cirrhosis with bleeding esophageal varices. It has both an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices, manifested as vomiting of blood (hematemesis). The remaining options are unrelated to deflating the esophageal balloon.

A client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse should plan a dietary consultation to limit the amount of which ingredient in the client's diet? a. Protein b. Calories c. Minerals d. Carbohydrates

A Rationale: Ammonia is formed as a product of protein metabolism. Clients with hepatic encephalopathy have a high serum ammonia level, which is responsible for the symptoms of encephalopathy. Limiting protein intake will prevent further elevation in the serum ammonia level and prevent further deterioration of the client's mental status. It is not necessary to limit calories, minerals, or carbohydrates.

The nurse is caring for an older client. The nurse should anticipate that medication dosages will be further adjusted if the client has dysfunction of which organ? a. Liver b. Stomach c. Pancreas d. Gallbladder

A Rationale: An important function of the liver is to break down medications and other toxic substances. The older client with liver disease is at increased risk for toxic medication effects and should be monitored carefully for adverse effects. Diseases of the stomach, pancreas, and gallbladder are a lesser concern for prolonged medication effects.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence? a. Inability to pass flatus b. Loss of anal sphincter control c. Severe, constant pain with rapid onset d. Firm, nontender mass palpable at the lower right costal margin

A Rationale: An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction.

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? a. I should increase the fiber in my diet b. I will need to avoid caffeinated beverages c. I'm going to learn some stress reduction techniques d. I can have exacerbations and remissions with Crohn's

A Rationale: Crohn's disease is an inflammatory disease that can occur anywhere in the gastrointestinal tract but most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and remissions. If stress increases the symptoms of the disease, the client is taught stress management techniques and may require additional counseling. The client is taught to avoid gastrointestinal stimulants containing caffeine and to follow a high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially during periods of exacerbation.

Diphenoxylate hydrochloride with atropine sulfate is prescribed for a client with ulcerative colitis. The nurse should monitor the client for which therapeutic effect of this medication? a. Decreased diarrhea b. Decreased cramping c. Improved intestinal tone d. Elimination of peristalsis

A Rationale: Diphenoxylate hydrochloride with atropine sulfate is an antidiarrheal product that decreases the frequency of defecation, usually by reducing the volume of liquid in the stools. The remaining options are not associated therapeutic effects of this medication.

The nurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a history of Laënnec's cirrhosis. Which question related to the client's history would be most important to ask? a. "Do you abuse alcohol?" b. "Do you have any known cardiac disease?" c. "Does your type of employment cause you to have exposure to chemicals?" d. "Have you ever been told that you have had obstruction to your biliary ducts?"

A Rationale: Laënnec's cirrhosis results from long-term alcohol abuse; therefore, the question inquiring about alcohol abuse is most appropriate. Cardiac cirrhosis most commonly is caused by long-term right-sided heart failure. Exposure to hepatotoxins, chemicals, or infections or a metabolic disorder can cause postnecrotic cirrhosis. Biliary cirrhosis results from a decrease in bile flow and is most commonly caused by long-term obstruction of bile ducts.

Sulfasalazine is prescribed for a client with a diagnosis of ulcerative colitis, and the nurse instructs the client about the medication. Which statement made by the client indicates a need for further teaching? a. "The medication will cause constipation." b. "I need to take the medication with meals." c. "I may have increased sensitivity to sunlight." d. "This medication should be taken as prescribed."

A Rationale: Sulfasalazine is an antiinflammatory sulfonamide. Constipation is not associated with this medication. It can cause photosensitivity, and the client should be instructed to avoid sun and ultraviolet light. It should be administered with meals, if possible, to prolong intestinal passage. The client needs to take the medication as prescribed and continue the full course of treatment even if symptoms are relieved.

The nurse is reviewing the health care provider's prescriptions written for a client admitted to the hospital with acute pancreatitis. Which prescription requires follow-up by the nurse? a. Full liquid diet b. Morphine sulfate for pain c. Nasogastric tub inserstion d. An anticholinergic medication

A Rationale: The client with acute pancreatitis is placed on NPO (nothing by mouth) status to decrease the activity of the pancreas, which occurs with oral intake. Pain management for acute pancreatitis typically begins with the administration of opioids by patient-controlled analgesia. Medications such as morphine or hydromorphone are typically used. Nasogastric tube insertion is done to provide suction of secretions and administer medications as necessary.

A client with chronic pancreatitis needs information on dietary modification to manage the health problem. Which item in the diet should the nurse teach the client to limit? a. Fat b. Protein c. Carbohydrate d. Water-soluble vitamins

A Rationale: The client with chronic pancreatitis should limit fat in the diet and also take in small meals, which will reduce the amount of carbohydrates and protein that the client must digest at any one time. The client does not need to limit water-soluble vitamins in the diet.

The nurse is providing dietary instructions to a client hospitalized for pancreatitis. Which food should the nurse instruct the client to avoid? a. Chili b. Bagel c. Lentil soup d. Watermelon

A Rationale: The client with pancreatitis needs to avoid alcohol, coffee and tea, spicy foods, and heavy meals, which stimulate pancreatic secretions, producing attacks of pancreatitis. The client is instructed in the benefit of eating small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates.

The nurse is caring for a client with biliary obstruction. The nurse interprets that obstruction of which passage is related to the client's condition? a. Cystic duct b. Liver canaliculi c. Common bile duct d. Right hepatic duct

A Rationale: The gallbladder receives bile from the liver through the cystic duct. The liver collects bile in the canaliculi, from which bile flows into the right and left hepatic ducts and then into the common hepatic duct. From there, the bile can be transported for storage in the gallbladder through the cystic duct, or it can flow directly into the duodenum by way of the common bile duct.

The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis? a. "Does the pain in your stomach radiate to your back?" b. "Does the pain in your lower abdomen radiate to your hip?" c. "Does the pain in your lower abdomen radiate to your groin?" d. "Does the pain in your stomach radiate to your lower middle abdomen?"

A Rationale: The pain that is associated with acute pancreatitis is often severe, is located in the epigastric region, and radiates to the back. The remaining options are incorrect because they are not specific for the pain experienced by the client with pancreatitis.

The nurse is caring for a client with acute pancreatitis. Which finding should the nurse expect to note when reviewing the laboratory results? a. Elevated serum lipase level b. Elevated serum bilirubin level c. Decreased serum trypsin level d. Decreased serum amylase level

A Rationale: The serum lipase level is elevated in the presence of pancreatic cell injury. Serum trypsin and amylase levels are also elevated in pancreatic injury. Although bilirubin can be elevated in the client with pancreatitis, it is secondary to the hepatobiliary obstructive process.

The nurse is caring for a client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the bestunderstanding of the material if the client states to increase intake of which food? a. Pork b. Milk c. Chicken d. Broccoli

A Rationale: Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin. Other good sources include peanuts, asparagus, and whole-grain and enriched cereals.

The nurse is caring for a client with a low thrombin level as a result of liver dysfunction. Based on this finding it is most important for the nurse to monitor the client for signs and symptoms of which potential complication? a. Bleeding b. Infection c. Dehydration d. Malnutrition

A Rationale: Thrombin is produced by the liver and is necessary for normal clotting. The client who has an insufficient level of this substance is at risk for bleeding. Therefore, the client should be monitored for evidence of blood loss, such as visual cues and vital sign changes.

The nurse is providing instructions to a client diagnosed with irritable bowel syndrome (IBS) who is experiencing abdominal distention, flatulence, and diarrhea. What interventions should the nurse include in the instructions? Select all that apply. a. Eat yogurt b. Take loperamide to treat diarrhea c. Use stress management techniques d. Avoid foods such as cabbage and broccoli e. Decrease fiber intake to less than 15 g/day

A, B, C, D Rationale: IBS is a common, chronic functional disorder, meaning that no organic cause is currently known. Treatment is directed at psychological and dietary factors and medications to regulate stool output. Options 1, 2, 3, and 4 are correct, as clients diagnosed with IBS whose primary symptoms are abdominal distention and flatulence should be advised to avoid common gas-producing foods such as broccoli and cabbage and to consume yogurt, as it may be better tolerated than milk. In addition, the probiotics found in yogurt may be beneficial because alterations in intestinal bacteria are believed to exacerbate IBS. The client should be advised to take loperamide, a synthetic opioid that slows intestinal transit and treats diarrhea when it occurs. Also, psychological stressors are associated with development and exacerbation of IBS, so stress management techniques are important. Option 5, decrease fiber intake, is incorrect, as clients should be encouraged to have a dietary fiber intake of at least 20 g/day.

The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions should be included in the care plan for this client? Select all that apply. a. Monitor daily weight b. Measure abdominal girth c. Monitor respiratory status d. Place the client in a supine position e. Assist the client with care as needed

A, B, C, E Rationale: Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the client's breathing patterns. The client should be placed in a semi Fowler's position with the arms supported on a pillow to allow for free diaphragm movement. The correct options identify appropriate nursing interventions to be included in the plan of care for the client with ascites.

A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply. a. Orthopena and dyspnea b. Petechiae and ecchymosis c. Inguinal or umbilical hernia d. Poor body posture and balance e. Abdominal distention and tenderness

A, B, C, E Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal cavity and dependent areas of the body, can occur in the client with cirrhosis. Ascites can cause physical problems because of the overdistended abdomen and resultant pressure on internal organs and vessels. These problems include respiratory difficulty, petechiae and ecchymosis, development of hernias, and abdominal distention and tenderness. Poor body posture and balance are unrelated to increased abdominal pressure.

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. a. Maintain NPO status b. Encourage coughing and deep breathing c. Give small, frequent high-calorie feedings d. Maintain the client in a supine and flat position e. Give hydromorphone IV per orders for pain f. Maintain IV fluids at 10ml/hr to keep vein open

A, B, E Rationale: The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions, so adequate intravenous hydration is necessary. Because abdominal pain is a prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help to ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted.

A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which client statement indicates a need for further instruction? a. "I will obtain adequate rest." b. "I will take acetaminophen if I get a headache." c. "I should monitor my weight on a regular basis." d. "I need to include sufficient amounts of carbohydrates in my diet."

B Rationale: Acetaminophen is avoided because it can cause fatal liver damage in the client with cirrhosis. Adequate rest and nutrition are important. The client's weight should be monitored on a regular basis. The diet should supply sufficient carbohydrates with a total daily calorie intake of 2000 to 3000.

The nurse is assessing a client with liver disease for signs and symptoms of low albumin. Which sign or symptom should the nurse expect to note? a. Weight loss b. Peripheral edema c. Capillary refill of 5 seconds d. Bleeding from previous puncture sites

B Rationale: Albumin is responsible for maintaining the osmolality of the blood. When the albumin level is low, osmotic pressure is decreased, which in turn can lead to peripheral edema. Weight loss is not a sign or symptom for hypoalbuminemia. Capillary refill of 5 seconds is a delayed filling time but is not associated with decreased albumin levels. Clotting factors produced by the liver (not albumin) are responsible for coagulation, and lack of clotting factors can result in bleeding from old puncture sites. The total protein level may decrease if the albumin level is low.

A client is experiencing blockage of the common bile duct. Which food selection made by the client indicates the need for further teaching? a. Rice b. Whole milk c. Broiled fish d. Baked chicken

B Rationale: Bile acids or bile salts are produced by the liver to emulsify or break down fats. Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum, thus preventing breakdown of fatty intake. Knowledge of this should direct you to the option of whole milk. Dairy products, such as whole milk, ice cream, butter, and cheese, are high in cholesterol and fat and should be avoided.

The nurse is obtaining a health history for a client with chronic pancreatitis. The health history is most likely to include which as a most common causative factor in this client's disorder? a. Weight gain b. Use of alcohol c. Exposure to occupational chemicals d. Abdominal pain relieved with food or antacids

B Rationale: Chronic pancreatitis occurs most often in alcoholics. Abstinence from alcohol is important to prevent the client from developing chronic pancreatitis. Clients usually experience malabsorption with weight loss. Chemical exposure is associated with cancer of the pancreas. Pain will not be relieved with food or antacids.

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? a. Muffled heart sounds b. A rise in blood pressure c. Jugular vein distention d. Client expressions of dyspnea

B Rationale: Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs with cardiac tamponade.

The nurse is caring for a client who is prescribed a nasogastric (NG) tube for the purpose of stomach decompression. The nurse should anticipate a health care provider prescription for which type of suction? a. High and intermittent b. Low and intermittent c. High and continuous d. Low and continuous

B Rationale: Gastric mucosa can be traumatized and pulled into the tube if the suction pressure is placed on high or if the suction is continuous. The suction should be set on low pressure and intermittent suction control.

The nurse is assessing a client with an abdominal aortic aneurysm. Which assessment finding by the nurse is unrelated to the aneurysm? a. Pulsatile abdominal mass b. Hyperactive bowel sounds in the area c. Systolic bruit over the area of the mass d. Subjective sensation of "heart beating" in the abdomen

B Rationale: Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm. Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass.

The nurse is performing discharge teaching for a client with chronic pancreatitis. Which information should the nurse include? a. Alcohol should be consumed in moderation. b. Avoid caffeine because it may aggravate symptoms. c. Diet should be high in carbohydrates, fats, and proteins. d. Frothy, fatty stools indicate that enzyme replacement is working.

B Rationale: Knowing that caffeinated beverages, such as coffee, tea, and soda, will worsen symptoms, such as pain, will direct you to select the correct option. Alcohol can precipitate an attack of pancreatitis and needs to be avoided. The recommended diet is moderate carbohydrates, low fat, and moderate protein. Frothy, fatty stools indicate that the replacement enzyme dose needs to be increased.

Lactulose is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy. Which assessment finding indicates that the client is responding to this medication therapy as anticipated? a. Vomiting occurs b. The fecal pH is acidic c. The client experiences diarrhea d. The client is able to tolerate a full diet

B Rationale: Lactulose is an osmotic laxative used to decrease ammonia levels, which are elevated in hepatic encephalopathy. The desired effect is 2 or 3 soft stools per day with an acid fecal pH. Lactulose creates an acid environment in the bowel, resulting in a fall of the colon's pH from 7 to 5. This causes ammonia to leave the circulatory system and move into the colon for excretion. Diarrhea may indicate excessive administration of the medication. Vomiting and ability to tolerate a full diet do not determine that a desired effect has occurred.

A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which would the nurse expect the client to report about the pain? a. Eating helps to decrease the pain. b. The pain usually increases after vomiting. c. The pain is mostly around the umbilicus and comes and goes. d. The pain increases when the client sits up and bends forward.

B Rationale: Pain with acute pancreatitis usually increases after vomiting because of an increase in intraductal pressure caused by retching, which leads to further obstruction of the outflow of pancreatic secretions. The pain is a steady and intense epigastric pain that radiates to the client's back and flank. The pain may lessen when the client sits up or bends forward. Eating exacerbates the pain by stimulating the secretion of enzymes.

A client with ulcerative colitis has a prescription to begin a salicylate compound medication to reduce inflammation. What instruction should the nurse give the client regarding when to take this medication? a. On arising b. After meals c. On an empty stomach d. 30 minutes before meals

B Rationale: Salicylate compounds, such as sulfasalazine, act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and increase fluid intake throughout the day. The medication needs to be taken after meals to reduce gastrointestinal irritation. The other options are incorrect and could cause gastric irritation.

A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that education about positioning to reduce pain was effective if the client avoids which action? a. Sitting up b. Lying flat c. Leaning forward d. Drawing the legs to the chest

B Rationale: The pain of pancreatitis is aggravated by lying supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation will intensify the irritation of the posterior peritoneal wall with these positions or movements. Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) will alleviate some of the pain associated with pancreatitis. The fetal position (with the legs drawn up to the chest) may decrease the abdominal pain of pancreatitis.

The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal hypertension? a. Flat neck veins b. Abdominal distention c. Hemoglobin of 14.2 g/dl (142 mmol/L) d. Platelet count of 600,000 mm3 (600 × 109/L)

B Rationale: With portal hypertension, proteins shift from the blood vessels via the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, they leak through the liver capsule into the peritoneal cavity. This is called ascites, and abdominal distention would be the consequence. Increased portal pressure can lead to findings associated with right-sided heart failure, such as distended jugular veins. Thrombocytopenia, leukopenia, and anemia are caused by the splenomegaly that results from backup of blood from the portal vein into the spleen (portal hypertension).

The nurse caring for a client diagnosed with inflammatory bowel disease (IBD) recognizes that which classifications of medications may be prescribed to treat the disease and induce remission? Select all that apply. a. Antidiarrheal b. Antimicrobial c. Corticosteroid d. Aminosalicylate e. Biological therapy f. Immunosuppressant

B, C, D, E, F Rationale: Pharmacological treatment for IBD aims to decrease the inflammation to induce and then maintain a remission. Five major classes of medications used to treat IBD are antimicrobials, corticosteroids, aminosalicylates, biological and targeted therapy, and immunosuppressants. Medications are chosen based on the location and severity of inflammation. Depending on the severity of the disease, clients are treated with either a "step-up" or "step-down" approach. The step-up approach uses less toxic therapies (e.g., aminosalicylates and antimicrobials) first, and more toxic medications (e.g., biological and targeted therapy) are started when initial therapies do not work. The step-down approach uses biological and targeted therapy first. Option 1, antidiarrheals, is incorrect. Although an antidiarrheal may be used to treat the symptoms of IBD, it does not treat the disease (the inflammation) or induce remission. In addition, antidiarrheals should be used cautiously in IBD because of the danger of toxic megacolon (colonic dilation greater than 5 cm).

The nurse is caring for a client with acute pancreatitis. Which medications should the nurse expect to be prescribed for treatment of this problem? Select all that apply. a. Insulin b. Morphine c. Dicyclomine d. Pancrelipase e. Pantoprazole f. Acetazolamide

B, C, E, F Rationale: Medications used to treat acute pancreatitis include pain medications such as morphine, antispasmodics such as dicyclomine, proton pump inhibitors such as pantoprazole, and acetazolamide to decrease the volume and bicarbonate concentration of pancreatic secretions. Insulin is used in chronic pancreatitis to treat diabetes mellitus or hyperglycemia if needed, and pancreatic enzyme products are used for replacement of pancreatic enzymes.

A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? a. Call the surgeon to report the problem. b. Reposition the NG tube to the proper location. c. Check the suction device to make sure it is working. d. Irrigate the NG tube with saline to remove the obstruction.

C Rationale: After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working correctly. The tip of the NG tube may be placed near the suture line. Because of this possibility, the nurse should never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the nurse should call the surgeon, who would do this repositioning under fluoroscopy.

The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? a. Flat neck veins b. A pulse rate of 60 beats/minute c. Muffled or distant heart sounds d. Wheezing on auscultation of the lungs

C Rationale: Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). The other options are not signs of cardiac tamponade.

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? a. Dorsiflex the client's foot b. Measure the abdominal girth c. Ask the client to extend the arms d. Instruct the client to lean forward

C Rationale: Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect.

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? a. Roast pork b. Cheese omelet c. Pasta with sauce d. Tuna fish sandwich

C Rationale: Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. The serum ammonia level assesses the ability of the liver to deaminate protein byproducts. Normal reference interval is 10 to 80 mcg/dL (6 to 47 mcmol/L). Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. Foods high in protein should be avoided since the client's ammonia level is elevated above the normal range; therefore, pasta with sauce would be the best selection.

The nurse is caring for a client experiencing an exacerbation of Crohn's disease. Which intervention should the nurse anticipate the health care provider prescribing? a. Enteral feedings b. Fluid restrictions c. Oral corticosteroids d. Activity restrictions

C Rationale: Crohn's disease is a form of inflammatory bowel disease that is a chronic inflammation of the gastrointestinal (GI) tract. It is characterized by periods of remission interspersed with periods of exacerbation. Oral corticosteroids are used to treat the inflammation of Crohn's disease, so option 3 is the correct one. In addition to treating the GI inflammation of Crohn's disease with medications, it is also treated by resting the bowel. Therefore, option 1 is incorrect. Option 2 is incorrect, as clients with Crohn's disease typically have diarrhea and would not be on fluid restrictions. Option 4, activity restrictions, is not indicated. The client can do activities as tolerated but should avoid stress and strain.

The nurse is assisting a client with Crohn's disease to ambulate to the bathroom. After the client has a bowel movement, the nurse should assess the stool for which characteristic that is expected with this disease? a. Blood in the stool b. Chalky gray stool c. Loose, watery stool d. Dry, hard, constipated stool

C Rationale: Crohn's disease is characterized by nonbloody diarrhea of usually not more than 4 or 5 stools daily. Over time, the episodes of diarrhea increase in frequency, duration, and severity. Options 1, 2, and 4 are not characteristics of the stool in Crohn's disease.

The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, should the nurse report to the health care provider (HCP)? a. Hypotension b. Bloody diarrhea c. Rebound tenderness d. A hemoglobin level of 12 mg/dL (120mmol/L)

C Rationale: Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the HCP.

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? a. "I know I must sign the consent form." b. "I hope the throat spray keeps me from gagging." c. "I'm glad I don't have to lie still for this procedure." d. "I'm glad some IV medication will be given to relax me."

C Rationale: The client does have to lie still for ERCP, which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.

A client with Crohn's disease is experiencing acute pain, and the nurse provides information about measures to alleviate the pain. Which statement by the client indicates the need for further teaching? a. "I know I can massage my abdomen." b. "I will continue using antispasmodic medication." c. "One of the best things I can do is use relaxation techniques." d. "The best position for me is to lie supine with my legs straight."

D Rationale: Pain associated with Crohn's disease is alleviated by the use of analgesics and antispasmodics and also by practicing relaxation techniques, applying local cold or heat to the abdomen, massaging the abdomen, and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen, which could aggravate inflamed intestinal tissues as the abdominal muscles are stretched.

The nurse is caring for a client on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, the nurse should take which action? a. Document the findings b. Reassess the pH in 4 hours c. Instill 30 ml of sterile water d. Administer a dose of a prescribed antacid

D Rationale: The client on a mechanical ventilator who has a nasogastric tube in place should have the gastric pH monitored at the beginning of each shift or least every 12 hours. Because of the risk of stress ulcer formation, a pH lower than 5 (acidic) should be treated with prescribed antacids. If there is no prescription for the antacid, the health care provider should be notified. Documentation of the findings should be done after the administration of an antacid. Sterile water instillation is not an appropriate treatment.

A client with cirrhosis complicated by ascites is admitted to the hospital. The client reports a 10-lb weight gain over the past 1½ weeks. The client has edema of the feet and ankles, and his abdomen is distended, taut, and shiny with striae. Which client problem is most appropriate at this time? a. Difficulty with sleeping b. Risk for skin breakdown c. Difficulty with breathing d. Excessive body fluid volume

D Rationale: The client with weight gain who also has cirrhosis complicated by ascites most often is retaining fluid. This is especially true when the client has not demonstrated an appreciable increase in food intake or when the weight gain is massive in relation to the time frame given. Therefore, excessive body fluid volume is the most appropriate problem. No data are given to support difficulty with breathing, although in some clients upward pressure on the diaphragm from ascites does impair respiration. Risk for skin breakdown assumes a lower priority because it is a risk rather than an actual problem. There are no data in the question that indicate that the client is having difficulty with sleep.

A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? a. Carrots and ranch dip b. Whole-grain cereal and milk c. A cup of popcorn and a cola drink d. Applesauce and a graham cracker

D Rationale: The diet for the client with ulcerative colitis should be low fiber (low residue). The nurse should avoid providing foods such as whole-wheat grains, nuts, and fresh fruits or vegetables. Typically, lactose-containing foods also are poorly tolerated. The client also should avoid caffeine, pepper, and alcohol.

A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? a. Monitoring the temperature b. Monitoring complaints of heartburn c. Giving warm gargles for a sore throat d. Assessing for the return of the gag reflex

D Rationale: The nurse places highest priority on assessing for return of the gag reflex. This assessment addresses the client's airway. The nurse also monitors the client's vital signs and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway is the priority.

The nurse assists a health care provider in performing a liver biopsy. After the procedure, the nurse should place the client in which position? a. Prone b. Supine c. Left side d. Right side

D Rationale: To splint and provide pressure at the puncture site, the client is kept on the right side for a minimum of 2 hours after a liver biopsy. Therefore, the remaining positions are incorrect.

The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? a. Hypercalcemia b. Hypernatremia c. Frothy, fatty stools d. Decresed hemoglobin

D Rationale: Ulcerative colitis is an inflammatory disease of the large colon. Findings associated with ulcerative colitis include diarrhea with up to 10 to 20 liquid bloody stools per day, weight loss, anorexia, fatigue, increased white blood cell count, increased erythrocyte sedimentation rate, dehydration, hyponatremia, and hypokalemia (not hypercalcemia). Because of the loss of blood, clients with ulcerative colitis commonly have decreased hemoglobin and hematocrit levels. Clients with ulcerative colitis have bloody diarrhea, not steatorrhea (fatty, frothy, foul-smelling stools).

A health care provider (HCP) prescribes a Salem sump tube for gastrointestinal intubation. Which item should the nurse obtain from the supply room? a. A Dobbhoff weighted tube b. A Sengstaken-Blakemore tube c. A tube with a large lumen and an air vent d. A tube with a single lumen that connects to suction

C Rationale: A tube with a large lumen and an air vent is a Salem sump tube. A Dobbhoff weighted tube is a type of feeding tube. A Sengstaken-Blakemore tube is used to control bleeding in the esophagus. A tube with a single lumen is called a Levin tube.

The nurse is caring for a hospitalized client with pancreatitis. Which findings should the nurse look for and expect to note when reviewing the laboratory results? Select all that apply. a. Elevated lipase level b. Elevated lactase level c. Elevated trypsin level d. Elevated amylase level e. Elevated sucrase level

A, C, D Rationale: Lipase, trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively. Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Sucrase is produced in the small intestine and converts sucrose into glucose and fructose.

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an IV infusion at a rate of 150 ml/hr, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28ml. The client's BUN level is 35 mg/dl and the serum creatinine level is 1.8 mg/dL, measured this morning. Which nursing action is priority? a. Check the urine specific gravity b. Call the health care provider c. Put the IV line on a pump so that the infusion rate is sure to stay stable d. Check to see if the client had a blood sample for a serum albumin level drawn

B

The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy? a. Restlessness b. Presence of asterixis c. Complaints of fatigue d. Decreased serum ammonia levels

B Asterixis is a flapping tremor of the hand that is an early sign of hepatic encephalopathy. The exact cause of this disorder is not known, but abnormal ammonia metabolism may be implicated. Increased serum ammonia levels are thought to interfere with normal cerebral metabolism. Tremors and drowsiness also would be noted.

The nurse is providing dietary instructions to a client with a diagnosis of irritable bowel syndrome. The nurse determines that education was effective if the client states the need to avoid which food? a. Rice b. Corn c. Broiled chicken d. Cream of wheat

B Rationale: The client with irritable bowel should take in a diet that consists of 30 to 40 g of fiber daily because dietary fiber will help produce bulky, soft stools and establish regular bowel habits. The client should also drink 8 to 10 glasses of fluid daily and chew food slowly to promote normal bowel function. Foods that are irritating to the intestines need to be avoided. Corn is high in fiber but can be very irritating to the intestines and should be avoided. The food items in the other options are acceptable to eat.

The nurse is caring for a client with pancreatitis. Which finding should the nurse expect to note when reviewing the client's laboratory results? a. Elevated level of pepsin b. Decreased level of lactase c. Elevated level of amylase d. Decreased level of enterokinase

C Rationale: The serum level of amylase, an enzyme produced by the pancreas, increases with pancreatitis. Amylase normally is responsible for carbohydrate digestion. Pepsin is produced by the stomach and is used in protein digestion. Lactase and enterokinase are enzymes produced by the small intestine; lactase splits lactose into galactose and fructose, and enterokinase activates trypsin.

A client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which actions should the nurse plan to promote client safety? Select all that apply. a. Monitor serum potassium levels b. Weigh client daily, and monitor trends c. Monitor for symptoms of fluid retention d. Provide the client with a soft toothbrush e. Instruct the client to use an electric razor f. Monitor all secretions for frank or occult blood

D, E, F Rationale: Fibrinogen is produced by the liver and is necessary for normal clotting. A client who has insufficient levels is at risk for bleeding. The PT is prolonged when one or more of the clotting factors (II, V, VII, or X) is deficient, so the client's risk for bleeding is also increased. A soft toothbrush, an electric razor, and monitoring secretions for evidence of bleeding are measures that provide for client safety.

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. a. Diarrhea b. Black, tarry stools c. Hyperactive bowel sounds d. Gray-blue color at the flank e. Abdominal guarding and tenderness f. LUQ pain w/ radiation to the back

D, E, F Rationale: Grayish-blue discoloration at the flank is known as Grey-Turner's sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. The client may demonstrate abdominal guarding and may complain of tenderness with palpation. The pain associated with acute pancreatitis is often sudden in onset and is located in the epigastric region or left upper quadrant with radiation to the back. The other options are incorrect.