GI System problems
The nurse is assessing a patient who is experiencing hepatocellular failure. Which finding best indicates that the patient is developing ascites? 1. accumulation of fluid in the abdomen 2. jaundiced skin 3. ecchymosis 4. upper-right-quadrant pain
Correct Answer: 1 Rationale: Ascites is the accumulation of the fluid in the abdomen and is a result of hepatocellular failure. Jaundice is manifested as yellow-tinged skin and is the result of hepatic disorders. The patient experiencing hepatic problems might have bleeding and bruising due to inadequate vitamin K. Obstructed biliary flow could be the cause of upper-right-quadrant pain.
During a health assessment the nurse becomes concerned that a patient is at high risk for pancreatic cancer. What assessment findings caused this concern? Select all that apply. 1. The patient smokes cigarettes. 2. The patient has a body mass index of 32.5. 3. The patient has been treated for osteoarthritis. 4. The patient's uncle died from pancreatic cancer. 5. The patient has been diagnosed with chronic pancreatitis.
Correct Answer: 1, 2, 4, 5 Rationale: Identified risk factors for pancreatic cancer include cigarette smoking, obesity, a genetic predisposition, and chronic pancreatitis. Osteoarthritis is not a risk factor for pancreatic cancer.
A patient who returned from a humanitarian trip to Central America 2 weeks ago is jaundiced and diagnosed with hepatitis A. The patient is the parent of three school-age children. Which patient statement should the nurse follow up with the patient? 1. "I can't go home and expose my children to this." 2. "We cared for several very ill people on our trip." 3. "I plan to get a lot of rest in the next few days." 4. "I am likely to recover fully eventually."
Correct Answer: 1 Rationale: Once jaundice develops, the amount of virus in the stool and the risk of spreading the disease decrease significantly. The nurse should teach that the patient was likely more contagious in the last 2 weeks than at the current time. This disease is spread through the fecal-oral route. It is likely the patient contracted the illness on the trip. Rest is recommended for the patient with hepatitis A. Full recovery is the typical scenario with this illness.
The nurse, teaching a patient about portal hypertension, knows teaching has been effective when the patient makes which statement? 1. "In portal hypertension, blood backs up in the liver. It causes enlarged blood vessels in my esophagus." 2. "In portal hypertension, blood leaks from my liver. It causes me to feel hungry frequently." 3. "Portal hypertension means fast-spreading high blood pressure. It causes red veins on my arms." 4. "Portal hypertension means high blood pressure throughout my abdomen. It causes me to feel confused."
Correct Answer: 1 Rationale: Portal hypertension, increased pressure in the portal system, has several effects when it is prolonged, including dilation of veins in the gastrointestinal tract and the abdominal wall. This congestion tends to suppress (not increase) the appetite, and lead to formation of collateral vessels in the distal esophagus, stomach, and rectum. The dilated, congested vessels in the esophagus are known as esophageal varices; in the rectum, they lead to the development of hemorrhoids. In advanced liver failure, superficial varices may develop around the umbilicus (not on the arms), a feature known as caput medusae. Portal hypertension does not mean blood is leaking from the liver. It is not fast-spreading hypertension, and it is not defined as high blood pressure throughout the abdomen. Portal systemic encephalopathy (or hepatic encephalopathy), impaired consciousness and mental status, results from the accumulation of toxic waste products in the blood (ammonia in particular) as blood bypasses the congested liver. This is not caused by high abdominal blood pressure.
The nurse is assessing the nutritional status of a patient who has cholelithiasis and a body mass index of 35. What action should the nurse take initially? 1. ask the patient to discuss typical daily menu choices 2. ask the patient to discuss strategies used to manage weight 3. ask if the patient takes daily supplemental vitamin C 4. ask if the patient has been skipping meals to reduce gallbladder pain
Correct Answer: 1 Rationale: The nurse begins by assessing nutritional status, particularly diet history, height and weight, and skinfold measurements. Even though often obese, patients with gallbladder disease may have an imbalanced diet or specific vitamin deficiencies, particularly of the fat-soluble vitamins. Vitamin C is a water-soluble vitamin. Discussing strategies used to manage weight may be important in assessing causes of cholelithiasis pain, as fluctuating weight gains and losses can contribute to cholelithiasis, but this is the not the priority when assessing the patient's nutritional status. Asking if the patient has been skipping meals is important, but not as important as the diet history and typical food
A patient scheduled for a laparoscopic cholecystectomy in 4 days asks how pain can be controlled until the surgery. How should the nurse respond? 1. "You will feel better if you sit in a recliner and drink water and try not to eat anything. Do not eat any fat." 2. "You will feel better if you rest in bed and do not eat anything until the procedure. Drink only water and milk." 3. "You will feel better if you alternate lying on your back and lying on your abdomen. You may eat anything except fatty food." 4. "You will feel better if you walk as frequently as possible. You may drink coffee, but not soda."
Correct Answer: 1 Rationale: For greatest comfort the patient should sit in the Fowler's position, which reduces pressure on the inflamed gallbladder. A person in the Fowler's position is sitting straight up or leaning slightly back. The legs may be either straight or bent. Fat intake should be reduced to minimize gallbladder contractions and pain. Resting in bed, lying on the back and abdomen, and walking will not help with pain control before the surgery. The patient should not eat anything during an acute episode of pain.
The nurse notes new areas of ecchymosis on the arms and legs of a patient with liver cirrhosis. Which laboratory test results should the nurse monitor because of this finding? Select all that apply. 1. complete blood count with platelets 2. coagulation studies 3. serum albumin 4. serum ammonia levels 5. serum hepatitis antibodies
Correct Answer: 1, 2 Rationale: A CBC with platelets should be monitored. A low RBC count, hemoglobin, and hematocrit indicate anemia related to bone marrow suppression, increased RBC destruction, bleeding, and deficiencies of folic acid and vitamin B12. Platelets are low, related to increased destruction by the spleen. Leukopenia (low WBC count) also relates to splenomegaly. Coagulation studies reveal the patient's tendency to bleed and the ability of the blood to clot. These studies show a prolonged prothrombin time due to impaired production of coagulation proteins and lack of vitamin K. Both the CBC and coagulation studies are key parts of the nurse's analysis of this patient's condition. Albumin levels reflect liver impairment and/or nutritional status and are not related to risk for bleeding. Serum ammonia levels elevate during liver failure due to the liver's inability to convert ammonia to urea for renal excretion. This test does not provide information regarding bleeding risk. Testing for the presence of hepatitis antibodies in the blood does not provide information regarding coagulation.
The nurse is assessing a patient with liver cirrhosis. Which findings should the nurse relate to the patient's failed liver function? Standard Text: Select all that apply. 1. The patient had two episodes of epistaxis. 2. The patient had toxic levels of a prescribed medication. 3. The patient is oriented to person and place but not to time. 4. The patient's urinary output has decreased. 5. The patient has cholelithiasis.
Correct Answer: 1, 2, 3 Rationale: The liver produces clotting factors. Two episodes of epistaxis are likely related to the patient's liver failure. The liver metabolizes medications. Toxic levels of prescribed medication in the absence of other factors are likely related to liver failure. The patient who is disoriented may be experiencing high serum ammonia levels, an effect of liver failure. Decreased urinary output is not associated with liver failure, but with kidney failure. Cholelithiasis is not caused by liver failure.
The nurse has instructed a patient about the possible complications of unresolved cholecystitis. Which patient statements indicate that teaching has been effective? Select all that apply. 1. "I could have infected pus stored in my gallbladder." 2. "My gallbladder could rot and cause a big infection in my abdomen." 3. "A hole could form a connection between my gallbladder and intestines."' 4. "My intestines could be blocked with a gallstone." 5. "My gallbladder could turn inside out into the bile duct."
Correct Answer: 1, 2, 3, 4 Rationale: Complications of cholecystitis include empyema, a collection of infected fluid within the gallbladder. Gangrene and perforation with resulting peritonitis may occur. An abscess may form. A fistula may form into an adjacent organ (such as the duodenum, colon, or stomach). The small intestine may be obstructed by a large gallstone (gallstone ileus). The gallbladder will not turn inside out into the bile duct.
The nurse is caring for a patient taking chenodiol (Chenix). Which patient statements indicate the need for immediate follow-up by the nurse? Select all that apply. 1. "I could see the big gallstone on the x-ray, but this medication doesn't seem to be helping at all. I don't feel better after taking it for 4 months." 2. "My rectal area is tender from all the diarrhea I've been having." 3. "My skin looks yellow." 4. "I can't afford my medication and have been cutting pills in half to make it last longer." 5. "I can see bits of gallstones in my stools."
Correct Answer: 1, 2, 3, 4Rationale: Chenodiol (Chenix) reduces the cholesterol content of gallstones, leading to their gradual dissolution. Chenodiol has a high incidence of diarrhea at therapeutic doses and is hepatotoxic, so periodic liver function studies are required during therapy. A primary disadvantage of pharmacologic treatment for gallstones is its cost. Because of the gradual rate at which the medication acts, pieces of gallstones are not visible in the patient's stools.
A patient recovering from Whipple's procedure is being transferred to the medical-surgical care area. On which interventions should the nurse focus to determine if the patient is developing a complication from the surgery? Select all that apply. 1. assessing heart rate every 2 hours 2. monitoring urine output ever hour 3. turning and repositioning every 2 hours 4. measuring blood pressure every 2 hours 5. assisting to a standing position every 4 hours
Correct Answer: 1, 2, 4 Rationale: The major complications following Whipple's procedure are hemorrhage, bile leak, hypovolemic shock, and hepatorenal failure. The nurse should measure blood pressure and heart rate every 2 hours. Urine output should be measured. Turning and repositioning and assisting the patient to a standing position will not help prevent complications from this procedure.
The nurse is teaching a patient about the effects of liver failure. The nurse knows the patient understands when the patient identifies which manifestations as related to liver failure? Select all that apply. 1. "My abdomen is becoming very large." 2. "My blood sugar is sometimes too high and sometimes too low." 3. "My left lower leg is red and swollen." 4. "My menstrual cycle has become very irregular." 5. "My skin appears yellow."
Correct Answer: 1, 2, 4, 5 Rationale: Ascites occurs during liver failure due to low oncotic pressure related to a deficiency of serum albumin. The liver's ability to use glycogen is impaired by liver failure, leading to difficulty controlling hypoglycemia and/or hyperglycemia. Impaired metabolism of steroid hormones interferes with the menstrual cycle. Impaired ability to metabolize and excrete bilirubin leads to a buildup of bilirubin in skin, causing a jaundiced appearance. The patient is describing symptoms of a blood clot. This is not associated with liver failure. Excessive bleeding is associated with liver failure.
A patient wants to reduce the risk of developing gallstones and cholecystitis. What should the nurse instruct this patient? Select all that apply. 1. Walk for 30 minutes five times a week. 2. Eat a low-fiber, high-carbohydrate diet. 3. Eat unsaturated rather than saturated fats. 4. Eat a low-carbohydrate diet. 5. Lose weight by any means possible.
Correct Answer: 1, 3, 4 Rationale: Physical activity, a high-fiber, low-carbohydrate diet, and consumption of unsaturated fats all appear to have a protective effect, reducing the incidence of cholelithiasis and cholecystitis. A low-fiber, high-carbohydrate diet would not prevent the development of gallstones. The dangers of yo-yo dieting and extremely low-calorie diets should be reviewed with the patient.
A patient with chronic pancreatitis is prescribed pancrelipase (Lipancreatin). What should the nurse instruct the patient about this medication? Select all that apply. 1. Take the medication with meals or snacks. 2. Take the medication with milk or ice cream. 3. Stop taking the medication if bowel movements increase 4. Do not crush enteric coated doses of the medication. 5. Take this medication until advised otherwise by the healthcare provider.
Correct Answer: 1, 4, 5 Rationale: Pancrelipase enhances the digestion of starches and fats in the gastrointestinal tract by supplying an exogenous source of the enzymes protease, amylase, and lipase. The drug promotes nutrition and decreases the number of bowel movements. This medication should be taken with meals or snacks but should not be taken with alkaline foods such as milk or ice cream. Enteric coated doses of this medication should not be crushed. This medication should be taken until advised otherwise by the healthcare provider.
The nurse is assessing a patient with liver failure and jaundice. Which question should the nurse ask to determine if the cause of the jaundice is hemolytic? 1. "Have you been diagnosed with a disorder of red blood cell destruction?" 2. "What color is your urine?" 3. "What color are your stools?" 4. "Do you have any gallbladder problems?"
Correct Answer: 1. Rationale: Hemolytic jaundice develops when excess RBC destruction releases more bilirubin into circulation than the liver is able to process. Darkened urine and light or clay-colored stools are more commonly associated with hepatic or obstructive jaundice. Patients with gallbladder disorders are also at risk for jaundice; however, this patient's liver failure is a given.
A patient with liver failure is taking lactulose (Chronulac). Which laboratory data indicates that the medication is having the desired effect? 1. increased serum ammonia level 2. decreased serum ammonia level 3. increased serum ALT level 4. decreased serum ALT level
Correct Answer: 2 Rationale: Ammonia, a toxic by-product of protein metabolism, is converted to urea in the liver for elimination by the kidneys. Lactulose works by acidifying the contents of the bowel, which has the effect of keeping ammonia in the bowel, where it is excreted from the body in the stools, rather than being reabsorbed into the circulation. This medication should lower the serum ammonia level. It has no effect on the ALT level.
The nurse is caring for a patient with hepatitis C who is treating the illness with licorice root. Which statement by the patient requires follow-up regarding this medication? 1. "I feel so tired all the time." 2. "My fingers feel numb and tingly." 3. "I have a dull ache in my abdomen." 4. "I have antibodies for hepatitis C in my blood."
Correct Answer: 2 Rationale: Herbalists may use licorice root to treat hepatitis. It has both antiviral and anti-inflammatory effects. Long-term use of licorice root, however, can lead to hypertension and affect fluid and electrolyte balance. Reports of numbness and tingling in the fingers may be a sign of electrolyte imbalance. Feeling tired is expected in a patient with hepatitis C. A dull ache in the abdomen is often seen in patients with hepatitis. It is expected that this patient would have antibodies to hepatitis C in the blood.
A patient with pancreatitis asks the nurse, "Why are my stools so frothy and smell so bad?" How should the nurse respond? 1. "This is a sign of malnutrition." 2. "This indicates your stools have more fat in them." 3. "This is a sign of peptic ulcer disease." 4. "You may be developing diabetes mellitus."
Correct Answer: 2 Rationale: Steatorrhea is fatty, frothy, smelly stools associated with pancreatitis. It is caused by a decrease in pancreatic enzyme secretion; fat in the GI tract is not absorbed properly and a greater than normal amount of fat is excreted in the stool, causing the symptoms of steatorrhea. Pancreatitis can lead to malnutrition, but steatorrhea is not a sign of malnutrition. Peptic ulcer disease can be related to pancreatitis, but it is not related to steatorrhea. Diabetes mellitus causes increased urine production and could be the result of pancreatitis, but it does not affect stool characteristics.
The patient in the icteric phase of hepatitis asks the nurse, "Why are my stools no longer brown?" How should the nurse respond? 1. "Your liver isn't making any of the substance that makes stools brown." 2. "The pigment is backing up into your blood and turning your skin yellow." 3. "It is being released into your bloodstream and turning your blood darker red." 4. "The answer is not known. More research is needed regarding this question."
Correct Answer: 2 Rationale: The icteric (jaundiced) phase usually begins 5 to 10 days after the onset of symptoms. It is heralded by jaundice of the sclera, skin, and mucous membranes. Inflammation of the liver and bile ducts prevents bilirubin from being excreted into the small intestine. As a result, the serum bilirubin levels are elevated, causing yellowing of the skin and mucous membranes. The stools are light brown or clay colored because bile pigment is not excreted through the normal fecal pathway. Instead, the pigment is excreted by the kidneys, causing the urine to turn brown. The liver continues to make bilirubin, even during hepatitis. The blood does not become darker when bilirubin levels are elevated. The cause of this phenomenon is known.
A patient with hepatitis is receiving interferon alpha. Which manifestation indicates that the patient is experiencing an untoward effect of this medication? 1. jaundice 2. flulike syndrome 3. gallbladder pain 4. clay-colored stools
Correct Answer: 2 Rationale: The patient who is receiving interferon alpha may experience flulike symptoms such as fever, fatigue, body aches, headache, and chills. Jaundice is characterized by yellow-tinged skin as a result of hepatitis. Gallbladder pain is the result of stones in the gallbladder. Clay-coloreds stool are associated with liver or biliary disease.
A patient with a liver abscess is experiencing nausea and vomiting. Which problem should the nurse identify as a priority for this patient? 1. too much fluid 2. not enough fluid 3. problem breathing 4. altered self-image
Correct Answer: 2 Rationale: The patient with a liver abscess is at risk for developing dehydration due to fever, nausea, and vomiting as a result of the infection. It is important that the nurse assess for signs of dehydration. The patient is likely not experiencing a problem with too much fluid. The patient with a liver abscess is not usually in respiratory distress. There should be no problems with self-image, as the infection is in the liver.
The nurse is caring for a patient with chronic pancreatitis and a serum amylase level of 180 units/L. Which dietary plan should the nurse instruct the patient to follow? 1. low residue, no alcohol 2. low fat, no alcohol 3. low fat, no fiber 4. mechanical soft
Correct Answer: 2 Rationale: After the serum amylase level returns to normal, the patient experiencing pancreatitis should be instructed to consume a diet low in fat with no alcohol. A low-residue diet is prescribed for patients experiencing bowel disorders. Almost all patients should consume a low-fat diet, but most patients need increased fiber. A mechanical soft diet is reserved for the patient who needs to conserve energy or has a mouth or dentition disorder.
The nurse is concerned that a patient with injuries from a motor vehicle crash is experiencing bleeding from liver trauma. What did the nurse assess to make this clinical determination? Select all that apply. 1. new onset of pruritus 2. new onset of lightheadedness 3. heart rate 112 beats per minute 4. requesting more water to drink 5. respiratory rate 26 breaths per minute
Correct Answer: 2, 3, 4, 5 Rationale: Bleeding due to liver trauma may not be immediately apparent. The nurse should suspect bleeding in the presence of light-headedness, rapid heart rate, shortness of breath, or thirst. Pruritus is not a manifestation of bleeding.
A patient with cholelithiasis is recovering from extracorporeal shock wave lithotripsy. Which statements indicate that the patient remembers the procedure accurately? Select all that apply. 1. "It didn't take long, just a few hours." 2. "They gave me some medication in my IV. I didn't feel much." 3. "Afterwards the nurses kept asking me if my abdomen hurt or if I was nauseated." 4. "I was glad I could move around a lot during the procedure." 5. "They used a big machine to guide the shock waves to the stones."
Correct Answer: 2, 3, 5 Rationale: Mild sedation may be given during the procedure. Nursing care after the procedure includes monitoring for biliary colic, which can result from the gallbladder contracting to remove stone fragments. The patient with biliary colic is often nauseated. A machine is used to deliver shock waves to break up the gallstones. The procedure usually takes an hour. Positioning is important, and the patient most likely did not move around during the procedure.
The nurse is teaching a patient about modifiable risk factors for cholelithiasis. What risk factors will the nurse discuss? Select all that apply. 1. age 2. obesity 3. alternating weight loss and gain 4. family history 5. elevated serum cholesterol
Correct Answer: 2, 3, 5 Rationale: Modifiable risk factors for cholelithiasis include obesity, hyperlipidemia, and yo-yo dieting. Age and family history are not modifiable risk factors.
The nurse is assessing a patient with cholelithiasis. Which statements by the patient indicate a progression to cholecystitis? Select all that apply. 1. "I've been in terrible pain for 2 hours." 2. "I'm hot and sweating, then cold and shivering." 3. "The pain's in the same location as when I had appendicitis." 4. "I need an emesis basin; I've vomited four times." 5. "My abdomen and my back both hurt."
Correct Answer: 2, 4, 5 Rationale: Acute cholecystitis features pain that involves the entire upper-right quadrant (RUQ) and may radiate to the back, right scapula, or shoulder. Movement or deep breathing may aggravate the pain. Anorexia, nausea, and vomiting are common. Fever often is present and may be accompanied by chills. The RUQ is tender to palpation. Descriptions of feeling hot and diaphoretic, then cold and shivering, should be recognized as describing a febrile state. The pain usually lasts longer than that of biliary colic, continuing for 12 to 18 hours.
A patient with epigastric pain has a serum amylase level of 369 units/L. What should the nurse do? 1. continue to monitor the patient 2. refer the patient to a dietician 3. contact the primary healthcare provider 4. question the patient regarding alcohol use patterns
Correct Answer: 3 Rationale: A normal level for serum amylase is between 0 and 130 units/L. In pancreatitis, the serum amylase increases to two to three times the normal level and remains elevated for 3 to 4 days. The primary healthcare provider should be notified of the patient's symptoms and the laboratory findings. The patient could develop shock. A dietitian is not needed at this time. The nurse can assess the patient's alcohol intake at a later time.
A patient has been given instructions about a laparoscopic cholecystectomy. Which patient statement indicates further teaching is needed? 1. "I should be able to go home within a day after the procedure." 2. "I will probably have bandages over the puncture sites." 3. "I am glad I won't need to have an open cholecystectomy." 4. "I will tell the nurse if I feel nauseated after surgery."
Correct Answer: 3 Rationale: A patient with a laparoscopic cholecystectomy is at risk for needing an open cholecystectomy if the procedure cannot be completed laparoscopically due to complications. Patients are typically discharged within 24 hours. The patient will likely have adhesive bandages over the puncture sites. Nausea is common after surgery and should be reported to the nurse.
A patient with acute cholecystitis is concerned about having the flu because of an oral temperature of 101.8°F. What should the nurse respond to the patient? 1. "Your cholecystectomy cannot be performed laparoscopically now." 2. "Tell me exactly what you ate for your last meal." 3. "Bacterial infection is often present in cholelithiasis." 4. "I will call the surgeon and ask to postpone the cholecystectomy."
Correct Answer: 3 Rationale: Bacterial infection is often present in acute cholecystitis and may cause an elevated temperature and respiratory rate. Offering to call the surgeon to postpone surgery and asking about the last meal consumed are not appropriate responses. The surgeon will make the determination about the type of surgery to be performed.
The nurse is reviewing pathophysiology concepts to understand what is occurring with an adult patient who has abdominal pain and a serum conjugated bilirubin level of 1.2 mg/dL. What should the nurse suspect is occurring with this patient? 1. a disease that requires phototherapy 2. a disorder that causes large amounts of red blood cell death 3. a disorder of the biliary system 4. a small bowel obstruction
Correct Answer: 3 Rationale: Elevated direct (conjugated) bilirubin may indicate obstructed bile flow in the biliary duct system. The laboratory finding does not provide information to identify red blood cell death or small bowel obstruction. Phototherapy is used in the care of the newborn.
The patient with acute cholelithiasis asks why a nasogastric tube has to be inserted. What is the nurse's best response? 1. "You have not been able to follow your prescribed diet and exercise plan." 2. "We need to suck the bile out through your nose as it isn't going to your duodenum." 3. "Keeping your stomach empty allows your gallbladder to rest, reducing pain." 4. "The tube will prevent pancreatitis."
Correct Answer: 3 Rationale: Emptying the stomach reduces the amount of chyme entering the duodenum and the stimulus for gallbladder contractions, thus reducing pain. The nasogastric tube is not placed because the patient has not been following a prescribed diet or exercise plan. The tube is not inserted to remove bile. It reduces nausea and vomiting; its use is not related to the prevention of pancreatitis.
The nurse is teaching a patient with an acute attack of cholecystitis about nutritional interventions. Which patient statement indicates additional teaching is required? 1. "I need to stop eating and drinking everything for a while." 2. "I may need a tube inserted into my nose that goes all the way into my stomach." 3. "I may be prescribed vitamins B and C." 4. "I may need extra bile salts to promote health."
Correct Answer: 3 Rationale: Food intake may be eliminated during an acute attack of cholecystitis, and a nasogastric tube may be inserted to relieve nausea and vomiting. If bile flow is obstructed, fat-soluble vitamins (A, D, E, and K) and bile salts may need to be administered.
A patient is notified of a diagnosis of hepatitis by the healthcare provider and informed that it can be transmitted to others even though the patient has not been ill. The patient has a distant history of injection substance use. For which type of hepatitis should the nurse plan care for this patient? 1. hepatitis A 2. hepatitis B 3. hepatitis C 4. hepatitis D
Correct Answer: 3 Rationale: Hepatitis C is the primary worldwide cause of chronic hepatitis, cirrhosis, and liver cancer. It is transmitted through infected blood and body fluids. Injection drug use is the primary risk factor for HCV infection, accounting for nearly half of all new infections. Acute hepatitis C usually is asymptomatic; if symptoms do develop, they often are mild and nonspecific. The disease often is recognized long after exposure occurred, when secondary effects of the disease (such as chronic hepatitis or cirrhosis) develop. Few acute infections completely resolve; most progress to chronic active hepatitis. Hepatitis A usually resolves completely and rarely results in a carrier state. Patients with hepatitis B are typically very ill following the preicteric phase, which is not consistent with this patient's history. Hepatitis D infects only people already infected with hepatitis B.
A patient with an acutely inflamed gallbladder states that the pain has suddenly stopped. The patient wants to go home. What is the nurse's best response? 1. "It is your choice. You are feeling better and not required to stay." 2. "Please stay until your healthcare provider sees you tomorrow." 3. "I will inform your healthcare provider of the change in your symptoms." 4. "Yes, as soon as we perform the prescribed ultrasound of the gallbladder."
Correct Answer: 3 Rationale: Rupture of an acutely inflamed gallbladder may be heralded by abrupt but transient pain relief as contents are released from the distended gallbladder into the abdomen. This change should be promptly reported to the healthcare provider. The patient should not go home, wait a day to be seen, or have an ultrasound before being seen by the healthcare provider.
A patient who reports a severe, steady pain in the epigastric area, nausea, and vomiting states, "This happens every time I eat barbecued ribs." What should the nurse consider as the most likely cause of the patient's symptoms? 1. intolerance to pork 2. obesity 3. cholelithiasis 4. pancreatitis
Correct Answer: 3 Rationale: Symptoms of cholelithiasis (gallstone) include severe, steady pain in the epigastric region or upper-right quadrant of the abdomen. The pain may radiate to the back, right scapula, or shoulder. The pain often begins suddenly following a meal, and may last as long as 5 hours. It often is accompanied by nausea and vomiting. These symptoms are not related to porcine intolerance, obesity, or pancreatitis.
The nurse is caring for a patient with a Sengstaken-Blakemore tube. Which assessment finding should the nurse immediately report for follow-up? 1. left lower leg swollen and reddened 2. absent bowel sounds to lower-left quadrant 3. decreased level of consciousness 4. 3 cm darkened area on left heel
Correct Answer: 3 Rationale: The Sengstaken-Blakemore tube has two balloons, which are used to tamponade the esophageal bleeding. One balloon is in the stomach and the other is in the esophagus, and if the tube migrates, the airway can be obstructed. Decreased level of consciousness may indicate hypoxia and is the priority for follow-up. A swollen and reddened lower leg may indicate a venous thrombus. Absent bowel sounds may indicate ileus. A darkened area on the left heel may indicate a pressure ulcer. While all of these are potentially serious problems, the possibility of hypoxia is the priority for follow-up.
The nurse is planning care for a patient scheduled for paracentesis to treat ascites. Which outcome should the nurse use for this patient's plan of care? 1. The patient will have normal bilateral breath sounds. 2. The patient's spleen will not rupture. 3. The patient's respiratory effort will be lessened. 4. The patient will not manifest symptoms of hepatomegaly.
Correct Answer: 3 Rationale: The goal of paracentesis is to relieve respiratory distress caused by excess fluid in the abdomen. Paracentesis does not cause an enlarged liver or alter breath sounds. A ruptured spleen is not a complication of paracentesis.
A patient with cirrhosis is experiencing hypertension, edema, and shortness of breath. What should the nurse identify as the patient's priority problem? 1. insufficient fluid level 2. problem with tissue perfusion 3. too much bodily fluid 4. problem with integumentary status
Correct Answer: 3 Rationale: The patient with shortness of breath, edema, and hypertension is experiencing an excessive amount of fluid. Hypotension and dry mucous membranes are associated with a fluid volume deficit. There is no evidence that the patient is having problems with tissue perfusion. Edema can cause an alteration in skin integrity, but there is no evidence of such problems in this patient.
The nurse is teaching a patient about strategies for reducing the risk of hepatitis B transmission. Which statements by the patient indicate teaching has been effective? Select all that apply. 1. "I will wash my hands frequently to prevent fecal-oral transmission." 2. "I will avoid alcohol." 3. "I will avoid contact with blood and body fluids." 4. "I will avoid contaminated food and water." 5. "I will use safe sex techniques."
Correct Answer: 3, 5 Rationale: Hepatitis B is contracted through contaminated blood and body fluids. Strategies that reduce exposure to the blood and body fluids of others, including using safe sex techniques, reduce the risk of hepatitis B transmission. Hepatitis A is transmitted via the fecal-oral route and through contaminated food and water. Laënnec cirrhosis is related to alcohol consumption and to chronic hepatitis B or C.
The nurse is assessing a patient with ascites caused by liver failure. Which finding would require immediate follow-up by the nurse? 1. asterixis 2. jaundice 3. increased abdominal girth 4. dyspnea
Correct Answer: 4 Rationale: Dyspnea is the immediate priority for this patient. Asterixis or liver flap is a muscle tremor that interferes with the ability to maintain a fixed position of the extremities, causes involuntary jerking movements, and is an early sign of portal systemic encephalopathy. Jaundice is a chronic problem with liver failure and does not present an immediate threat to the patient. Increased abdominal girth is likely the result of ascites and may be contributing to the patient's shortness of breath. Although all of these symptoms should be reported to the primary healthcare provider, the nurse's immediate priority is the shortness of breath.
A patient with cholelithiasis has a serum amylase level of 300 units/L. What should the nurse consider as the most likely explanation for the laboratory finding? 1. The gallstone is causing acute cholecystitis. 2. The gallstone has migrated to the neck of the pancreas. 3. The gallstone has caused bile to back into the pancreas. 4. The gallstone is blocking the common bile duct.
Correct Answer: 4 Rationale: When a gallstone in the bile duct blocks the common bile duct, pancreatic enzymes cannot exit the common bile duct and back up into the pancreas, causing pancreatitis, which elevates pancreatic enzymes. A normal serum amylase level is 0-130 units/L. Acute cholecystitis does not elevate amylase levels. It would be highly unlikely for the gallstone to migrate to the neck of the pancreas. The gallstone does not cause bile to back into the pancreas, although it can cause pancreatic enzymes to back up into the pancreas.
The nurse is preparing instructions for a patient who is at risk for cholelithiasis. What lifestyle modification should the nurse include in this teaching? 1. Reduce sodium intake. 2. Increase fluids. 3. Reduce smoking. 4. Reduce fat consumption.
Correct Answer: 4 Rationale: Most gallstones consist primarily of cholesterol. Excess cholesterol in the bile is associated with obesity and a high-calorie, high-cholesterol diet. While all patients should be instructed to reduce sodium intake and stop smoking, these steps would not assist in reducing cholelithiasis or its pain. Increasing fluids would also not assist in reducing cholelithiasis or its pain.
A patient who has portal systemic encephalopathy is receiving Neomycin (neomycin sulfate). Which manifestation should indicate to the nurse that the patient's condition is improving? 1. increase in potassium level 2. asterixis 3. relief of jaundice 4. increased level of consciousness
Correct Answer: 4 Rationale: Portal systemic encephalopathy is characterized by impaired judgment, confusion, disorientation, and incoherence related to high level of ammonia in the blood. Administering Neomycin (neomycin sulfate) should reduce ammonia levels by decreasing the number of bacteria-producing microorganisms in the bowel. Neomycin (neomycin sulfate) causes diarrhea, which decreases rather than increases potassium. Asterixis, the downward flapping of the hands, is a sign of portal systemic encephalopathy and should improve with administration of Neomycin (neomycin sulfate). Neomycin does not improve jaundice.
A patient scheduled for a laparoscopic cholecystectomy asks the nurse why a surgical consent for a laparotomy must also be completed. How should the nurse respond? 1. "By signing both now, you'll never have to sign another one. We'll keep the extra on file for the future." 2. "Surgeons base their decision on whether to do the procedure laparoscopically or with a full incision on many factors. With this signed, the surgeon has options." 3. "You will be ready if the laparoscopic operating rooms are busy today." 4. "The surgeon will start the procedure laproscopically but may need to make an incision to complete the procedure."
Correct Answer: 4 Rationale: There is a risk that a laparoscopic cholecystectomy may be converted to a laparotomy (surgical opening into the abdomen) during the procedure. Surgical consents are not signed in advance of procedures. The consent is not intended to provide the surgeon with options. The busyness of the operating rooms has nothing to do with the consent form.
The nurse is instructing a patient recovering from a liver transplant. What should the nurse include in this teaching? 1. Eat a high-protein diet. 2. Reduce scheduled antirejection drugs to every other day if nausea occurs. 3. Take acetaminophen (Tylenol) if fever develops. 4. Report sore throats to the healthcare provider.
Rationale: The patient who has undergone a liver transplant should be instructed to report any signs of infection, such as a sore throat, as the medications prescribed to prevent organ rejection increase the risk of contracting infectious diseases. The patient should be instructed to eat a low-to-moderate-protein diet to reduce the workload of the liver in terms of protein metabolism. The patient must adhere to the prescribed medication schedule unless otherwise instructed by the healthcare provider. Acetaminophen (Tylenol) should not be taken, as it is liver-toxic.