HEPATOBILIARY AND PANCREATIC DISORDERS PRACTICE Q'S

A client who had been hospitalized with pancreatitis is being discharged with home health services. The client is severely weakened after this illness. Which nursing intervention is the highest priority in conserving the client's strength? A. Limiting the client's activities to one floor of the home B. Instructing the client to take an as-needed (PRN) sleeping medication at night C. Arranging for the client to have a nutritional consult to assess the client's diet D. Asking the health care provider for a request for PRN nasal oxygen

A. Limiting the client's activities to one floor of the home Limiting the client's activities to one floor of the home will prevent tiring the client with stair climbing. Taking a PRN sleeping medication may not necessarily increase the client's strength level or conserve strength; also, the client may not be experiencing difficulty sleeping. Arranging for a nutritional consult or placing the client on PRN nasal oxygen will not necessarily result in an increase in the client's strength level or conserve strength; no information suggests that the client has any history of breathing difficulties.

The RN has just received the change-of-shift report for the medical unit. Which client should the RN see first? A. Client with ascites who had a paracentesis 2 hours ago and is reporting a headache B. Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse C. Client with hepatic cirrhosis and jaundice who has hemoglobin of 10.9 g/dL and thrombocytopenia D. Client with hepatitis A who has elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST)

B. Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse A change in the level of consciousness (LOC) of the client with PSE is the greatest concern; actions to improve the client's LOC should be rapidly implemented. Although uncomfortable, a headache in the client with ascites is not likely related to liver disease and does not pose an immediate threat or complication. A hemoglobin of 10.9 g/dL and thrombocytopenia are expected findings in a client with cirrhosis and do not pose an immediate threat. Elevated ALT and AST levels are expected for the client with hepatitis A and do not indicate a risk for severe complications.

The nurse is caring for clients in the outpatient clinic. Which of these phone calls should the nurse return first? A. Client with hepatitis A reporting severe and ongoing itching B. Client with severe ascites who has a temperature of 101.4° F (38° C) C. Client with cirrhosis who has had a 3-pound weight gain over 2 days D. Client with esophageal varices and mild right upper quadrant pain

B. Client with severe ascites who has a temperature of 101.4° F (38° C) The client with ascites and an elevated temperature may have spontaneous bacterial peritonitis; the nurse should call this client first. Itching is anticipated with jaundice, this client may be called last. Weight gain with cirrhosis is not uncommon owing to low albumin levels. Cirrhosis may cause mild right upper quadrant pain; this client should be called after the client with severe ascites.

When providing dietary teaching to a client with hepatitis, what practice does the nurse recommend? A. Having a larger meal early in the morning B. Consuming increased carbohydrates and moderate protein C. Restricting fluids to 1500 mL/day D. Limiting alcoholic beverages to once weekly

B. Consuming increased carbohydrates and moderate protein To repair the liver, the client should have a high-carbohydrate and moderate-protein diet; fats may cause dyspepsia. The client with hepatitis feels full easily and should have four to six small meals daily. Fluids are restricted with ascites caused by cirrhosis; not all clients with hepatitis progress to cirrhosis. Complete abstention from alcohol is necessary until the liver enzymes return to normal.

Which activity by the nurse will best relieve symptoms associated with ascites? A. Administering oxygen B. Elevating the head of the bed C. Monitoring serum albumin levels D. Administering intravenous fluids

B. Elevating the head of the bed The enlarged abdomen of ascites limits respiratory excursion; Fowler's position will increase excursion and reduce shortness of breath. The client may need oxygen, but first the nurse should raise the head of the bed to improve respiratory excursion and oxygenation. Monitoring will detect anticipated decreased serum albumin levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

When providing community education, the nurse emphasizes that which group should receive immunization for hepatitis B? A. Clients who work with shellfish B. Men who prefer sex with men C. Clients traveling to a third-world country D. Clients with elevations of aspartate aminotransferase and alanine aminotransferase

B. Men who prefer sex with men Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity. Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A; hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.

The nurse expects that which client will be discharged to the home environment first? A. Older obese adult who has had a laparoscopic cholecystectomy B. Middle-aged thin adult who has had a laparoscopic cholecystectomy C. Middle-aged thin adult with a heart murmur who has had a traditional cholecystectomy D. Older obese adult with chronic obstructive pulmonary disease (COPD) who has had a traditional cholecystectomy

B. Middle-aged thin adult who has had a laparoscopic cholecystectomy The combination of client age, a thin frame, and the type of procedure performed will determine that the middle-aged thin client who had a laparoscopic cholecystectomy will be discharged first. Although the older obese client who had a laparoscopic cholecystectomy will have a faster discharge time than one with a traditional cholecystectomy, the client's obesity and age probably will require a longer stay. A traditional cholecystectomy will always require a longer recovery time. The older obese client with a history of COPD will likely have a more lengthy recovery because of associated breathing problems.

The nurse suspects that which client is at highest risk for developing gallstones? A. Obese male with a history of chronic obstructive pulmonary disease B. Obese female on hormone replacement therapy C. Thin male with a history of coronary artery bypass grafting D. Thin female who has recently given birth

B. Obese female on hormone replacement therapy Both obesity and altered hormone levels increase a woman's risk for developing gallstones. Men are at lower risk than women for developing gallstones. Although pregnancy increases the risk for a woman to develop gallstones, this woman's thin frame lessens that risk.

A client diagnosed with acalculous cholecystitis asks the nurse how the gallbladder inflammation developed when there is no history of gallstones. What is the nurse's best response? A. "This may be an indication that you are developing sepsis." B. "The gallstones are present, but have become fibrotic and contracted." C. "This type of gallbladder inflammation is associated with hypovolemia." D. "This may be an indication of pancreatic disease."

C. "This type of gallbladder inflammation is associated with hypovolemia." This type of gallbladder inflammation is associated with hypovolemia. Although this type of gallbladder inflammation is associated with sepsis, it is not an indicator that sepsis is developing. Fibrotic and contracted gallstones are associated with chronic cholecystitis. The presence of acalculous cholecystitis is not an indicator that pancreatic disease has developed.

The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN? A. Client who is taking lactulose and has diarrhea B. Client with hepatitis C who requires a dressing change C. Client with end-stage cirrhosis who needs teaching about a low-sodium diet D. Obtunded client with alcoholic encephalopathy who needs a blood draw

C. Client with end-stage cirrhosis who needs teaching about a low-sodium diet The RN is responsible for client teaching; therefore, the client with end-stage cirrhosis should be assigned to the RN. Assisting a client with toileting and recording stool number and amount can be accomplished by nonprofessional staff. The LPN/LVN can provide dressing changes. Ancillary staff can perform venipuncture.

The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose? A. Provides enzymes necessary to digest dairy products B. Reduces portal pressure C. Promotes gastrointestinal (GI) excretion of ammonia D. Decreases GI bleeding

C. Promotes gastrointestinal (GI) excretion of ammonia Lactulose reduces serum ammonia levels by excreting ammonia through the GI tract. Lactase is the enzyme that digests dairy products. The mechanism of action of lactulose is not to reduce portal pressure. Lactulose does not affect bleeding.

The RN is caring for a client with end-stage liver disease that has resulted in ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)? A. Assessing skin integrity and abdominal distention B. Drawing blood from a central venous line for electrolyte studies C. Evaluating laboratory study results for the presence of hypokalemia D. Placing the client in a semi-Fowler's position

D. Placing the client in a semi-Fowler's position Positioning the client in a semi-Fowler's position is included within UAP education and scope of practice, although the RN will need to supervise the UAP in providing care and will evaluate the effect of the semi-Fowler's position on client comfort and breathing. Assessment of skin integrity and abdominal distention, obtaining blood from a central line, and evaluation of laboratory results should be done by the RN.

A health care worker believes that he may have been exposed to hepatitis A. Which intervention is the highest priority to prevent him from developing the disease? A. Requesting vaccination for hepatitis A B. Using a needleless system in daily work C. Getting the three-part hepatitis B vaccine D. Requesting an injection of immunoglobulin

D. Requesting an injection of immunoglobulin The administration of immunoglobulin, antibodies to hepatitis A, may prevent development of the disease. The vaccine for hepatitis A will take several weeks to stimulate the development of antibodies; passive immunity in the form of immunoglobulin is needed. Implementing a needleless system and getting the three-part vaccine may prevent the development of hepatitis B, not hepatitis A.

How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Evalose)? A. Provides small frequent meals for the client B. Suggests taking daily potassium supplements C. Elevates the head of the bed in high-Fowler's position D. Requests a bedside commode for the client

D. Requests a bedside commode for the client Lactulose therapy increases the frequency of stools, so a bedside commode should be made available to the client, especially if he or she has difficulty reaching the toilet. Small frequent meals and elevating the head of the bed will not have any effect on the side effects of lactulose. Although lactulose produces excessive stools and could potentially result in loss of potassium, it is inappropriate for the nurse to suggest that the client take potassium supplements.

The nurse is attempting to position a client having an acute attack of pancreatitis in the most comfortable position possible. In which position does the nurse place this client? A. Supine, with a pillow supporting the abdomen B. Up in a chair between frequent periods of ambulation C. High-Fowler's position, with pillows used as needed D. Side-lying position, with knees drawn up to the chest

D. Side-lying position, with knees drawn up to the chest The side-lying position with the knees drawn up has been found to relieve abdominal discomfort related to acute pancreatitis. No evidence suggests that supine position, sitting up in a chair, or high-Fowler's position have any effect on abdominal discomfort related to acute pancreatitis.

Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the heath care provider? A. The dressing has a 2-cm area of serous drainage. B. The client's platelet count is 135,000/mm3. C. The client's albumin level is 2.8 mg/dL. D. The client's heart rate is 122 beats/min.

D. The client's heart rate is 122 beats/min. Rapid removal of fluid may cause symptoms of shock; tachycardia, especially when associated with hypotension, should be reported to the provider. A small amount of serous fluid may leak; the dressing should be reinforced. Platelets will be checked before the procedure; these are slightly low, but this is not a cause for concern. An albumin level of 2.8 mg/dL is an expected finding for a client with cirrhosis; it is not life threatening. Awarded 1.0 points out of 1.0 possible points.

The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which individual should the nurse refer for an immunoglobin (IG) injection? a. A caregiver who lives in the same household with the patient b. A friend who delivers meals to the patient and family each week c. A relative with a history of hepatitis A who visits the patient daily d. A child living in the home who received the hepatitis A vaccine 3 months ago

a. A caregiver who lives in the same household with the patient IG is recommended for persons who do not have anti-HAV antibodies and are exposed as a result of close contact with persons who have HAV or foodborne exposure. Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.

After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select all that apply)? a. Administer hepatitis B vaccine. b. Test for antibodies to hepatitis B. c. Teach about -interferon therapy. d. Give hepatitis B immune globulin. e. Teach about choices for oral antiviral therapy.

a. Administer hepatitis B vaccine. b. Test for antibodies to hepatitis B. d. Give hepatitis B immune globulin. The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis.

A patient has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider? a. Asterixis and lethargy b. Jaundiced sclera and skin c. Elevated total bilirubin level d. Liver 3 cm below costal margin

a. Asterixis and lethargy The patient's findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center.

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.

a. The patient is alert and oriented. The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient.

The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)? a. There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. b. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. c. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. d. Osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluids orally. e. Overactivity of the enlarged spleen results in increased removal of blood cells from the circulation, which decreases the vascular pressure.

a. There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. b. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. c. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. The ascites related to cirrhosis are caused by decreased colloid oncotic pressure from the lack of albumin from liver inability to synthesize it and the portal hypertension that shifts the protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not directly contribute to ascites.

When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)? a. Use smallest gauge needle possible when giving injections or drawing blood. b. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. c. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. d. Apply gentle pressure for the shortest possible time period after performing venipuncture. e. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.

a. Use smallest gauge needle possible when giving injections or drawing blood. b. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. c. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. e. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present. Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding.

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply)? a. Vitamin A b. Vitamin D c. Vitamin E d. Vitamin K e. Vitamin B

a. Vitamin A b. Vitamin D c. Vitamin E d. Vitamin K Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstruction.

Nursing management of the patient with acute pancreatitis includes (select all that apply) a. checking for signs of hypocalcemia. b. providing a diet low in carbohydrates. c. giving insulin based on a sliding scale. d. observing stools for signs of steatorrhea. e. monitoring for infection, particularly respiratory tract infection.

a. checking for signs of hypocalcemia. e. monitoring for infection, particularly respiratory tract infection. Rationale: During the acute phase, it is important to monitor vital signs. Hemodynamic stability may be compromised by hypotension, fever, and tachypnea. Intravenous fluids are ordered, and the response to therapy is monitored. Fluid and electrolyte balances are closely monitored. Frequent vomiting, along with gastric suction, may result in decreased levels of chloride, sodium, and potassium. Because hypocalcemia can occur in acute pancreatitis, the nurse should observe for symptoms of tetany, such as jerking, irritability, and muscular twitching. Numbness or tingling around the lips and in the fingers is an early indicator of hypocalcemia. The patient should be assessed for Chvostek's sign or Trousseau's sign. A patient with acute pancreatitis should be observed for fever and other manifestations of infection. Respiratory infections are common because the retroperitoneal fluid raises the diaphragm, which causes the patient to take shallow, guarded abdominal breaths.

The patient with suspected gallbladder disease is scheduled for an ultrasound of the gallbladder. The nurse explains to the patient that this test a. is noninvasive and is a very reliable method of detecting gallstones b. is used only when other tests cannot be used because of allergy to contrast media c. is an adjunct to liver function tests to determine whether the gallbladder is inflamed d. will outline the gallbladder and the ductal system to enable visualization of stones

a. is noninvasive and is a very reliable method of detecting gallstones Ultrasonography is 90-95% accurate in detecting gallstones, and is noninvasive. Liver function tests will be elevated if there is damage to the liver, not with gallbladder.

The nurse is planning care for a patient with acute severe pancreatitis. The highest priority patient outcome is a. maintaining normal respiratory function. b. expressing satisfaction with pain control. c. developing no ongoing pancreatic disease. d. having adequate fluid and electrolyte balance.

a. maintaining normal respiratory function. Respiratory failure can occur as a complication of acute pancreatitis and maintenance of adequate respiratory function is the priority goal.

A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on the knowledge that a. pruritus is a common problem with jaundice in this phase. b. the patient is most likely to transmit the disease during this phase. c. gastrointestinal symptoms are not as severe in hepatitis A as they are in hepatitis B. d. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase. (Lewis 1042)

a. pruritus is a common problem with jaundice in this phase. Rationale: The acute phase of jaundice may be icteric or anicteric. Jaundice results when bilirubin diffuses into the tissues. Pruritus sometimes accompanies jaundice. Pruritus is the result of an accumulation of bile salts beneath the skin.

A patient newly diagnosed with acute hep B asks about drug therapy to treat the disease. The most appropriate response by the nurse is informing the patient that a. there are no specific drugs that are effective for treating acute viral hepatitis b. only chronic hep C is treatable, primarily with antiviral agents and alpha interferon. c. no drugs can be used for treatment of viral hepatitis because of the risk of additional liver damage. d. alpha interferon combined with lamivudine (EPivir) will decrease viral load and liver damage if taken for 1 year

a. there are no specific drugs that are effective for treating acute viral hepatitis No specific drugs are effective in treating acute viral hepatitis, although supportive drugs, such as anti-emetics, sedative, or atipruritics, may be used for symptom control. Antiviral agents, such as lamivudine or ribavirin, and alpha interferon may be used for treating chronic hepatitis B or C.

A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate? a. "Do you have a history of IV drug use?" b. "Do you use any over-the-counter drugs?" c. "Have you used corticosteroids for any reason?" d. "Have you recently traveled to a foreign country?"

b. "Do you use any over-the-counter drugs?" The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis.

The nurse recognizes that teaching a patient following a laparoscopic cholecystectomy has been effective when the patient makes which statement? a. "I can expect yellow-green drainage from the incision for a few days." b. "I can remove the bandages on my incisions tomorrow and take a shower." c. "I should plan to limit my activities and not return to work for 4 to 6 weeks." d. "I will need to maintain a low-fat diet for life because I no longer have a gallbladder."

b. "I can remove the bandages on my incisions tomorrow and take a shower." After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a lifelong requirement.

Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms forward. c. Request that the patient walk with eyes closed. d. Ask the patient to perform the Valsalva maneuver.

b. Ask the patient to extend both arms forward. Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy.

The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient? a. Prevent all oral intake. b. Control abdominal pain. c. Provide enteral feedings. d. Avoid dietary cholesterol.

b. Control abdominal pain. Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelithiasis. Enteral feedings should not be needed, and avoiding dietary cholesterol is not used to treat cholelithiasis.

The nurse identifies a need for further teaching when the patient with hepatitis B states a. I should avoid alcohol completely for as long as a year b. I must avoid all physical contact with my family until the jaundice is gone c. I should use a condom to prevent spread of the disease to my sexual partners d. I will need to rest several times a day, gradually increasing my activity as I tolerate it.

b. I must avoid all physical contact with my family until the jaundice is gone The patient with hep B is infectious for 4 to 6 months, and precautions to prevent transmission through percutaneous and sexual contact should be maintained until tests for HBsAg are negative. Close contact does not have to be avoided, but close contacts of the patient should be vaccinated. Alcohol should not be used for at least a year, and rest with increasing activity during convalescence is recommended

The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care? a. Immediately start enteral feeding to prevent malnutrition. b. Insert an NG and maintain NPO status to allow pancreas to rest. c. Initiate early prophylactic antibiotic therapy to prevent infection. d. Administer acetaminophen (Tylenol) every 4 hours for pain relief.

b. Insert an NG and maintain NPO status to allow pancreas to rest. Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.

The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit? a. Hematochezia b. Left upper abdominal pain c. Ascites and peripheral edema d. Temperature over 102o F (38.9o C)

b. Left upper abdominal pain Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).

Which goal has the highest priority in the plan of care for a 26-yr-old patient who is homeless who was admitted with viral hepatitis who has severe anorexia and fatigue? a. Increase activity level. b. Maintain adequate nutrition. c. Establish a stable environment. d. Identify source of hepatitis exposure.

b. Maintain adequate nutrition. The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration.

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Monitor the patient for shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea.

b. Monitor the patient for shortness of breath. The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. Balloons may be deflated briefly every 8 to 12 hours to avoid tissue necrosis, but if only the gastric balloon is deflated, the esophageal balloon may occlude the airway.

For a patient with cirrhosis, which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)? a. Assessing the patient for jaundice b. Providing oral hygiene after a meal c. Palpating the abdomen for distention d. Teaching the patient the prescribed diet

b. Providing oral hygiene after a meal Providing oral hygiene is within the scope of UAP.

Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B? a. Advise limiting alcohol intake to 1 drink daily. b. Schedule for liver cancer screening every 6 months. c. Initiate administration of the hepatitis C vaccine series. d. Monitor anti-hepatitis B surface antigen (anti-HBs) levels.

b. Schedule for liver cancer screening every 6 months. Patients with chronic hepatitis are at higher risk for development of liver cancer and should be screened for liver cancer every 6 to 12 months. Patients with chronic hepatitis are advised to completely avoid alcohol. There is no hepatitis C vaccine.

The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? a. The patient complains of right upper-quadrant pain with palpation. b. The patient's hands flap back and forth when the arms are extended. c. The patient has ascites and a 2-kg weight gain from the previous day. d. The patient's abdominal skin has multiple spider-shaped blood vessels.

b. The patient's hands flap back and forth when the arms are extended. Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment.

Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis? a. The patient's urine is bright yellow. b. The patient's stools are tan colored. c. The patient has increased pain after eating. d. The patient complains of chronic heartburn.

b. The patient's stools are tan colored. Tan or gray stools indicate biliary obstruction, which requires rapid intervention to resolve.

To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor a. bilirubin levels. b. ammonia levels. c. potassium levels. d. prothrombin time.

b. ammonia levels. The protein in the blood in the gastrointestinal tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well.

Laboratory test results that the nurse would expect to find in a patient with cirrhosis include a. serum albumin 7.0 g/dL b. bilirubin total 3.2 mg/dL c. serum cholesterok 260 mg/dL d. aspartate aminotransferase (AST) 6.0 U/L

b. bilirubin total 3.2 mg/dL Serum bilirubin, both direct and indirect, would be expected to be increased in cirrhosis. Serum albumin and cholesterol are decreased, and liver enzymes, such as AST and ALT, are elevated

A risk factor associated with cancer of the pancreas is a. alcohol intake b. cigarette smoking c. exposure to asbestos d. increased dietary intake of milk and milk products

b. cigarette smoking

Combined with clinical manifestations, the laboratory finding that is most commonly used to diagnose acute pancreatitis is a. increased serum calcium b. increased serum amylase c. increased urinary amylase d. decreased serum glucose

b. increased serum amylase Although serum lipase levels and urinary amylase levels are increased, an increased serum amylase level is the criterion most commonly used to diagnose acute pancreatitis in the first 24 to 72 hours. Serum calcium levels are decreased.

The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity. b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel. d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid. (Lewis 1042)

b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. Rationale: Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity and is a common manifestation of cirrhosis. With portal hypertension, proteins shift from the blood vessels through 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, those substances leak through the liver capsule into the peritoneal cavity. Osmotic pressure of the proteins pulls additional fluid into the peritoneal cavity. A second mechanism of ascites formation is hypoalbuminemia, which results from the inability of the liver to synthesize albumin. Hypoalbuminemia results in decreased colloidal oncotic pressure. A third mechanism is hyperaldosteronism, which occurs when aldosterone is not metabolized by damaged hepatocytes. The increased level of aldosterone causes increases in sodium reabsorption by the renal tubules. Sodium retention and an increase in antidiuretic hormone levels cause additional water retention.

Teaching in relation to home management after a laparoscopic cholecystectomy should include a. keeping the bandages on the puncture sites for 48 hours. b. reporting any bile-colored drainage or pus from any incision. c. using over-the-counter antiemetics if nausea and vomiting occur. d. emptying and measuring the contents of the bile bag from the T tube every day. (Lewis 1042)

b. reporting any bile-colored drainage or pus from any incision. Rationale: The following discharge instructions are taught to the patient and caregiver after a laparoscopic cholecystectomy: First, remove the bandages on the puncture site the day after surgery and shower. Second, notify the surgeon if any of the following signs and symptoms occur: redness, swelling, bile-colored drainage or pus from any incision; and severe abdominal pain, nausea, vomiting, fever, or chills. Third, gradually resume normal activities. Fourth, return to work within 1 week of surgery. Fifth, resume a usual diet, but a low-fat diet is usually better tolerated for several weeks after surgery.

A patient with acute hepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to a. avoid alcohol for the first 3 weeks. b. use a condom during sexual intercourse. c. have family members get an injection of immunoglobulin. d. follow a low-protein, moderate-carbohydrate, moderate-fat diet.

b. use a condom during sexual intercourse. Rationale: Hepatitis B virus may be transmitted by mucosal exposure to infected blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B.

The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase) a. at bedtime. b. with meals. c. in the morning. d. for abdominal pain.

b. with meals. Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.

The nurse provides discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective? a. "It is safe to take acetaminophen up to four times a day for pain." b. "Lactulose (Cephulac) should be taken every day to prevent constipation." c. "Herbs and other spices should be used to season my foods instead of salt." d. "I will eat foods high in potassium while taking spironolactone (Aldactone)."

c. "Herbs and other spices should be used to season my foods instead of salt." A low-sodium diet is indicated for the patient with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided as these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.

The nurse instructs a 50-year-old woman about cholestyramine to reduce pruritis caused by gallbladder disease. Which statement by the patient to the nurse indicates she understands the instructions? a. "This medication will help me digest fats and fat-soluble vitamins." b. "I will apply the medicated lotion sparingly to the areas where I itch." c. "The medication is a powder and needs to be mixed with milk or juice." d. "I should take this medication on an empty stomach at the same time each day."

c. "The medication is a powder and needs to be mixed with milk or juice." For treatment of pruritus, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in powder form and should be mixed with milk or juice before oral administration.

During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first? a. A 40-yr-old patient with chronic pancreatitis who has gnawing abdominal pain b. A 58-yr-old patient who has compensated cirrhosis and is complaining of anorexia c. A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) d. A 36-yr-old patient recovering from a laparoscopic cholecystectomy who has severe shoulder pain

c. A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) This patient's history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy.

The nurse is caring for a patient with pancreatic cancer. Which nursing action is the highest priority? a. Offer psychologic support for depression. b. Offer high-calorie, high-protein dietary choices. c. Administer prescribed opioids to relieve pain as needed. d. Teach about the need to avoid scratching any pruritic areas.

c. Administer prescribed opioids to relieve pain as needed. Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to teaching, or manage anxiety or depression.

A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings? a. Malnutrition b. Osteomyelitis c. Alcohol abuse d. Diabetes mellitus

c. Alcohol abuse The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal 30-122 U/L) and serum lipase (normal 31-186 U/L) levels as shown.

Which topic is most important to include in patient teaching for a 41-yr-old patient diagnosed with early alcoholic cirrhosis? a. Taking lactulose b. Maintaining good nutrition c. Avoiding alcohol ingestion d. Using vitamin B supplements

c. Avoiding alcohol ingestion The disease progression can be stopped or reversed by alcohol abstinence.

Which action should the nurse in the emergency department take first for a new patient who is vomiting blood? a. Insert a large-gauge IV catheter. b. Draw blood for coagulation studies. c. Check blood pressure and heart rate. d. Place the patient in the supine position.

c. Check blood pressure and heart rate. The nurse's first action should be to determine the patient's hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter are also appropriate.

When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the chart. d. Notify the health care provider immediately.

c. Check the calcium level in the chart. The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse checks the patient's calcium level.

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Muscle twitching and finger numbness d. Upper abdominal tenderness and guarding

c. Muscle twitching and finger numbness Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered.

A patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the health care provider before administration? a. Ribavirin (Rebetol, Copegus) 600 mg PO bid b. Diphenhydramine 25 mg PO every 4 hours PRN itching c. Pegylated -interferon (PEG-Intron, Pegasys) 1.5 mcg/kg PO daily d. Dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea

c. Pegylated -interferon (PEG-Intron, Pegasys) 1.5 mcg/kg PO daily Pegylated -interferon is administered subcutaneously, not orally. The medications are all appropriate for a patient with chronic hepatitis C infection.

A patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator to the nurse that the medication has been effective? a. The patient reports no chest pain. b. Blood pressure is 140/90 mm Hg. c. Stools test negative for occult blood. d. The apical pulse rate is 68 beats/minute.

c. Stools test negative for occult blood. Because the purpose of -blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools.

Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices? a. The medication will reduce the risk for aspiration. b. The medication will inhibit development of gastric ulcers. c. The medication will prevent irritation of the enlarged veins. d. The medication will decrease nausea and improve the appetite.

c. The medication will prevent irritation of the enlarged veins. Esophageal varices are dilated submucosal veins. The therapeutic action of H2-receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents.

A patient with chronic cholecystitis asks the nurse whether she will need to continue a low fat diet after she has a cholecystectomy. The best response by the nurse is a. a low fat diet will prevent development of further gallstones and should be continued b. yes, because you will not have a gallbladder to store bile, you will not be able to digest fats adequately c. a low fat diet is recommended for a few weeks after surgery until the intestine adjusts to receiving a continuous flow of bile d. removal of the gallbladder will eliminate the source of your pain associated with fat intake, so you may eat whatever you like

c. a low fat diet is recommended for a few weeks after surgery until the intestine adjusts to receiving a continuous flow of bile

In discussing long term management with the patient with alcoholic cirrhosis, the nurse advises the patient that a. a daily exercise regimen is important to increase the blood flow through the liver b. cirrhosis can be reversed if the patient follows a regimen of proper rest and nutrition c. abstinence from alcohol is the most important factor in improvement of the patient's condition d. the only over the counter analgesic that should be used for minor aches and pains is acetaminophen

c. abstinence from alcohol is the most important factor in improvement of the patient's condition Abstinence from alcohol is very important in alcoholic cirrhosis and may result in improvement if started when liver damage is reduced by rest and nutrition, most changes in the liver cannot be reversed. Exercise does not promote portal circulation, and very moderate exercise is recommended. Acetaminophen should not be used by the patient with liver disease because it is potentially hepatotoxic.

Following laparoscopic cholecystectomy, the nurse would expect the patient to a. return to work in 2 to 3 weeks b. be hospitalized for 3 to 5 days postoperatively c. have four small abdominal incisions covered with small dressings d. have a T tube placed in the common bile duct to provide bile drainage

c. have four small abdominal incisions covered with small dressings

During the treatment of the patient with bleeding esophageal varices, it is most important that the nurse a. prepare the patient for immediate portal shunting surgery b. perform guaiac testing on all stools to detect occult blood c. maintain the patient's airway and prevent aspiration of blood d. monitor for the cardiac effects of IV vasopressin and nitroglycerin

c. maintain the patient's airway and prevent aspiration of blood Bleeding esophageal varices are a medical emergency. During an episode of bleeding, management of the airway and prevention of aspiration of blood are critical factors. Occult blood as well as fresh blood from the GI tract would be expected and is not tested. Vasopressin causes vasoconstriction, decreased HR, and decreased coronary blood flow; nitroglycerin is given with the vasopressin to counter these side effects. Portal shunting surgery is performed for esophageal varices but not during an acute hemorrhage

When assessing a patient with acute pancreatitis, the nurse would expect to find a. hyperactive bowel sounds b. hypertension and tachycardia c. severe midepigastric pain or LUQ pain d. a temperature greater than 102 F

c. severe midepigastric pain or LUQ pain The predominant symptom of acute pancreatitis is severe, deep abdominal pain that is usually located in the left upper quadrant (LUQ) but may be in the midepigastrium. Bowel sounds are decreased or absent, temperature is elevated only slightly, and the patient has hypovolemia and may manifest symptoms of shock.

A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to a. perform leg exercises hourly while awake. b. ambulate the evening of the operative day. c. turn, cough, and deep breathe every 2 hours. d. choose preferred low-fat foods from the menu.

c. turn, cough, and deep breathe every 2 hours. Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing.

When teaching the patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? a. "I will use care when kissing my wife to prevent giving it to her." b. "I will need to take adofevir (Hepsera) to prevent chronic HCV." c. "Now that I have had HCV, I will have immunity and not get it again." d. "I will need to be checked for chronic HCV and other liver problems."

d. "I will need to be checked for chronic HCV and other liver problems." The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.

d. Abdominal pain is decreased. NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status has been effective. Electrolyte levels may be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.

Which focused data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level

d. Albumin level The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema.

The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what? a. Relief of constipation b. Relief of abdominal pain c. Decreased liver enzymes d. Decreased ammonia levels

d. Decreased ammonia levels Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy.

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a. Increased serum albumin level b. Decreased indirect bilirubin level c. Improved alertness and orientation d. Fewer episodes of bleeding varices

d. Fewer episodes of bleeding varices TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices.

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? a. Impaired skin integrity related to edema, ascites, and pruritus b. Imbalanced nutrition: less than body requirements related to anorexia c. Excess fluid volume related to portal hypertension and hyperaldosteronism d. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

d. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.

The nursing management of the patient with cholecystitis associated with cholelithiasis is based on the knowledge that a. shock-wave therapy should be tried initially. b. once gallstones are removed, they tend not to recur. c. the disorder can be successfully treated with oral bile salts that dissolve gallstones. d. laparoscopic cholecystectomy is the treatment of choice in most patients who are symptomatic.

d. Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis.

Which assessment finding is of most concern for a patient with acute pancreatitis? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

d. Palpable abdominal mass A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis.

A nurse is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice? a. Patient who is receiving chemotherapy for liver cancer b. Patient who is receiving treatment for acute hepatitis C c. Patient who has a wound infection after cholecystectomy d. Patient who requires pain management for chronic pancreatitis

d. Patient who requires pain management for chronic pancreatitis The patient with chronic pancreatitis does not present an infection risk to the immunosuppressed patient who had a liver transplant. The other patients either are at risk for infection or currently have an infection, which will place the immunosuppressed patient at risk for infection.

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? a. Restrict daily dietary protein intake. b. Reposition the patient every 4 hours. c. Perform passive range of motion twice daily. d. Place the patient on a pressure-relief mattress.

d. Place the patient on a pressure-relief mattress. The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure.

The systemic effects of viral hepatitis are caused primarily by a. cholestasis b. impaired portal circulation c. toxins produced by the infected liver d. activation of the complement system by antigen-antibody complexes

d. activation of the complement system by antigen-antibody complexes The systemic manifestations of rash, angioedema, arthritis, fever, and malaise in viral hepatitis are caused by the activation of the complement system by circulating immune complexes. Liver manifestations include jaundice from hepatic cell damage and cholestasis as well as anorexia perhaps caused by toxins produced by the damaged liver. Impaired portal circulation usually does not occur in uncomplicated viral hepatitis but would be a liver manifestation

The nurse will ask a patient being admitted with acute pancreatitis specifically about a history of a. diabetes mellitus. b. high-protein diet. c. cigarette smoking. d. alcohol consumption.

d. alcohol consumption. Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking (i think this may be a risk factor as well), diabetes, and high-protein diets are not risk factors.

A patient with cirrhosis that is refractory to other treatments for esophageal varices undergoes a peritoneovenous shunt. As a result of this procedure, the nurse would expect the patient to experience a. an improved survival rate b. decreased serum ammonia levels c. improved metabolism of nutrients d. improved hemodynamic function and renal perfusion

d. improved hemodynamic function and renal perfusion By shunting fluid sequestered in the peritoneum into the venous system, pressur eon esophageal veins is decreased, and more volume is returned to the circulation, improving CO and renal perfusion. However, because ammonia is diverted past the liver, hepatic encephalopathy continues. These procedures do not prolong life or promote liver function.

The nurse recognizes early signs of hepatic encephalopathy in the patient who a. manifests asterixis b. becomes unconscious c. has increasing oliguria d. is irritable and lethargic

d. is irritable and lethargic Early signs of this neurologic condition include euphoria, depression, apathy, irritability, confusion, agitation, drowsiness, and lethargy. Loss of consciousness is usually preceded by asterixis, disorientation, hyperventilation, hypothermia, and alterations in reflexes. Increasing oliguria is a sign of hepatorenal syndrome.

Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago? a. Dry palpebral and oral mucosa b. Crackles at bilateral lung bases c. Temperature 100.8° F (38.2° C) d. No bowel movement for 4 days

c. Temperature 100.8° F (38.2° C) The risk of infection is high in the first few months after liver transplant, and fever is frequently the only sign of infection.

A client with syndrome of inappropriate antidiuretic hormone is admitted with a serum sodium level of 105 mEq/L. Which request by the health care provider does the nurse address first? A. Administer infusion of 150 mL of 3% NaCl over 3 hours. B. Draw blood for hemoglobin and hematocrit. C. Insert retention catheter and monitor urine output. D. Weigh the client on admission and daily thereafter.

A. Administer infusion of 150 mL of 3% NaCl over 3 hours. The client with a sodium level of 105 mEq/L is at high risk for seizures and coma. The priority intervention is to increase the sodium level to a more normal range. Ideally, 3% NaCl should be infused through a central line or with a small needle through a large vein to prevent irritation. Monitoring laboratory values for fluid balance and monitoring urine output are important, but are not the top priority. Monitoring client weight will help in the assessment of fluid balance; however, this is also not the top priority.

A client presents to the emergency department with a history of adrenal insufficiency. The following laboratory values are obtained: Na+ 130 mEq/L, K+ 5.6 mEq/L, and glucose 72 mg/dL. Which is the first request that the nurse anticipates? A. Administer insulin and dextrose in normal saline to shift potassium into cells. B. Give spironolactone (Aldactone) 100 mg orally. C. Initiate histamine2 (H2) blocker therapy with ranitidine for ulcer prophylaxis. D. Obtain arterial blood gases to assess for peaked T waves.

A. Administer insulin and dextrose in normal saline to shift potassium into cells. This client is hyperkalemic. The nurse should anticipate a request to administer 20 to 50 units of insulin with 20 to 50 mg of dextrose in normal saline as an IV infusion to shift potassium into the cells. Spironolactone is a potassium-sparing diuretic that helps the body keep potassium, which the client does not need. Although H2 blocker therapy would be appropriate for this client, it is not the first priority. Arterial blood gases are not used to assess for peaked T waves associated with hyperkalemia; an electrocardiogram needs to be obtained instead.

A client with pheochromocytoma is admitted for surgery. What does the nurse do for the admitting assessment? A. Avoids palpating the abdomen B. Monitors for pulmonary edema with a chest x-ray C. Obtains a 24-hour urine specimen on admission D. Places the client in a room with a roommate for distraction

A. Avoids palpating the abdomen The abdomen must not be palpated in a client with pheochromocytoma because this action could cause a sudden release of catecholamines and severe hypertension. The tumor on the adrenal gland causes sympathetic hyperactivity, increasing blood pressure and heart rate, not pulmonary edema. A 24-hour urine collection will already have been completed to determine the diagnosis of pheochromocytoma. A client diagnosed with a pheochromocytoma may feel anxious as part of the disease process; providing a roommate for distraction will not reduce the client's anxiety.

After receiving change-of-shift report about these four clients, which client does the nurse attend to first? A. Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL B. Client with diabetes insipidus who has a dose of desmopressin (DDAVP) due C. Client with hyperaldosteronism who has a serum potassium of 3.4 mEq/L D. Client with pituitary adenoma who is reporting a severe headache

A. Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL A glucose level of 36 mg/dL is considered an emergency; this client must be assessed and treated immediately. Although it is important to maintain medications on schedule, the client requiring a dose of desmopressin is not the first client who needs to be seen. A serum potassium of 3.4 mEq/L in the client with hyperaldosteronism may be considered normal (or slightly hypokalemic), based on specific hospital levels. The client reporting a severe headache needs to be evaluated as soon as possible after the client with acute adrenal insufficiency. As an initial measure, the RN could delegate obtaining vital signs to unlicensed assistive personnel.

The nurse is teaching a client about how to monitor therapy effectiveness for syndrome of inappropriate antidiuretic hormone. What does the nurse tell the client to look for? A. Daily weight gain of less than 2 pounds B. Dry mucous membranes C. Increasing heart rate D. Muscle spasms

A. Daily weight gain of less than 2 pounds The client must monitor daily weights because this assesses the degree of fluid restriction needed. A weight gain of 2 pounds or more daily or a gradual increase over several days is cause for concern. Dry mucous membranes are a sign of dehydration and an indication that therapy is not effective. An increased heart rate indicates increased fluid retention or dehydration and hypovolemia, and either condition is an indication that therapy is not effective. Muscle spasms are associated with hyponatremia and are an indication of a change in the client's neurologic status. Untreated hyponatremia can lead to seizures and coma.

A client has been admitted to the medical intensive care unit with a diagnosis of diabetes insipidus (DI) secondary to lithium overdose. Which medication is used to treat the DI? A. Desmopressin (DDAVP) B. Dopamine hydrochloride (Intropin) C. Prednisone D. Tolvaptan (Samsca)

A. Desmopressin (DDAVP) Desmopressin is the drug of choice for treatment of severe DI. It may be administered orally, nasally, or by intramuscular or intravenous routes. Dopamine hydrochloride is a naturally occurring catecholamine and inotropic vasopressor; it would not be used to treat DI. Prednisone would not be used to treat DI. Tolvaptan is a selective competitive arginine vasopressin receptor 2 antagonist and is not used with DI.

When caring for a client with portal hypertension, the nurse assesses for which potential complications? (Select all that apply.) A. Esophageal varices B. Hematuria C. Fever D. Ascites E. Hemorrhoids

A. Esophageal varices D. Ascites E. Hemorrhoids Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid). Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

A client with diabetes insipidus (DI) has dry lips and mucous membranes and poor skin turgor. Which intervention does the nurse provide first? A. Force fluids B. Offer lip balm C. Perform a 24-hour urine test D. Withhold desmopressin acetate (DDAVP)

A. Force fluids Dry lips and mucous membranes and poor skin turgor are indications of dehydration, which can occur with DI. This is a serious condition that must be treated rapidly. Encouraging fluids is the initial step, provided the client is able to tolerate oral intake. Lip balm may make the client more comfortable, but does not address the problem of dehydration. A 24-hour urine test will identify loss of electrolytes and adrenal androgen metabolites, but will not correct the dehydration that this client is experiencing. Desmopressin acetate is a synthetic form of antidiuretic hormone that is given to reduce urine production; it improves DI and should not be withheld.

Which diagnostic results lead the nurse to suspect that a client may have gallbladder disease? A. Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall B. Decreased WBC count, visualization of calcified gallstones, increased alkaline phosphatase C. Increased WBC count, visualization of noncalcified gallstones, edema of the gallbladder wall D. Decreased WBC count, visualization of noncalcified gallstones, increased alkaline phosphatase

A. Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall An increased WBC count is evidence of inflammation. Only calcified gallstones will be visualized on abdominal x-ray. Ultrasonography of the right upper quadrant is the best diagnostic test for cholecystitis. Acute cholecystitis is seen as edema of the gallbladder wall and pericholecystic fluid. Alkaline phosphatase will be elevated if liver function is abnormal; this is not common in gallbladder disease.

When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? A. Kidney failure B. Refractory ascites C. Fetor hepaticus D. Paracentesis scheduled for today

A. Kidney failure The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and should not be taken by the client with hepatic encephalopathy. Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.

After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? A. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min B. Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain C. Middle-aged client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography D. Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL

A. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min Acute respiratory distress syndrome is a possible complication of acute pancreatitis. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. The client with cholecystitis and the client with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse's immediate attention. The older adult client's glucose level will require intervention but, again, is not a medical emergency.

A client has developed acute pancreatitis after also developing gallstones. Which is the highest priority instruction for this client to avoid further attacks of pancreatitis? A. "You may need a surgical consult for removal of your gallbladder." B. "See your health care provider immediately when experiencing symptoms of a gallbladder attack." C. "If you have a gallbladder attack and pain does not resolve within a few days, call your health care provider." D. "You'll need to drastically modify your alcohol intake."

B. "See your health care provider immediately when experiencing symptoms of a gallbladder attack." In this case, the client's pancreatitis was likely triggered by the development of gallstones. A diagnostic statement must come from the provider. Also, the client may not require removal of the gallbladder. The client must see the provider promptly when experiencing gallbladder disease and should not wait. Because this client's acute pancreatitis is likely related to gallstones, alcohol consumption need not be restricted.

In caring for a client who has undergone paracentesis, which changes in the client's status should be promptly reported to the provider? A. Increased blood pressure, increased respiratory rate B. Decreased blood pressure, increased heart rate C. Increased respiratory rate, increased apical pulse, pallor D. Tachypnea, diaphoresis, increased blood pressure

B. Decreased blood pressure, increased heart rate Decreased blood pressure and increased heart rate are indicative of shock. Increased blood pressure, increased respiratory rate, increased apical pulse, pallor, tachypnea, and diaphoresis are all indicative of anxiety on the client's part.

A client has undergone a transsphenoidal hypophysectomy. Which intervention does the nurse implement to avoid increasing intracranial pressure (ICP) in the client? A. Encourages the client to cough and deep-breathe B. Instructs the client not to strain during a bowel movement C. Instructs the client to blow the nose for postnasal drip D. Places the client in the Trendelenburg position

B. Instructs the client not to strain during a bowel movement Straining during a bowel movement increases ICP and must be avoided. Laxatives may be given and fluid intake encouraged to help with this. Although deep breathing is encouraged, the client must avoid coughing early after surgery because this increases pressure in the incision area and may lead to a cerebrospinal fluid (CSF) leak. If the client has postnasal drip, he or she must inform the nurse and not blow the nose; postnasal drip may indicate leakage of CSF. The head of the bed must be elevated after surgery.

A client presents to the emergency department with acute adrenal insufficiency and the following vital signs: P 118 beats/min, R 18 breaths/min, BP 84/44 mm Hg, pulse oximetry 98%, and T 98.8° F oral. Which nursing intervention is the highest priority for this client? A. Administering furosemide (Lasix) B. Providing isotonic fluids C. Replacing potassium losses D. Restricting sodium

B. Providing isotonic fluids Providing isotonic fluid is the priority intervention because this client's vital signs indicate volume loss that may be caused by nausea and vomiting and may accompany acute adrenal insufficiency. Isotonic fluids will be needed to administer IV medications such as hydrocortisone. Furosemide is a loop diuretic, which this client does not need. Potassium is normally increased in acute adrenal insufficiency, but potassium may have been lost if the client has had diarrhea; laboratory work will have to be obtained. Any restrictions, including sodium, should not be started without obtaining laboratory values to establish the client's baseline.

The nurse is providing discharge instructions to a client on spironolactone (Aldactone) therapy. Which comment by the client indicates a need for further teaching? A. "I must call the provider if I am more tired than usual." B. "I need to increase my salt intake." C. "I should eat a banana every day." D. "This drug will not control my heart rate."

C. "I should eat a banana every day." Spironolactone increases potassium levels, so potassium supplements and foods rich in potassium, such as bananas, should be avoided to prevent hyperkalemia. While taking spironolactone, symptoms of hyponatremia such as drowsiness and lethargy must be reported; the client may need increased dietary sodium. Spironolactone will not have an effect on the client's heart rate.

The nurse is assessing a client's alcohol intake to determine whether it is the underlying cause of the client's attacks of pancreatitis. Which question does the nurse ask to elicit this information? A. "Do you usually binge drink?" B. "Do you tend to drink more on holidays or weekends?" C. "Tell me more about your alcohol intake." D. "Estimate how many episodes of binge drinking you do in a week."

C. "Tell me more about your alcohol intake." Asking the client about his or her alcohol intake is the only way that will allow the client to provide information in the client's own words and to the extent that the client wishes to provide it. Asking the client if he or she binge drinks or tends to drink more on holidays or weekends may put the client on the defensive rather than provide the desired information. It has not yet been determined whether the client engages in binge drinking.

A client with Cushing's disease begins to laugh loudly and inappropriately, causing the family in the room to be uncomfortable. What is the nurse's best response? A. "Don't mind this. The disease is causing this." B. "I need to check the client's cortisol level." C. "The disease can sometimes affect emotional responses." D. "Medication is available to help with this."

C. "The disease can sometimes affect emotional responses." The client may have neurotic or psychotic behavior as a result of high blood cortisol levels. Being honest with the family helps them to understand what is happening. Telling the family not to mind the laughter and that the disease is causing it is vague and minimizes the family's concern. This is the perfect opportunity for the nurse to educate the family about the disease. Cushing's disease is the hypersecretion of cortisol, which is abnormally elevated in this disease and, because the diagnosis has already been made, blood levels do not need to be redrawn. Telling the family that medication is available to help with inappropriate laughing does not assist them in understanding the cause of or the reason for the client's behavior.

A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? A. Measure intake and output every shift. B. Do not administer food or fluids by mouth. C. Administer opioid analgesic medication. D. Assist the client to assume a position of comfort.

C. Administer opioid analgesic medication. For the client with acute pancreatitis, pain relief is the highest priority. Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.

The following data are obtained by the RN who is assessing a client who had a transsphenoidal hypophysectomy yesterday. What information has the most immediate implications for the client's care? A. Dry lips and oral mucosa on examination B. Nasal drainage that tests negative for glucose C. Client report of a headache and stiff neck D. Urine specific gravity of 1.016

C. Client report of a headache and stiff neck Headache and stiff neck (nuchal rigidity) are symptoms of meningitis that have immediate implications for the client's care. Dry lips and mouth are not unusual after surgery. Frequent oral rinses and the use of dental floss should be encouraged because the client cannot brush the teeth. Any nasal drainage should test negative for glucose; nasal drainage that tests positive for glucose indicates the presence of a cerebrospinal fluid leak. A urine specific gravity of 1.016 is within normal limits.

Which client does the nurse identify as being at highest risk for acute adrenal insufficiency resulting from corticosteroid use? A. Client with hematemesis, upper epigastric pain for the past 3 days not relieved with food, and melena B. Client with right upper quadrant pain unrelieved for the past 2 days, dark-brown urine, and clay-colored stools C. Client with shortness of breath and chest tightness, nasal flaring, audible wheezing, and oxygen saturation of 85% for the second time this week D. Client with three emergency department visits in the past month for edema, shortness of breath, weight gain, and jugular venous distention

C. Client with shortness of breath and chest tightness, nasal flaring, audible wheezing, and oxygen saturation of 85% for the second time this week Corticosteroids may be used to treat signs and symptoms of asthma, such as shortness of breath and chest tightness, nasal flaring, audible wheezing, and oxygen saturation of 85%. This places the client at risk for adrenal insufficiency. Corticosteroids are not used to treat signs and symptoms of GI bleeding or peptic ulcer disease (hematemesis, upper epigastric pain for the past 3 days not relieved with food, and melena), gallbladder disease (right upper quadrant pain unrelieved for the past 2 days, dark brown urine, and clay-colored stools), or congestive heart failure (edema, shortness of breath, weight gain, and jugular venous distention).

The nurse suspects that a client may have acute pancreatitis as evidenced by which group of laboratory results? A. Deceased calcium, elevated amylase, decreased magnesium B. Elevated bilirubin, elevated alkaline phosphatase C. Elevated lipase, elevated white blood cell count, elevated glucose D. Decreased blood urea nitrogen (BUN), elevated calcium, elevated magnesium

C. Elevated lipase, elevated white blood cell count, elevated glucose Elevated lipase is more specific to a diagnosis of acute pancreatitis. Many pancreatic and nonpancreatic disorders can cause increased serum amylase levels. Bilirubin and alkaline phosphatase levels will be increased only if pancreatitis is accompanied by biliary dysfunction. Usually, calcium and magnesium will be increased and BUN increased, not decreased, in acute pancreatitis.

Which laboratory result indicates that fluid restrictions have been effective in treating syndrome of inappropriate antidiuretic hormone (SIADH)? A. Decreased hematocrit B. Decreased serum osmolality C. Increased serum sodium D. Increased urine specific gravity

C. Increased serum sodium Increased serum sodium due to fluid restriction indicates effective therapy. Hemoconcentration is a result of hypovolemic hyponatremia caused by SIADH and diabetes insipidus. Plasma osmolality is decreased as a result of SIADH. Urine specific gravity is decreased with diabetes insipidus and is increased with SIADH.

A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action does the nurse take first? A. Obtain the charts from the previous admission. B. Listen for bowel sounds in all quadrants. C. Obtain pulse and blood pressure. D. Ask about abdominal pain.

C. Obtain pulse and blood pressure. The nurse should assess vital signs to detect hypovolemic shock caused by hemorrhage. Obtaining charts, assessing bowel sounds, and pain assessment can be delayed until the client has stabilized. Assessment for adequate perfusion is the highest priority at this time.

Which problem for a client with cirrhosis takes priority? A. Insufficient knowledge related to the prognosis of the disease process B. Discomfort related to the progression of the disease process C. Potential for injury related to hemorrhage D. Inadequate nutrition related to an inability to tolerate usual dietary intake

C. Potential for injury related to hemorrhage Potential for injury related to hemorrhage is the priority client problem because this complication could be life-threatening. Insufficient knowledge, discomfort, and inadequate nutrition are not priorities because these issues are not immediately life-threatening.

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? A. "Cirrhosis is a chronic disease that has scarred my liver." B. "The scars on my liver create problems with blood circulation." C. "Because of the scars on my liver, blood clotting and blood pressure are affected." D. "My liver is scarred, but the cells can regenerate themselves and repair the damage."

D. "My liver is scarred, but the cells can regenerate themselves and repair the damage." Although cells and tissues will attempt to regenerate, this will result in permanent scarring and irreparable damage. Cirrhosis is a chronic condition that leaves scars on the liver. Permanent scars form in response to attempts by the cells to regenerate and create problems in blood circulation moving through the liver. Liver scarring will create problems with blood clotting, cholesterol levels, and blood pressure, as well as with the metabolism of drugs and toxins.

The nurse is caring for a client recently diagnosed with type 1 diabetes mellitus who has had an episode of acute pancreatitis. The client asks the nurse how he developed diabetes when the disease does not run in the family. What is the nurse's best response? A. "The diabetes could be related to your obesity." B. "What has your doctor told you about your disease?" C. "Do you consume alcohol on a frequent basis?" D. "Type 1 diabetes can occur when the pancreas is destroyed by disease."

D. "Type 1 diabetes can occur when the pancreas is destroyed by disease." Telling the client that type 1 diabetes can occur when the pancreas is destroyed by disease is the only response that accurately describes the relationship of the client's diabetes to pancreatic destruction. Type 2, not type 1, diabetes is usually related to obesity. Asking the client what the provider has said is an evasive response by the nurse and does not address the client's question. Many factors could produce acute pancreatitis other than alcohol consumption.

The nurse asks a client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? A. Positive Babinski's sign B. Hyperreflexia C. Kehr's sign D. Asterixis

D. Asterixis Liver flap or asterixis is related to increased serum ammonia levels—the dorsiflexed hands begin to flap upward and downward when outstretched for a few moments. Babinski's sign is positive when, as the sole of the foot is stroked, the great toe points up and the toes fan out. Hyperreflexia refers to deep tendon reflexes that are overactive. Kehr's sign is reflected by increased abdominal pain, exaggerated by deep breathing, and referred to the right shoulder.

The charge nurse is making client assignments for the medical-surgical unit. Which client will be best to assign to an RN who has floated from the pediatric unit? A. Client in Addisonian crisis who is receiving IV hydrocortisone B. Client admitted with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to lung cancer C. Client being discharged after a unilateral adrenalectomy to remove an adrenal tumor D. Client with Cushing's syndrome who has elevated blood glucose and requires frequent administration of insulin

D. Client with Cushing's syndrome who has elevated blood glucose and requires frequent administration of insulin An RN who works with pediatric clients would be familiar with glucose monitoring and insulin administration. A client in Addisonian crisis would best be monitored by an RN from the medical-surgical floor. Although the float RN could complete the admission history, the client with SIADH secondary to lung cancer might require teaching and orientation to the unit that a nurse more familiar with that area would be better able to provide. Discharge teaching specific to adrenalectomy should be provided by the RN who is regularly assigned to the medical-surgical floor and is more familiar with taking care of postoperative adult clients with endocrine disorders.

When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? A. Vitamin K-containing products B. Potassium-sparing diuretics C. Nonabsorbable antibiotics D. Nonsteroidal anti-inflammatory drugs (NSAIDs)

D. Nonsteroidal anti-inflammatory drugs (NSAIDs) Clients who have cirrhosis should not take NSAIDs because they may predispose to bleeding. The client with cirrhosis is prone to bleeding; vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia levels.

A client with acute cholecystitis is admitted to the medical-surgical unit. Which nursing activity associated with the client's care will be best for the nurse to delegate to unlicensed assistive personnel (UAP)? A. Assessing dietary risk factors for cholecystitis B. Checking for bowel sounds and distention C. Determining precipitating factors for abdominal pain D. Obtaining the admission weight, height, and vital signs

D. Obtaining the admission weight, height, and vital signs Obtaining height, weight, and vital signs is included in the education for UAP and usually is included in the job description for these staff members. Assessment, checking bowel sounds, and determining precipitating factors for abdominal pain require broader education and are within the scope of practice of licensed nursing staff.

Which set of assessment findings indicates to the nurse that a client may have acute pancreatitis? A. Absence of jaundice, pain of gradual onset B. Absence of jaundice, pain in right abdominal quadrant C. Presence of jaundice, pain worsening when sitting up D. Presence of jaundice, pain worsening when lying supine

D. Presence of jaundice, pain worsening when lying supine Pain that worsens when lying supine and the presence of jaundice are the only assessment findings indicative of acute pancreatitis. Pain associated with acute pancreatitis usually has an abrupt onset, is located in the mid-epigastric or upper left quadrant, and lessens with sitting up; also, jaundice is present.

A client with a possible adrenal gland tumor is admitted for testing and treatment. Which nursing action is most appropriate for the charge nurse to delegate to the nursing assistant? A. Assess skin turgor and mucous membranes for hydration status. B. Discuss the dietary restrictions needed for 24-hour urine testing. C. Plan ways to control the environment that will avoid stimulating the client. D. Remind the client to avoid drinking coffee and changing position suddenly.

D. Remind the client to avoid drinking coffee and changing position suddenly. Drinking caffeinated beverages and changing position suddenly are not safe for a client with a potential adrenal gland tumor because of the effects of catecholamines. Reminding the client about previous instructions is an appropriate role for a nursing assistant who may observe the client doing potentially risky activities. Client assessment, client teaching, and environment planning are higher-level skills that require the experience and responsibility of the RN, and are not within the scope of practice of the nursing assistant.

A client is referred to a home health agency after a transsphenoidal hypophysectomy. Which action does the RN case manager delegate to the home health aide who will see the client daily? A. Document symptoms of incisional infection or meningitis. B. Give over-the-counter laxatives if the client is constipated. C. Set up medications as prescribed for the day. D. Test any nasal drainage for the presence of glucose.

D. Test any nasal drainage for the presence of glucose. Cerebrospinal fluid (CSF) will test positive using a glucose "dipstick." Nasal drainage that is positive for glucose after a transsphenoidal hypophysectomy would indicate a CSF leak that would require immediate notification of the health care provider. Home health aides can be taught the correct technique to perform this procedure. Assessing for symptoms of infection and documenting them in the record, medication administration, and setting up medication are not within the scope of practice of the home health aide.

A client with Cushing's disease says that she has lost 1 pound. What does the nurse do next? A. Auscultates the lungs for crackles B. Checks urine for specific gravity C. Forces fluids D. Weighs the client

D. Weighs the client Fluid retention with weight gain is more of a problem than weight loss in clients with Cushing's disease. Weighing the client with Cushing's disease is part of the nurse's assessment. Crackles in the lungs indicate possible fluid retention, which would cause weight gain, not weight loss. Urine specific gravity will help assess hydration status, but this would not be the next step in the client's assessment. Forcing fluids is not appropriate because usually excess water and sodium reabsorption cause fluid retention in the client with Cushing's disease.

How does the drug desmopressin (DDAVP) decrease urine output in a client with diabetes insipidus (DI)? A. Blocks reabsorption of sodium B. Increases blood pressure C. Increases cardiac output D. Works as an antidiuretic hormone (ADH) in the kidneys

D. Works as an antidiuretic hormone (ADH) in the kidneys Desmopressin is a synthetic form of ADH that binds to kidney receptors and enhances reabsorption of water, thus reducing urine output. Desmopressin does not have any effect on sodium reabsorption. It may cause a slight increase or a transient decrease in blood pressure, but this does not affect urine output. Desmopressin does not increase cardiac output.

When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include? a. A lower-fat diet may be better tolerated for several weeks. b. Do not return to work or normal activities for 3 weeks. c. Bile-colored drainage will probably drain from the incision. d. Keep the bandages on and the puncture site dry until it heals.

a. A lower-fat diet may be better tolerated for several weeks. Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks following surgery. Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.

A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades. How should the nurse respond? a. "Ambulating in the hallway twice a day will help." b. "I will apply a cold compress to the painful area on your back." c. "Drinking a warm beverage can relieve this referred pain." d. "You should cough and deep breathe every hour."

a. "Ambulating in the hallway twice a day will help." The client who has undergone a laparoscopic cholecystectomy may report free air pain due to retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide. Cold compresses and drinking a warm beverage would not be helpful. Coughing and deep breathing are important postoperative activities, but they are not related to discomfort from carbon dioxide.

A nurse cares for a client who has obstructive jaundice. The client asks, "Why is my skin so itchy?" How should the nurse respond? a. "Bile salts accumulate in the skin and cause the itching." b. "Toxins released from an inflamed gallbladder lead to itching." c. "Itching is caused by the release of calcium into the skin." d. "Itching is caused by a hypersensitivity reaction."

a. "Bile salts accumulate in the skin and cause the itching." In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate.

Which key points does the nurse include when teaching the patient with cirrhosis and his family about drug therapy before discharge? (Select all that apply.) a. "Do not take over-the-counter medications unless approved by your health care provider." b. "The beta blocker called propranolol (Inderal) will cause your heart rate to increase." c. "The lactulose syrup should cause you to have two to three bowel movements every day." d. "Take your furosemide (Lasix) early in the day so that it does not keep you up at night." e. "Report any muscle weakness or light- headedness to your health care provider right away."

a. "Do not take over-the-counter medications unless approved by your health care provider." c. "The lactulose syrup should cause you to have two to three bowel movements every day." d. "Take your furosemide (Lasix) early in the day so that it does not keep you up at night." e. "Report any muscle weakness or light- headedness to your health care provider right away."

A nurse cares for a client with end-stage pancreatic cancer. The client asks, "Why is this happening to me?" How should the nurse respond? a. "I don't know. I wish I had an answer for you, but I don't." b. "It's important to keep a positive attitude for your family right now." c. "Scientists have not determined why cancer develops in certain people." d. "I think that this is a trial so you can become a better person because of it."

a. "I don't know. I wish I had an answer for you, but I don't." The client is not asking the nurse to actually explain why the cancer has occurred. The client may be expressing his or her feelings of confusion, frustration, distress, and grief related to this diagnosis. Reminding the client to keep a positive attitude for his or her family does not address the client's emotions or current concerns. The nurse should validate that there is no easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a trial is untrue and may diminish the client-nurse relationship.

The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? a. "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." b. "I need to take good care of my belly and ankle skin where it is swollen." c. "A scrotal support may be more comfortable when I have scrotal edema." d. "I can use pillows to support my head to help me breathe when I am in bed."

a. "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, as this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.

The nurse is teaching a patient with cirrhosis about lactulose therapy. Which statement by the patient indicates the teaching has been effective? a. "This therapy will promote the removal of ammonia in my stool." b. "Constipation is a frequent side effect of this therapy." c. "I will know the therapy is working when I am less itchy." d. "The drug tastes bitter and is watery."

a. "This therapy will promote the removal of ammonia in my stool."

Which statements about a patient with cirrhosis and esophageal varices are accurate? (Select all that apply.) a. All patients with cirrhosis should be screened for esophageal varices to detect them before they bleed. b. Bleeding esophageal varices are a medical emergency. c. Esophageal balloon tamponade is often used to control bleeding esophageal varices. d. A nonselective beta blocker such as propranolol (Inderal) is prescribed to prevent varices from bleeding. e. Bleeding esophageal varices can be managed by use of endoscopic variceal ligation.

a. All patients with cirrhosis should be screened for esophageal varices to detect them before they bleed. b. Bleeding esophageal varices are a medical emergency. d. A nonselective beta blocker such as propranolol (Inderal) is prescribed to prevent varices from bleeding. e. Bleeding esophageal varices can be managed by use of endoscopic variceal ligation.

A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this client's condition? (Select all that apply.) a. Body mass index of 46 b. Vegetarian diet c. Drinking 4 ounces of red wine nightly d. Pregnant with twins e. History of metabolic syndrome f. Glycosylated hemoglobin level of 15%

a. Body mass index of 46 d. Pregnant with twins f. Glycosylated hemoglobin level of 15% Obesity, pregnancy, and diabetes are all risk factors for the development of cholelithiasis. A diet low in saturated fats and moderate alcohol intake may decrease the risk. Although metabolic syndrome is a precursor to diabetes, it is not a risk factor for cholelithiasis. The client should be informed of the connection.

The nurse is teaching a patient with cirrhosis about nutrition therapy. Which key points must the nurse include? (Select all that apply.) a. Do not use table salt. b. Adding salt when cooking is acceptable. c. Eat small frequent meals. d. Drink supplemental liquids such as Ensure. e. Be sure to take a multivitamin every day.

a. Do not use table salt. c. Eat small frequent meals. d. Drink supplemental liquids such as Ensure. e. Be sure to take a multivitamin every day.

The nurse is assessing a male patient with cirrhosis. Which male-specific characteristics does the nurse expect to find? (Select all that apply.) a. Gynecomastia b. Testicular atrophy c. Ascites d. Impotence e. Spider angiomas

a. Gynecomastia b. Testicular atrophy d. Impotence

What is the priority focus in caring for a patient with advanced liver cancer? a. Hospice and end-of life care b. Getting placed on the liver transplant list c. Hepatic arterial infusion of chemotherapy d. Cryotherapy to freeze and destroy liver tumors

a. Hospice and end-of life care

Which patients would not be considered candidates for a liver transplant? (Select all that apply.) a. Patient with metastatic tumors b. Patient with type 2 diabetes c. Patient with severe respiratory disease d. Patient with chronic liver disease e. Patient with advanced cardiac disease

a. Patient with metastatic tumors c. Patient with severe respiratory disease e. Patient with advanced cardiac disease

A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Take a 20-minute walk at least 5 days each week." b. "Attend local Alcoholics Anonymous (AA) meetings weekly." c. "Choose whole grains rather than foods with simple sugars." d. "Use cooking spray when you cook rather than margarine or butter." e. "Stay away from milk and dairy products that contain lactose." f. "We can talk to your doctor about a prescription for nicotine patches."

b. "Attend local Alcoholics Anonymous (AA) meetings weekly." d. "Use cooking spray when you cook rather than margarine or butter." f. "We can talk to your doctor about a prescription for nicotine patches." The client should be advised to stay sober, and AA is a great resource. The client requires a low-fat diet, and cooking spray is low in fat compared with butter or margarine. If the client smokes, he or she must stop because nicotine can precipitate an exacerbation. A nicotine patch may help the client quit smoking. The client must rest until his or her strength returns. The client requires high carbohydrates and calories for healing; complex carbohydrates are not preferred over simple ones. Dairy products do not cause a problem.

After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "Drinking at least 2 liters of water each day is suggested." b. "I will decrease the amount of fatty foods in my diet." c. "Drinking fluids with my meals will increase bloating." d. "I will avoid concentrated sweets and simple carbohydrates."

b. "I will decrease the amount of fatty foods in my diet." After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a special diet is not recommended for most clients. Good fluid intake is healthy for all people but is not related to the surgery. Drinking fluids between meals helps with dumping syndrome, which is not seen with this procedure. Restriction of sweets is not required.

The nurse is teaching a patient with cirrhosis about nutrition therapy. Which statement by the patient indicates teaching has been effective? a. "I will only use table salt with my dinner meal." b. "I will read the sodium content labels on all food and beverages." c. "I will avoid the use of vinegar." d. "I will not take vitamin supplements."

b. "I will read the sodium content labels on all food and beverages."

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.) a. "Do not allow the client to eat between meals." b. "Make sure the client receives a protein shake." c. "Do not allow caffeine-containing beverages." d. "Make sure the foods are bland with little spice." e. "Do not allow high-carbohydrate food items."

b. "Make sure the client receives a protein shake." c. "Do not allow caffeine-containing beverages." d. "Make sure the foods are bland with little spice." During the healing phase of pancreatitis, the client should be provided small, frequent, moderate- to high-carbohydrate, high-protein, low-fat meals. Protein shakes can be provided to supplement the diet. Foods and beverages should not contain caffeine and should be bland.

The nurse identifies which laboratory value as the usual indication of hepatic encephalopathy? a. Elevated sodium level b. Elevated ammonia level c. Increased blood urea nitrogen (BUN) d. Increased clotting time

b. Elevated ammonia level

A nurse cares for a client who is prescribed patient-controlled analgesia (PCA) after a cholecystectomy. The client states, "When I wake up I am in pain." Which action should the nurse take? a. Administer intravenous morphine while the client sleeps. b. Encourage the client to use the PCA pump upon awakening. c. Contact the provider and request a different analgesic. d. Ask a family member to initiate the PCA pump for the client

b. Encourage the client to use the PCA pump upon awakening. The nurse should encourage the client to use the PCA pump prior to napping and upon awakening. Administering additional intravenous morphine while the client sleeps places the client at risk for respiratory depression. The nurse should also evaluate dosages received compared with dosages requested and contact the provider if the dose or frequency is not adequate. Only the client should push the pain button on a PCA pump.

Which statements about hepatitis are accurate? (Select all that apply.) a. Hepatitis D is the leading cause of cirrhosis and liver failure in the U.S. b. Hepatitis A is spread through the fecal-oral route. c. Hepatitis B can be transmitted through unprotected sexual intercourse. d. Hepatitis carriers have chronic obvious signs of hepatitis B. e. Hepatitis C is transmitted by casual contact or intimate household contact. f. Hepatitis D only occurs with hepatitis B to cause viral replication.

b. Hepatitis A is spread through the fecal-oral route. c. Hepatitis B can be transmitted through unprotected sexual intercourse. f. Hepatitis D only occurs with hepatitis B to cause viral replication.

A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client's plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowler's position with the head of bed elevated.

b. Maintain nothing by mouth (NPO) and administer intravenous fluids. The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.

What is the major source of hepatitis B transmission to health care workers? a. Improper handwashing b. Needlesticks c. Touching contaminated surfaces d. Contact with infected stool

b. Needlesticks

A nurse cares for a client with acute pancreatitis. The client states, "I am hungry." How should the nurse reply? a. "Is your stomach rumbling or do you have bowel sounds?" b. "I need to check your gag reflex before you can eat." c. "Have you passed any flatus or moved your bowels?" d. "You will not be able to eat until the pain subsides."

c. "Have you passed any flatus or moved your bowels?" Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this has resolved. Bowel sounds and decreased pain are not reliable indicators of peristalsis. Instead, the nurse should assess for passage of flatus or bowel movement.

A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute? a. Temperature of 100.1° F (37.8° C) b. Positive Murphy's sign c. Light-colored stools d. Upper abdominal pain after eating

c. Light-colored stools Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen equally with both chronic and acute cholecystitis.

To prepare a patient with ascites for paracentesis, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.

c. asks the patient to empty the bladder. The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing.

A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take? a. Withhold both drugs. b. Administer both drugs c. Administer the furosemide. d. Administer the spironolactone.

d. Administer the spironolactone. Spironolactone is a potassium-sparing diuretic and will help increase the patient's potassium level.

After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice

d. Roasted chicken breast, baked potato with chives, and orange juice Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.

The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? a. Has completed a college education b. Has been able to stop smoking cigarettes c. Has well-controlled type 1 diabetes mellitus d. The chest x-ray showed another lung cancer lesion.

d. The chest x-ray showed another lung cancer lesion. Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug and/or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course.