test 9 chapter 49-38 , practice
A client asks the nurse how to identify rheumatoid nodules with rheumatoid arthritis. What characteristic will the nurse include?
located over bony prominence Explanation: Rheumatoid nodules usually are nontender, movable, and evident over bony prominences, such as the elbow or the base of the spine. The nodules are not reddened.
Gynecomastia is a common side effect of which of the following diuretics?
Spironolactone (Aldactone)
Which client is most likely to develop systemic lupus erythematosus (SLE)?
A 27-year-old black female
The nurse is teaching a newly diagnosed client about systemic lupus erythematosus(SLE). What statement by the client indicates the teaching was successful?
"The belief is that it is an autoimmune disorder with an unknown trigger."
A client with early stage rheumatoid arthritis asks the nurse what to do to help ease the symptoms of the disease. What would be the best response by the nurse?
"The health care provider could prescribe anti-inflammatory drugs." Explanation: Drug therapy using antiinflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Antipyretic and antihypertensive drugs are not prescribed for autoimmune diseases. An antineoplastic drug is not ordered for an autoimmune disorder until it is in its' late stages and uncontrolled by the first line drugs.
A client with end-stage liver disease is scheduled to undergo a liver transplant. The client tells the nurse, "I am worried that my body will reject the liver." Which statement is the nurse's best response to the client?
"You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs." Explanation: Rejection is a primary concern. A transplanted liver is perceived by the immune system as a foreign antigen. This triggers an immune response, leading to the activation of T lymphocytes that attack and destroy the transplanted liver. Immunosuppressive agents are used as long-term therapy to prevent this response and rejection of the transplanted liver. These agents inhibit the activation of immunocompetent T lymphocytes to prevent the production of effector T cells. Although the 1- and 5-year survival rates have increased dramatically with the use of new immunosuppressive therapies, these advances are not without major side effects. The other statements are inaccurate or will not decrease the client's anxiety.
A client with an acute exacerbation of arthritis is temporarily confined to bed. What position will the nurse recommend to prevent flexion deformities? You Selected:
A client with an acute exacerbation of arthritis is temporarily confined to bed. What position will the nurse recommend to prevent flexion deformities? You Selected:
A patient comes to the clinic with an inflamed wrist. How should the nurse splint the joint to immobilize it?
A patient comes to the clinic with an inflamed wrist. How should the nurse splint the joint to immobilize it?
What intervention does the nurse anticipate providing for the patient with ascites that will help correct the decrease in effective arterial blood volume that leads to sodium retention?
Albumin infusion Explanation: Albumin infusions help to correct decreases in effective arterial blood volume that lead to sodium retention. The use of this colloid reduces the incidence of postparacentesis circulatory dysfunction with renal dysfunction, hyponatremia, and rapid reaccumulation of ascites associated with decreased effective arterial volume.
The side effect of bone marrow depression may occur with which medication used to treat gout?
Allopurinol Explanation: A client taking allopurinol needs to be monitored for the side effects of bone marrow depression, vomiting, and abdominal pain.
A nurse is managing the care of a client who has gout. Which medication would be prescribed as the drug of choice to prevent tophi formation and promote tophi regression?
Allopurinol Explanation: Allopurinol (Zyloprim), a xanthine oxidase inhibitor, is considered the drug of choice for preventing the precipitation of an attack, preventing tophi formation, and promoting the regression of existing tophi. Uricosuric agents, such as probenecid (Benemid), correct hyperuricemia and dissolve deposited urate.
A health care provider orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis?
An above-normal anti-deoxyribonucleic acid (DNA) test Explanation: Laboratory results specific for SLE include an above-normal anti-DNA test, a positive antinuclear antibody test, and a positive lupus erythematosus cell test. Because the anti-DNA test rarely is positive in other diseases, this test is important in diagnosing SLE. (The anti-DNA antibody level may be depressed in clients who are in remission from SLE.) Decreased total serum complement levels indicate active SLE.
Which of the following refers to fixation of a joint?
Ankylosis Explanation: Fixation of a joint, called ankylosis, eliminates friction, but at the drastic cost of immobility. Inflammation is manifested in the joints as synovitis. Pannus has a destructive effect on the adjacent cartilage and bone. Articulations are joints.
The nurse intervenes to assist the client with fibromyalgia to cope with which symptoms?
Chronic fatigue, generalized muscle aching, and stiffness Explanation: Fibromyalgia is a common condition that involves chronic fatigue, generalized muscle aching, and stiffness. The cause is unknown, and no pathologic characteristics specific for the condition have been identified. Treatment consists of attention to the specific symptoms reported by the client. NSAIDs may be used to treat the diffuse muscle aching and stiffness. Tricyclic antidepressants are used to improve or restore normal sleep patterns, and individualized programs of exercise are used to decrease muscle weakness and discomfort and to improve the general deconditioning that occurs in these individuals.
Which finding is consistent with the diagnosis of rheumatoid arthritis?
Cloudy synovial fluid Explanation: In a client with rheumatoid arthritis, arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement.
The nurse is assessing a patient with a diagnosis of scleroderma. What clinical manifestations of scleroderma does the nurse assess? (Select all that apply.)
Decreased ventilation owing to lung scarring Dysphagia owing to hardening of the esophagus Dyspnea owing to fibrotic cardiac tissue
A client is receiving treatment for an acute episode of gout with colchicine. The nurse is administering the medication every 2 hours. What should the nurse be sure the client communicates so that the drug can be temporarily stopped? Select all that apply.
Diarrhea Intestinal cramping Nausea and vomiting Explanation: Colchicine is administered every 1 or 2 hours until the pain subsides or nausea, vomiting, intestinal cramping, and diarrhea develop. When one or more of these symptoms occurs, the drug should be stopped temporarily. Tingling in the arms and increase in pain are not normal adverse reactions that are seen with this drug.
Which of the following are usually the first choice in the treatment of rheumatoid arthritis (RA)?
Disease-modifying antirheumatic drugs (DMARDs) Explanation: Once a diagnosis of RA has been made, treatment should begin with DMARDs. NSAIDs are used for pain and inflammation relief but must be used with caution in long-term chronic diseases due to the possibility of gastric ulcers. TNF blockers interfere with the action of tumor necrosis factor (TNF). Oral glucocorticoids, such as prednisone and prednisolone, are indicated for patients with generalized symptoms.
What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct?
Endoscopic retrograde cholangiopancreatography (ERCP) Explanation: ERCP locates stones that have collected in the common bile duct. A colonoscopy will not locate gallstones but only allows visualization of the large intestine. Abdominal x-ray is not a reliable locator of gallstones. A cholecystectomy is the surgical removal of the gallbladder.
A client with rheumatoid arthritis is prescribed a tumor necrosis factor (TNF)-alpha inhibitor. What medication might be prescribed?
Etanercept Explanation: Etanercept is an example of a tumor necrosis factor (TNF)-alpha inhibitor used to treat rheumatoid arthritis. Diclofenac and indomethacin are nonsteroidal anti-inflammatory drugs (NSAIDs). Celecoxib is a cyclooxygenase-2 (COX-2) inhibitor.
A nurse assesses a client in the health care provider's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?
Facial erythema, pericarditis, pleuritis, fever, and weight loss Explanation: An autoimmune disorder characterized by chronic inflammation of the connective tissues, SLE causes fever, weight loss, malaise, fatigue, skin rashes, and polyarthralgia. Nearly half of clients with SLE have facial erythema, (the classic butterfly rash). SLE also may cause profuse proteinuria (excretion of more than 0.5 g/day of protein), pleuritis, pericarditis, photosensitivity, and painless mucous membrane ulcers. Weight gain, hypervigilance, hypothermia, and edema of the legs and arms don't suggest SLE.
The nurse is caring for a client who has been diagnosed with a "rheumatic disease." What nursing diagnoses will most likely apply to this client's care? Select all that apply.
Fatigue Pain Alteration of self-concept Explanation: Clients with rheumatic diseases, which typically involve joints and muscles, experience problems with mobility, fatigue, and pain. Because of the limitations of the disease, clients often have an altered self-image and self-concept. Fluid and electrolyte imbalances are not typically associated with these types of diseases.
Which type of deficiency results in macrocytic anemia?
Folic acid Explanation: Folic acid deficiency results in macrocytic anemia. Vitamin C deficiency results in hemorrhagic lesions of scurvy. Vitamin A deficiency results in night blindness and eye and skin changes. Vitamin K deficiency results in hypoprothrombinemia, which is characterized by spontaneous bleeding and ecchymosis.
A client arrives at the clinic with reports of pain in the left great toe. The nurse assesses a swollen, warm, erythematous left great toe. What disorder will the nurse relate the client symptoms to?
Gout Explanation: The metatarsophalangeal joint of the big toe is the most commonly affected joint (90% of patients) in gout. The abrupt onset often occurs at night, awakening the patient with severe pain, redness, swelling, and warmth of the affected joint. Clients with osteoarthritis and rheumatoid arthritis will have joint swelling and tenderness in the hands, knees and spine. Clients with fibromyalgia will have chronic fatigue, generalized muscle aching, stiffness, sleep disturbances, and functional impairment.
A client who has been diagnosed with osteoarthritis asks if he or she will eventually begin to notice deformities in the hands and fingers as the condition progresses. Which concept should the nurse include in the response?
Hand and finger deformities are associated with the development of rheumatoid arthritis. Explanation: The nurse should explain to the client that joint deformities occur with rheumatoid arthritis, not osteoarthritis. Osteoarthritis typically follows a pattern of cartilage destruction and increased pain. The nurse is part of the interdisciplinary health care team and is capable of answering the client's questions about the typical progression of disease.
nurse is developing a teaching plan for a client diagnosed with osteoarthritis. What instruction should the nurse give to the client to minimize injury?
Install safety devices in the home. Explanation: Most accidents occur in the home, and safety devices such as hand rails are the most important element in minimizing injury. Shoes should be supportive and not too worn. The client needs to use proper body mechanics when stooping or lifting objects. Protective devices aren't usually necessary when the client exercises.
A client has a history of osteoarthritis. Which signs and symptoms should the nurse expect to find on physical assessment?
Joint pain, crepitus, Heberden's nodes
Which of the following maybe the first and only physical sign of symptomatic osteoarthritis (OA)? You Selected:
Limited passive movement Explanation: Limited passive movement can be the first and only physical sign of symptomatic OA. Physical assessment of the musculoskeletal system reveals joint enlargement, joint instability, and limb shortening.
A client with ankylosing spondylitis has a stooped position and is being positioned in the bed prior to the nurse taking vital signs. The nurse listens to the client's lungs after positioning. What finding does the nurse hear when listening to lung sounds?
Lung sounds are diminished in the apical area. Explanation: The lumbar curve of the spine may flatten. The neck can be permanently flexed, and the client appears to be in a perpetual stooped position. Aortic regurgitation or atrioventricular node conduction disturbances may occur. Lung sounds may be reduced, especially in the apical area. The nurse would not hear rhonchi, crackles, or a pericardial friction rub unless the client had underlying cardiac or respiratory disorders.
What intervention is a priority for a client diagnosed with osteoarthritis?
Physical therapy and exercise Explanation: Clients with osteoarthritis need to maintain joint mobility. To preserve joint function, individuals need to learn appropriate activities. Colchicine and allopurinol are used for gout, not osteoarthritis. Hydrotherapy is not a priority for care.
A client with degenerative joint disease asks the nurse for suggestions to avoid unusual stress on the joints. Which suggestion would be most appropriate?
Maintain good posture. Explanation: The nurse needs to remind the client with degenerative joint disease to maintain good posture. While the client need not maintain complete bed rest, performing aerobic exercises is not advisable as it may place undue stress on the joint worsening the condition. Shifting weight from one foot to the other does not help avoid unusual stress on a joint.
applications of ice Explanation: Application of ice is not part of the treatment regimen. Encouraging the client to eat a healthy diet, avoiding caffeine and alcohol, regular exercise, and stress reduction are part of the teaching plan.
Methotrexate (Rheumatrex) Explanation: Methotrexate is a DMARD that reduces the amount of joint damage and slows the damage to other tissues as well. Etanercept and Infliximab are TNF-alpha inhibitors that reduce pain and inflammation. Methylprednisolone is a steroid to reduce pain and inflammation and slow joint destruction.
A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis?
My finger joints are oddly shaped."
Nursing care for the client with fibromyalgia should be guided by the assumption that patients with fibromyalgia
Nursing care for the client with fibromyalgia should be guided by the assumption that patients with fibromyalgia
A client is actively bleeding from esophageal varices. Which medication would the nurse most expect to be administered to this client?
Octreotide Explanation: In an actively bleeding client, medications are administered initially because they can be obtained and administered quicker than other therapies. Octreotide (Sandostatin) causes selective splanchnic vasoconstriction by inhibiting glucagon release and is used mainly in the management of active hemorrhage. Propranolol (Inderal) and nadolol (Corgard), beta-blocking agents that decrease portal pressure, are the most common medications used both to prevent a first bleeding episode in clients with known varices and to prevent rebleeding. Beta-blockers should not be used in acute variceal hemorrhage, but they are effective prophylaxis against such an episode. Spironolactone (Aldactone), an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. Lactulose (Cephulac) is administered to reduce serum ammonia levels in clients with hepatic encephalopathy.
A client has had several diagnostic tests to determine if he has systemic lupus erythematosus (SLE). What result is very specific indicator of this diagnosis?
Positive Anti-dsDNA antibody test Explanation: Anti-double-stranded DNA (anti-dsDNA) antibody test is a test that shows high titers of antibodies against native DNA. This is very specific for SLE because this test is not positive for other autoimmune disorders. Anti-Smith (anti-Sm) antibodies are specific for SLE, but are found in only 20% to 30% of clients with SLE. ANA titre shows the presence of an autoimmune disease but is not specific to SLE. The other lab studies may also indicate multisystem involvement.
A client is seen in the office for reports of joint pain, swelling, and a low-grade fever. What blood studies does the nurse know are consistent with a positive diagnosis of rheumatoid arthritis (RA)? Select all that apply.
Positive C-reactive protein (CRP) Positive antinuclear antibody (ANA) Red blood cell (RBC) count of <4.0 million/mcL Explanation: Several assessment findings are associated with RA: rheumatoid nodules, joint inflammation detected on palpation, and laboratory findings. The history and physical examination focuses on manifestations such as bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tend to be significantly elevated in the acute phases of RA and are therefore useful in monitoring active disease and disease progression. The red blood cell count and C4 complement component are decreased. Antinuclear antibody (ANA) test results may also be positive.
The result of which diagnostic study is decreased in the client diagnosed with rheumatoid arthritis?
Red blood cell count Explanation: Clients diagnosed with rheumatic diseases have a decreased red blood cell count. ESR is increased in inflammatory connective tissue disease. Uric acid is increased in gout. Increased creatinine may indicate renal damage in SLE, scleroderma, and polyarteritis.
The nurse is performing discharge teaching for a client with rheumatoid arthritis. What teachings are priorities for the client? Select all that apply.
Safe exercise Medication dosages and side effects Assistive devices
Which connective tissue disorder is characterized by insoluble collagen being formed and accumulating excessively in the tissues? You Selected:
Scleroderma Explanation: Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death
A client with rheumatoid arthritis has infiltration of the lacrimal and salivary glands with lymphocytes as a result of the disease. What does the nurse understand that this clinical manifestation is?
Sicca syndrome Explanation: Sicca syndrome is a condition of dry eyes and dry mouth that can result from infiltration of the lacrimal and salivary glands with lymphocytes. Episcleritis is an inflammatory condition of the connective tissue between the sclera and conjunctiva. Glaucoma results from increased intraocular pressure, and cataracts are a clouding of the lens in the eye.
Which intervention should the nurse implement to manage pain for the client with rheumatoid arthritis? Select all that apply.
Support joints with splints and pillows. Provide diversional activities. Provide opportunities for the client to verbalize feelings. Explanation: To manage pain, the nurse maintains normal alignment of extremities as much as possible by supporting the joints with splints and pillows. Diversional activities distract the client's focus from the pain. Providing opportunities for the client to verbalize feelings facilitates coping with pain. Assistive devices for self-feeding help the client meet nutritional needs independently. Assisting the client to develop a sleep routine promotes rest and minimizes fatigue.
Limited passive movement Explanation: Limited passive movement can be the first and only physical sign of symptomatic OA. Physical assessment of the musculoskeletal system reveals joint enlargement, joint instability, and limb shortening.
Swan neck deformity
Which of the following disorders is characterized by an increased autoantibody production?
Systemic lupus erythematosus (SLE) Explanation: SLE is an immunoregulatory disturbance that results in increased autoantibody production. Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.
A client is taking ibuprofen for the treatment of osteoarthritis. What education will the nurse give the client about the medication?
Take the medication with food to avoid stomach upset. Explanation: Ibuprofen is a nonsteroidal anti-inflammatory drug. The nurse should advise the patient to take NSAIDs with food to avoid stomach upset. Ibuprofen is available over the counter, but it still has side effects. Aspirin is known to cause ringing in the ears, not NSAIDs.
What intervention will best help a client with ankylosing spondylitis (AS)?
Teach the client to use a walker or cane. Explanation: Ankylosing spondylitis (AS) affects the cartilaginous joints of the spine and can lead to decreased mobility and stability. Assisting the client to use a walker or cane will help prevent injury from falls. Range-of-motion exercises and traction will not help the client. The hallmark of the condition is back pain and sometimes fractures.
he client with an inflamed knee scheduled to have an arthrocentesis asks the nurse what the synovial fluid will look like. What is the best response by the nurse?
The fluid will be milky, cloudy, and dark yellow. Explanation: An arthrocentesis shows abnormal synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement.
The nurse is assessing a client who has had rheumatoid arthritis for several years. What clinical manifestation will the nurse expect to find in a client?
The nurse is assessing a client who has had rheumatoid arthritis for several years. What clinical manifestation will the nurse expect to find in a client?
The nurse is discussing the new medication that a client will be taking for treatment of rheumatoid arthritis. Which disease-modifying antirheumatic drug (DMARD) will the nurse educate the client about?
The nurse is discussing the new medication that a client will be taking for treatment of rheumatoid arthritis. Which disease-modifying antirheumatic drug (DMARD) will the nurse educate the client about?
The nurse is caring for a client who is being treated for fibromyalgia. What intervention will best assist the client to restore normal sleep patterns?
Tricyclic antidepressants Explanation: Tricyclic antidepressants and sleep hygiene measures are used to improve or restore normal sleep patterns in clients with fibromyalgia. Increasing activity during the day or using range-of-motion exercises will not increase the client's ability to sleep. Narcotics are generally not needed for pain control with this disorder.
Which of the following diagnostic studies definitely confirms the presence of ascites?
Ultrasound of liver and abdomen Explanation: Ultrasonography of the liver and abdomen will definitively confirm the presence of ascites. An abdominal x-ray, colonoscopy, and computed tomography of the abdomen would not confirm the presence of ascites.
Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?
Vasopressin Explanation: Vasopressin may be the initial therapy for esophageal varices because it produces constriction of the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Spironolactone and cimetidine do not decrease portal hypertension.
Which newer pharmacological therapy, used to treat osteoarthritis, is thought to prevent the loss of cartilage and repair chondral defects, as well as have some anti-inflammatory effects?
Viscosupplementation Explanation: Viscosupplementation, the intra-articular injection of hyaluronates, is thought to prevent the loss of cartilage and repair chondral defects. It may also have some anti-inflammatory effects. Glucosamine and chondroitin are thought to improve tissue function and retard breakdown of cartilage. Capsaicin is a topical analgesic.
Which drug is not used in the treatment of rheumatoid arthritis?
allopurinol Explanation: Allopurinol is used in the treatment of gout. Etanercept, adalimumab, and methotrexate are all used in the treatment of rheumatoid arthritis.
The nurse is providing medication teaching to a client with rheumatoid disease. What common actions are seen with diclofenac and aspirin? Select all that apply. You Selected:
anti-inflammatory analgesic antipyretic antiplatelet Explanation: Rheumatoid medications like aspirin and diclofenac actions are anti-inflammatory, analgesic, and antipyretic. Diclofenac has antiplatelet actions, but aspirin does not have antiplatelet and antispasmotic actions.
A client was seen in the clinic for musculoskeletal pain, fatigue, mood disorders, and sleep disturbances. The physician has diagnosed fibromyalgia. What would not be a part of teaching plan for this condition?
applications of ice Explanation: Application of ice is not part of the treatment regimen. Encouraging the client to eat a healthy diet, avoiding caffeine and alcohol, regular exercise, and stress reduction are part of the teaching plan.
A client with rheumatoid arthritis tells the nurse about experiencing mild tinnitus, gastric intolerance, and rectal bleeding. What medication does the nurse suspect is causing these side effects?
aspirin
A clent with a history of peptic ulcer disease is diagnosed with rheumatoid arthritis. What medication will the nurse anticipate will be prescribed to produce an anti-inflammatory effect and protect the stomach lining?
celecoxib Explanation: The cyclooxygenase-2 inhibitors, such as celecoxib, have been shown to inhibit inflammatory processes but do not inhibit the protective prostaglandin synthesis in the gastointestinal (GI) tract. Therefore, patients who are at increased risk for gastrointestinal complications, especially GI bleeding, have been managed effectively with celecoxib. Ibuprofen, methotrexate, and sulfasalazine may cause GI irritation.
When caring for a client with cirrhosis, which symptoms should a nurse report immediately? Select all that apply.
change in mental status signs of GI bleeding Explanation: The nurse reports any change in mental status or signs of GI bleeding immediately because they indicate secondary complications.
A client is being placed on a purine-restricted diet. What foods will the nurse include in the client's diet plan?
dairy products Explanation: Primary hyperuricemia may be caused by severe dieting or starvation, excessive intake of foods that are high in purines (shellfish, organ meats, and alcohol), or heredity.
A client is prescribed a disease-modifying antirheumatic drug that is successful in the treatment of rheumatoid arthritis but has side effects, including retinal eye changes. What medication will the nurse anticipate educating the client about?
hydroxychloroquine Explanation: The DMARD hydroxychloroquine is associated with visual changes, GI upset, skin rash, headaches, photosensitivity, and bleaching of hair. The nurse should emphasize the need for ophthalmologic examinations every 6-12 months. Azathioprine, diclofenac, and cyclophosphamide do not have visual changes as a side effect.
A client with rheumatoid arthritis has experienced increasing pain and progressing inflammation of the hands and feet. What would be the expected goal of the likely prescribed treatment regimen?
minimizing damage Explanation: Although RA cannot be cured, much can be done to minimize damage. Treatment goals include decreasing joint inflammation before bony ankylosis occurs, relieving discomfort, preventing or correcting deformities, and maintaining or restoring function of affected structures. Early treatment leads to the best results.
Which is not a symptom of osteoarthritis? You Selected:
morning stiffness that lasts at least 1 hour Explanation: Morning stiffness that lasts at least 1 hour is a symptom of rheumatoid arthritis. Symptoms of osteoarthritis include deep, aching pain with motion early in the disease; limited joint motion; and instability of weight-bearing joints.
A client who was recently diagnosed with carcinoma of the pancreas and is having a procedure in which the head of the pancreas is removed. In addition, the surgeon will remove the duodenum and stomach, redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the middle section of the small intestine. What procedure is this client having performed?
radical pancreatoduodenectomy
