Gallbladder Disease Summer Test 5

3 (SEVERE PAIN)

A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis. The client has severe abd. pain and N and has V 120 mL. Based on this data which nursing action would have the highest priority at this time? 1. manage anxiety 2 restore fluid loss 3. manage the pain 4. replace nutritional loss

2 (morphine is believed to cause biliary spasms, the preferred opiod would be meperidine except for elderly pt.)

A 40 year old client is admitted to the hospital with a diagnosis of acute cholecystitis. The nurse should contact the HCP to question which prescription? 1. IV fluid therapy of NS @100 mL/hr 2. Admin morphine sulfate 10 mg IM q4 PRN severe abdominal pain 3. NPO 4. Insert NG tube at low intermittant suction

a,b,c,e (Rationale Pharmacologic treatment for gallstones is used for clients who refuse surgery or for whom surgery is contraindicated. Medications used in the treatment of gallstones include​ ursodiol, chenodiol,​ antibiotics, cholestyramine, and opioid analgesics. A cholecystectomy is a surgical intervention used to completely remove the gallbladder. This is the treatment of choice for symptomatic gallbladder disease.​ However, this is not a pharmacologic treatment for cholelithiasis.)

A client is admitted for cholelithiasis. The client is not a surgical candidate at this time. Which pharmacologic treatments can be used for this client with​ cholelithiasis? ​(Select all that​ apply.) a Antibiotics b Ursodiol c Chenodiol d Cholecystectomy e Cholestyramine

b (Rationale Acute cholecystitis usually occurs after a gallstone obstructs the cystic duct. The obstruction increases pressure within the​ gallbladder, leading to ischemia of the gallbladder wall and mucosa. Obstruction of the common bile duct is the cause of choledocholithiasis. Choledocholithiasis occurs due to blockage of flow from the gallbladder and liver ducts. Gallstone ileus is an obstruction of the small intestine by a large gallstone. The ampulla of Vater is located where the common bile duct and pancreatic duct come together. Blockage of the ampulla of Vater can cause choledocholithiasis and gallbladder pancreatitis.)

A client is admitted with a diagnosis of acute cholecystitis. The nurse understands that acute cholecystitis occurs after which opening is obstructed with a​ gallstone? a The ampulla of Vater b The cystic duct c The common bile duct d The small intestine

a,b,c,e (Rationale Assessing height and​ weight, reviewing serum​ electrolytes, counseling on​ low-fat menu​ choices, and administering antiemetics per order are all nursing actions that address the​ client's nutritional status. It is outside the​ nurse's scope of practice to counsel regarding medical and surgical management of the disorder.)

A client with acute cholecystitis is experiencing nausea and vomiting. Which nursing actions address this​ client's nutritional​ status? ​(Select all that​ apply.) a Counseling regarding​ low-fat menu choices b Reviewing serum electrolytes c Administering antiemetics per order d Counseling on options for medical vs. surgical management e Assessing height and weight

1,2,3 (bile is created in the liver, stored in the gallbladder and released to the duodenum, giving stool its brown color. A bile duct obstruction can cause pale colored stools. Other S/s associated with cholelithiasis are RUQ tenderness, fever from inflammation or infection, jaundice from elevated serum bilirubin levels and N or RUQ pain after a fatty meal.)

A clients stools are light gray in color. For what finding should the nurse assess the client? 1. intolerance to fatty foods 2. fever 3. jaundice 4. respiratory distress 5. pain at McBurneys point 6. peptic ulcer disease

d (There are many risk factors for developing gallbladder disease. It would be appropriate to follow up this statement with an assessment for these risk factors. Pregnancy is a risk factor for biliary​ stasis, but nothing in the scenario indicates that Mrs. Darby is pregnant. Gallbladder disease has previously been considered a disease of those​ "female, fat, and​ forty," but that is no longer the case. Telling a client not to worry is never therapeutic and does not address Mrs.​ Darby's statement.)

Mrs. Darby is a​ 26-year-old woman who is seeing the healthcare provider because of severe upper right quadrant and right shoulder pain lasting for​ "hours at a​ time." The healthcare provider indicates she believes it might be gallbladder disease but needs to complete some tests. Mrs. Darby​ states, "That​ can't be.​ I'm too young.​ That's a disease of old​ people." What is your best​ response? ​a "Don't worry.​ We'll get to the bottom of​ it." ​b "It is. You must be that exception to the​ rule." ​c "It's because you are​ pregnant." d ​"There are many risk factors for gallbladder​ disease."

b (Rationale The blood tests are ordered to monitor the​ client's serum amylase and lipsase levels to determine if the client has developed pancreatitis. A white blood cell count would be monitored if the client had gallbladder inflammation and infection. An abdominal​ x-ray would be ordered to visualize the presence of gallstones. Gallbladder scans would be ordered to determine if the gallbladder is affected.)

The nurse is caring for a client who has been diagnosed with a common duct obstruction. The healthcare provider has ordered blood tests to determine if the client has pancreatitis. The client​ asks, "I thought my gallbladder was​ bad, why are we testing for problems with my​ pancreas?" Which response by the nurse is the most​ appropriate? ​a "The tests will allow us to see if you have​ gallstones." ​b "Your condition can lead to pancreatitis. That is why we are monitoring your serum amylase and lipase​ levels." c ​"Since you are bleeding internally we need to monitor your hemoglobin and​ hematocrit." ​d "This is the only way for us to determine if your gallbladder is​ affected."

1 3 4 2

The nurse is taking care of a client with an IV infusion pump. The pump alarm rings. What should the nurse do in order from first to last? 1. silence the pump alarm 2. determine if the infusion pump is plugged into an electrical outlet 3. assess the clients access site for infiltration/inflammation 4. assess the tubing for hinderances to flow of solution

2 3 1 4

Three days after surgery for cholecystectomy the client states I feel like my stomach is going to burst. The client is taking a reg diet. After determining the VS are stable, in which order of priority from first to last does the nurse assist the client? 1. position the client on the right side 2. offer 120 ml of hot liquids 3. auscultate for bowel sounds 4 encourage ambulation

a (Rapid weight​ loss, hyperlipidemia, not​ hypolipidemia, and female​ , not​ male, gender are risk factors for gallbladder disease. Hypocalcemia is not a risk factor)

What is one of the risk factors for gallbladder​ disease? a Rapid weight loss b Hypolipidemia c Male gender d Hypocalcemia

b (Serum bilirubin evaluates obstructed bile in the biliary duct. Serum amylase and serum lipase indicate possible pancreatitis related to common duct obstruction. A complete blood count shows an elevated white count with inflammation and infection.)

Which diagnostic test evaluates obstructed bile in the biliary​ duct? a WBC count b Serum bilirubin c Serum lipase d Serum amylase

a,c,d,e (Gallstones are formed due to abnormal bile​ composition, an inflammation of the​ gallbladder, biliary​ stasis, and excess cholesterol. Rapid weight​ loss, not weight​ gain, is a factor that contributes to the formation of gallstones.)

Which factors are present in the formation of​ gallstones? ​(Select all that​ apply.) a Excess cholesterol b Rapid weight gain c Abnormal bile composition d Inflammation of the gallbladder e Biliary stasis

a,d,e (To address gallbladder related​ pain, place the client in a Fowler position and administer opioid narcotic analgesics as prescribed. You could also teach about fat intake and the effect it has on gallbladder pain. A dietary consultation about a​ low-carbohydrate diet would address​ nutrition, not​ pain, as would administering vitamin supplements.)

Which interventions address pain management with gallbladder​ disease? ​(Select all that​ apply.) a Teaching about fat intake and gallbladder pain b Administering vitamin supplements as prescribed c Consulting a dietician about a​ low-carbohydrate diet d Placing the client in Fowler position e Administering opioid narcotics as prescribed

b (Cholestyramine​ (Questran) is used for severe jaundice and accumulation of bile salts on the skin. Chenodiol​ (Chenix) and ursodiol​ (Actigall) reduce cholesterol production in the​ liver, thereby reducing the amount of cholesterol available to form gallstones. Opioid analgesics are used for pain relief during an attack of cholecystitis.)

Which medication used in the treatment of gallbladder disorders is also used for severe​ jaundice? a Chenodiol​ (Chenix) b Cholestyramine​ (Questran) c Ursodiol​ (Actigall) d Opioid analgesics

a,b,c,e (Rationale To reduce the risk of infection the nurse will monitor​ vitals, including​ temperature, every 4​ hours, as changes in vital signs may be the first sign of infection. Assessment of the abdomen reveals signs of surgical wound infection.​ Turning, breathing, and incentive spirometry help prevent postsurgical atelectasis and subsequent pneumonia. Antibiotics are ordered to control infection. Fowler position may enhance the​ client's comfort but will have no effect on postsurgical infection.)

Which nursing actions are appropriate to reduce the risk of infection for a hospitalized client recovering from a laparoscopic​ cholecystectomy? ​(Select all that​ apply.) a Monitoring vital​ signs, including​ temperature, every 4 hours b Administering antibiotics as prescribed c Assisting client to deep breathe and cough or use incentive spirometers every 1 to 2 hours while awake d Placing the patient in Fowler position e Assessing abdomen every 4 hours as indicated postsurgery

3 (Right upper quadrant pain is a sign of hemorrhage or bile leak. The ability to void should return within 6 hours postoperatively. Right shoulder pain is related to unabsorbed carbon dioxide and will be resolved by placing the client in Sims position. Output that does not equal input after surgery for the first several hours is expected. Focus: Prioritization)

You are providing postoperative care for a client who underwent laparoscopic cholecystectomy. What should be reported immediately to the physician? 1. The client cannot void 5 hours postoperatively. 2. The client reports shoulder pain. 3. The client reports right upper quadrant pain. 4. Output does not equal input for the first few hours.

3 (T-tubes should not be irrigated, aspirated, or clamped without a specific order from the physician. All of the other actions are appropriate in the care of this client. Focus: Supervision)

You are supervising a nursing student who is caring for a client who had a cholecystectomy. There is a T-tube in place. You would intervene if the student performs which action? 1. Maintains the client in a semi-Fowler position 2. Checks the amount, color, and consistency of the drainage 3. Gently aspirates the drainage from the tube 4. Inspects the skin around the tube for redness or irritation

2, 3 (Both clients will need frequent pain assessments and medications. Clients with copious diarrhea or vomiting will frequently need enteric isolation. Cancer clients receiving chemotherapy are at risk for immunosuppression and are likely to need protective isolation. Focus: Assignment)

You must rearrange the room assignments for several clients. Which two clients would be best to put in the same room? 1. 35-year-old woman with copious intractable diarrhea and vomiting 2. 43-year-old woman who underwent cholecystectomy 2 days ago 3. 53-year-old woman with pain related to alcohol-associated pancreatitis 4. 62-year-old woman with colon cancer receiving chemotherapy and radiation _____, _____

b,c,d,e (Rationale The risk factors for developing gallbladder disorders such as cholecystitis and cholelithiasis include​ age, family history of​ gallstones, Native American​ race, obesity,​ hyperlipidemia, female​ gender, pregnancy, diabetes​ mellitus, cirrhosis, ileal​ disease, and sickle cell disease. Men have a lower risk of developing gallbladder disorders. These disorders affect approximately​ 10% of men and​ 20% of women by the age of 65 years.)

A client is admitted with cholecystitis and is scheduled for surgery in the morning. The client asks about risk factors for developing cholecystitis. Which risk factors for developing cholecystitis would the nurse indicate to the​ client? ​(Select all that​ apply.) a Male gender b Hyperlipidemia c Native American ethnicity d Obesity e Family history of gallstones

a,b,c,e (Rationale Diagnostic tests are used to identify the presence and location of​ gallstones, identify possible complications of the​ gallstones, and help differentiate gallbladder disorders from other disease processes. Diagnostic tests do not prevent the formation of gallstones but can give information necessary for treatments that prevent recurrence.)

A client presents to the emergency department with right upper quadrant abdominal​ pain, suspicious for cholelithiasis. The client asks the nurse why so many tests are being ordered. The nurse bases the response on which​ rationales? ​(Select all that​ apply.) a To diagnose the disorder b To identify possible complications c To determine the location of gallstones d To prevent recurrence e To determine if gallstones are present

3

A client undergoes a laproscopic cholecystectomy. Which dietary instructions should the nurse give the client immed after surgery? 1. you cannont eat or drink for 24 hours 2. you may resume your normal diet the day after surgery 3. drink liquids today and eat lightly for a few days 4. you can progress from a liquid to a bland diet as tolerated.

1 (Distention and rigidity can signal hemorrhage or peritonitis. The physician may also decide that these symptoms require a medication to stimulate peristalsis. Absence of bowel sounds is expected within the first 24 to 48 hours. Nausea and vomiting are not uncommon and are usually self-limiting, and an "as needed" (PRN) order for an antiemetic is usually part of the routine postoperative orders. The reason for displacement of the NG tube should be assessed and the tube secured as necessary. Focus: Prioritization)

A client underwent an exploratory laparotomy 2 days ago. The physician should be called immediately for which physical assessment finding? 1. Abdominal distention and rigidity 2. Displacement of the NG tube by the client 3. Absent or hypoactive bowel sounds 4. Nausea and occasional vomiting

a,b,c,d (Rationale Clients should be taught about health promotion​ activities, including the role of​ obesity, hyperlipidemia, and​ high-cholesterol diet on gallstone​ formation; the importance of a​ high-fiber, low-fat, and​ low-cholesterol diet to reduce the incidence of gallbladder​ disorders; and the dangers of rapid weight loss. Hypolipidemia does not promote gallstone formation.)

A client was recently admitted with a gallbladder disorder. The nurse is preparing to teach health promotion activities. Which topics are appropriate to include in the teaching​ session? ​(Select all that​ apply.) a Importance of a​ low-cholesterol diet b Importance of a​ high-fiber diet c Dangers of rapid weight loss d Role of a​ high-cholesterol diet on gallstone formation e Role of hypolipidemia on gallstone formation

a,b,c,e (Rationale The nurse will plan to instruct the client on the prescribed activity​ level, manifestations of postoperative complications that must be reported to the healthcare​ provider, pain control​ measures, and surgical incision care. A​ low-fat diet, not​ high-fat, must be followed by this client after discharge.)

A client was seen in the emergency department with an initial complaint of abdominal pain and was admitted to an​ in-patient unit earlier in the day. The client is now in surgery having her gallbladder removed. Which topics will be included in the​ client's discharge​ education? ​(Select all that​ apply.) a Instruct on prescribed activity level b Instruct on surgical incision care c Instruct on pain control measures d Instruct on a​ high-fat diet e Teach manifestations of postoperative complications

1,3,5

A client who has had a laparoscopic cholecystectomy has adhesive strips over the puncture sites. When preparing the client for discharge which client statements indicate that the teaching has been successful? 1. I can resume a normal diet when I want 2. I need to avoid driving for about 4 weeks 3. I may experience some pain in my right shoulder 4. I should spend 2-3 days in bed before resuming activity 5. I can take a shower 2 days later

d (Rationale Cholecystitis is the inflammation of the​ gallbladder, a common health problem in the United States. Clinical manifestations of cholecystitis include right upper quadrant pain and pain present for 12​ - 18 hours. Cholelithiasis is the presence of gallbladder​ stones, a common health problem in the United States. In​ cholelithiasis, pain may last 30 minutes to 5 hours. Choledocholithiasis is a type of cholelithiasis in which at least one gallstone is present in the common bile duct as well as the gallbladder. Biliary colic is the pain described in cholelithiasis. This pain is localized to the epigastrium and the right upper quadrant of the abdomen.)

An​ obese, Native American female is admitted for right upper quadrant pain present for the past 12​ hours. A right upper quadrant ultrasound shows inflammation of the​ gallbladder. What is the most likely diagnosis for this​ client? a Biliary colic b Choledocholithiasis c Cholelithiasis d Cholecystitis

a,b,c,e (Rationale The formation of gallstones occurs when several factors are​ present, including abnormal bile​ composition, biliary​ stasis, inflammation of the​ gallbladder, and excess cholesterol. Excess cholesterol in bile is associated with​ obesity, a​ high-calorie and​ high-cholesterol diet, and drugs that lower serum cholesterol levels. Biliary colic is the pain described in cholelithiasis. This pain is localized to the epigastrium and the right upper quadrant of the abdomen. Biliary colic does not lead to the formation of gallstones.)

A​ middle-aged obese woman presents with right upper quadrant abdominal pain present for the past several hours. The nurse suspects that the client is at risk for the formation of gallstones. Which risk factors will the nurse assess this client for during the health​ history? ​(Select all that​ apply.) a Excess cholesterol b Inflammation of the gallbladder c Abnormal bile composition d Biliary colic e Biliary stasis

d (Freedom from nausea and vomiting is an expected outcome according to the nursing care plan. If the interventions in place are​ ineffective, the nurse should consider consulting the healthcare provider. Small amounts of NG drainage are​ expected, particularly after the client eats ice chips. Pain is managed by narcotic​ analgesic, so the nurse should administer these as​ prescribed, not call the healthcare provider. Tolerating ice chips is​ expected, particularly because she still has an NG tube in place.)

Mrs. Reyes is a​ 53-year-old woman who has just had a cholecystectomy with​ T-tube placement. She is 12 hours postsurgery. She is in​ semi-Fowler position and is NPO with a nasogastric​ (NG) tube in place after surgery. Her​ T-tube is connected to a sterile container. Orders include routine vital signs and pain medications per​ protocol, or as​ tolerated, minimal ice​ chips, and measuring​ T-tube drainage. You are completing a​ head-to-toe assessment. Which assessment finding would require notification of the healthcare​ provider? a Pain is reported as being 6 on a​ 10-point scale. b Mrs. Reyes has tolerated ice chips well. c Small amounts of NG drainage d Vomiting after administration of ordered antiemetic

d (Whereas the ultrasound of the gallbladder shows presence of gallstones and also gallbladder​ emptying, the​ x-ray just shows presence of gallstones. There is no information in the scenario about what is covered by insurance. The healthcare provider wanted to have more information from the diagnostic tests than just the presence of​ gallstones, so it would be inappropriate to suggest the cancelling diagnostic procedure. The ultrasound does not show indications of pancreatitis. Serum amylase and lipase would indicate possible pancreatitis.)

Ms. Atchison is a​ 50-year-old woman who has been diagnosed with gallstones. She is preparing to have laboratory and diagnostic testing done. The healthcare provider explained the need for testing. She is scheduled for an​ ultrasound, complete blood​ count, and serum bilirubin. She asks why she is having an ultrasound instead of an​ x-ray. She is concerned that insurance will not cover it. What is your best​ response? ​a "The ultrasound will also show if you have​ pancreatitis." ​b "An x-ray is not indicated in your​ case, so it​ wouldn't be covered by​ insurance." ​c "Do you want us to cancel​ it" It really​ isn't necessary." ​d "An x-ray just shows the presence of​ gallstones, but an ultrasound also shows if the gallbladder is​ emptying."

3 (Giving written information about gallbladder disease and options will help Ms. H to prepare any questions she might have for the physician. If diagnostic results are pending, calling the physician is premature. Describing the surgical procedure is inappropriate because there is more than one type of procedure, and the one to be used is still undetermined. Explaining postoperative care would be appropriate once the need for cholecystectomy has been verified by the physician. Focus: Prioritization; QSEN: N/A; Concept: Patient Education)

Ms. H's physician told her that she would probably need a laparoscopic cholecystectomy; however, the hepatobiliary iminodiacetic acid scan and laboratory results are still pending. Ms. H asks, "What should I expect?" What is the best intervention at this point? 1. Describe the surgical procedure. 2. Call the physician to come and speak with her. 3. Provide some written material about gallbladder disease and options. 4. Explain general postoperative care, such as coughing and deep breathing exercises.

a,c,d (Rationale Food intake may be limited during the acute phase of the disorder in order to avoid symptoms of fat intolerance and nausea and vomiting. A nasogastric tube may be inserted to maintain an empty stomach and thus relieve nausea and vomiting. Fat intake is limited as a​ high-fat diet is a precipitating factor in the development of gallstones.​ Low-fiber, low-residue, and​ high-protein diets do not alter the course of cholecystitis.)

Which nutritional modifications are therapeutic for clients experiencing an episode of​ cholecystitis? ​(Select all that​ apply.) a Limiting food intake b ​Low-fiber, low-residue diet c Nasogastric tube insertion ​d Low-fat diet ​e High-protein diet

a (The importance of maintaining a​ low-fat diet is a good teaching point. You should promote a​ high-fiber diet, not a​ low-fiber diet.​ Hyperlipidemia, not​ hypolipidemia, is a risk for gallbladder disease. Although a​ low-carbohydrate diet is​ advised, a​ carbohydrate-free diet is not advised.)

Which therapeutic teaching point is related to preventing gallbladder​ disease? a The importance of a​ low-fat diet b The role of hypolipidemia in gallbladder disease c The promotion of a​ carbohydrate-free diet d The importance of a​ low-fiber diet