Honan-Chapter 25 Extened: Nursing Management: Patients With Hepatic and Biliary Disorders

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: yellow sclerae. light amber urine. circumoral pallor. black, tarry stools.

yellow sclerae. Explanation: Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? Acute pain related to biliary spasms Deficient knowledge related to prevention of disease recurrence Anxiety related to unknown outcome of hospitalization Imbalanced nutrition: Less than body requirements related to biliary inflammation

Acute pain related to biliary spasms Explanation: The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

A patient who has undergone liver transplantation is ready to be discharged home. The nurse is providing discharge teaching. Which topic will the nurse emphasize most related to discharge teaching? The patient will obtain measurement of drainage from the T-tube. The patient will exercise three times a week. The patient will take immunosuppressive agents as required. The patient will monitor for signs of liver dysfunction.

The patient will take immunosuppressive agents as required. Explanation: The patient is given written and verbal instructions about immunosuppressive agent doses and dosing schedules. The patient is also instructed on steps to follow to assure that an adequate supply of medication is available so that there is no chance of running out of the medication or skipping a dose. Failure to take medications as instructed may precipitate rejection. The nurse would not teach the patient to measure drainage from a T-tube as a patient wouldn't go home with a T-tube. The nurse may teach the patient about the need to exercise or what the signs of liver dysfunction are, but these are not as important as the immunosuppressive drug regimen.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery? Potassium Vitamin K Vitamin B Oral bile acids

Vitamin K Explanation: Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.

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 cholecystojejunostomy total pancreatectomy distal pancreatectomy

radical pancreatoduodenectomy Explanation: Radical pancreatoduodenectomy involves removing the head of the pancreas, resecting the duodenum and stomach, and redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the jejunum. Cholecystojejunostomy is a rerouting of the pancreatic and biliary drainage systems, which may be done to relieve obstructive jaundice. This measure is considered palliative only. A pancreatectomy is the surgical removal of the pancreas. A pancreatectomy may be total, in which case the entire organ is removed, usually along with the spleen, gallbladder, common bile duct, and portions of the small intestine and stomach. A distal pancreatectomy is a surgical procedure to remove the bottom half of the pancreas.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client? Relieving abdominal pain Preventing fluid volume overload Maintaining adequate nutritional status Teaching about the disease and its treatment

Relieving abdominal pain Explanation: The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can't help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

A patient who had surgery for gallbladder disease has just returned to the unit. The nurse caring for this patient knows to immediately report what assessment finding to the primary care provider? Decreased breath sounds Drainage of "bile-colored fluid" onto the abdominal dressing Rigidity of the abdomen Acute pain with movement

Rigidity of the abdomen Explanation: The location of the subcostal incision will likely cause the patient to take shallow breaths to prevent pain, and this may result in decreased breath sounds. The nurse should remind patients to take deep breaths and cough to expand the lungs fully and prevent atelectasis. Acute pain is an expected assessment finding following surgery, and analgesics should be administered for pain relief. Abdominal splinting or application of an abdominal binder may assist in reducing the pain. Bile may continue to drain from the drainage tract after surgery, and this will require frequent changes of the abdominal dressing. Increased abdominal tenderness and rigidity should be reported immediately to the health care provider, as it may indicate bleeding from an inadvertent puncture or nicking of a major blood vessel during the surgical procedure.

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from: The digestion of dietary and blood proteins. Excessive diuresis and dehydration. Severe infections and high fevers. Excess potassium loss subsequent to prolonged use of diuretics.

The digestion of dietary and blood proteins. Explanation: Circumstances that increase serum ammonia levels tend to aggravate or precipitate hepatic encephalopathy. The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. Ammonia from these sources increases as a result of GI bleeding (i.e., bleeding esophageal varices, chronic GI bleeding), a high-protein diet, bacterial infection, or uremia.

Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes mellitus. Which of the following explains the cause of this secondary diabetes? Dysfunction of the pancreatic islet cells Ingestion of foods high in sugar Inability for the liver to reabsorb serum glucose Renal failure

Dysfunction of the pancreatic islet cells Explanation: Diabetes mellitus resulting from dysfunction of the pancreatic islet cells is treated with diet, insulin, or oral antidiabetic agents. The hazard of severe hypoglycemia with alcohol consumption is stressed to the client and family. When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. A standard treatment with pancreatitis is to make the client NPO. The dysfunction is related to the pancreas, not the liver.

Serologic testing of a middle-aged woman with a recent history of severe flu-like symptoms has just resulted in a diagnosis of hepatitis A. Which of the following assessment questions should the nurse prioritize when discussing this diagnosis with the patient? "Are you currently in a monogamous sexual relationship?" "How would describe your typical diet? "Which restaurants have you eaten in over the past few weeks?" "Have you ever used recreational drugs?"

"Which restaurants have you eaten in over the past few weeks?" Explanation: The mode of transmission of hepatitis A virus (HAV) occurs through the fecal-oral route, primarily through person-to-person contact and/or ingestion of fecally contaminated food or water. Uncooked food or poor food handling practice is a common method of transmission of HAV. As a result, the patient is usually questioned about his or her recent restaurant visits. HAV is less commonly related to sexual contact, drug use, or poor diet.

The nurse is teaching a client who was admitted to the hospital with acute hepatic encephalopathy and ascites about an appropriate diet. The nurse determines that the teaching has been effective when the client chooses which food choice from the menu? Omelet with green peppers, onions, mushrooms, and cheese with milk Pancakes with butter and honey, and orange juice Ham and cheese sandwich, baked beans, potatoes, and coffee Baked chicken with sweet potato french fries, cornbread, and tea

Pancakes with butter and honey, and orange juice Explanation: Teach clients to select a diet high in carbohydrates with protein intake consistent with liver function. The client should identify foods high in carbohydrates and within protein requirements (moderate to high protein in cirrhosis and hepatitis, low protein in hepatic failure). The client with acute hepatic encephalopathy is placed on a low-protein diet to decrease ammonia concentration. The other choices are all higher in protein. The client's ascites indicates that a low-sodium diet is needed, and the other choices are all high in sodium.

A 37-year-old male patient presents at the emergency department complaining of nausea and vomiting and severe abdominal pain. While the nurse is assessing the patient, the patient's wife informs the nurse that the patient ingested 24 ounces of vodka last evening. The patient's abdomen is rigid, and there is bruising to the patient's flank. What is the patient exhibiting signs of? Pancreatitis with possible peritonitis Acute cholecystitis Obstruction of the bowel Acute appendicitis

Pancreatitis with possible peritonitis Explanation: Severe abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care. Pain in pancreatitis is accompanied by nausea and vomiting that does not relieve the pain or nausea. Abdominal guarding is present, and a rigid or board-like abdomen may be a sign of peritonitis. Ecchymosis (bruising) to the flank or around the umbilicus may indicate severe peritonitis. Pain generally occurs 24 to 48 hours after a heavy meal or alcohol ingestion.

After being in remission from Hodgkin's disease for 18 months, a client develops a fever of unknown origin. A healthcare provider orders a liver biopsy to rule out advancing Hodgkin's disease and infection. Twenty-four hours after the biopsy, the client has a fever, complains of severe abdominal pain, and seems increasingly confused. What should the nurse suspect? Peritonitis from bleeding in the liver caused by the liver biopsy Perforation of the colon caused by the liver biopsy An allergic reaction to the contrast media used during the liver biopsy Normal postprocedural pain, with a change in the level of consciousness resulting from the pre-existing fever

Peritonitis from bleeding in the liver caused by the liver biopsy Explanation: After any invasive procedure, the nurse must stay alert for complications in the affected region—in this case, the abdomen. This client exhibits classic signs and symptoms of peritonitis caused by blood or bile after the liver biopsy. There is a reason to suspect bleeding resulting from the liver biopsy. It is rare to have a perforation of the colon after a biopsy. Liver biopsy doesn't involve the use of contrast media. The client's symptoms are not normal for a liver biopsy.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure? Administering an analgesic once per shift, as ordered, to prevent drug addiction Positioning the client on the side with the knees flexed Encouraging frequent visits from family and friends Administering frequent oral feedings

Positioning the client on the side with the knees flexed Explanation: The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

The nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. What will the nurse document this condition as in the patient's chart? Asterixis Constructional apraxia Fetor hepaticus Palmar erythema

Asterixis Explanation: The nurse will document that a patient exhibiting a flapping tremor of the hands is demonstrating asterixis. Constructional apraxia is also a motor disturbance, but it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.

A client is actively bleeding from esophageal varices. Which medication would the nurse most expect to be administered to this client? Octreotide Spironolactone Propranolol Lactulose

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 patient has been admitted to the critical care unit from the subacute medical unit because his signs and symptoms of liver failure have become more pronounced over the past 24 hours. The critical care nurse who is planning this patient's care should prioritize which of the following nursing diagnoses? Risk for bleeding related to complications of liver failure Knowledge deficit related to the causes of liver failure Bowel incontinence related to treatments for liver failure Risk for impaired gas exchange related to complications of liver failure

Risk for bleeding related to complications of liver failure Explanation: Hematological changes and the possibility of esophageal varices present an acute risk of hemorrhage in the patient with liver failure. This risk supersedes the possibility of respiratory complications. Knowledge deficit and bowel incontinence are likely, but are not more important than the possibility of hemorrhage.

A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is board-like and no bowel sounds are detected. What is the major concern for this patient? The patient requires more pain medication. The patient is developing a paralytic ileus. The patient has developed peritonitis. The patient has developed renal failure.

The patient has developed peritonitis. Explanation: Abdominal guarding is present. A rigid or board-like abdomen may develop and is generally an ominous sign, usually indicating peritonitis (Privette et al., 2011).

The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason? To decrease metabolism To depress the central nervous system and increase the pain threshold To reduce gastric and pancreatic secretions To relieve nausea and vomiting

To reduce gastric and pancreatic secretions Explanation: Anticholinergic medications reduce gastric and pancreatic secretion.

A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis? A liver biopsy A CT scan A prothrombin time Platelet count

A liver biopsy Explanation: A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client? Placing the client in a semi-Fowler's position Maintaining nothing-by-mouth (NPO) status Administering morphine I.V. as ordered Providing mouth care

Administering morphine I.V. as ordered Explanation: The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highestnursing priority for this client? Assisting the client to turn, cough, and deep breathe every 2 hours Teaching the client to choose low-fat foods from the menu Performing range-of-motion (ROM) leg exercises hourly while the client is awake Assisting the client to ambulate the evening of the operative day

Assisting the client to turn, cough, and deep breathe every 2 hours Explanation: Assessment should focus on the client's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation.

Which foods should be avoided following acute gallbladder inflammation? Cooked fruits Cheese Coffee Mashed potatoes

Cheese Explanation: The client should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the client that fatty foods may induce an episode of cholecystitis. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea may be consumed as tolerated.

A client with calculi in the gallbladder is said to have Cholecystitis Cholelithiasis Choledocholithiasis Choledochotomy

Cholelithiasis Explanation: Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition. Cholecystitis is acute inflammation of the gallbladder. Choledocholithiasis is a gallstone in the common bile duct. Choledochotomy is an incision into the common bile duct.

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report? Yellow-green Black and tarry Blood tinged Clay-colored or whitish

Clay-colored or whitish Explanation: Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.

Which is a clinical manifestation of cholelithiasis? Epigastric distress before a meal Clay-colored stools Abdominal pain in the upper left quadrant Nonpalpable abdominal mass

Clay-colored stools Explanation: The client with gallstones has clay-colored stools and excruciating upper right quadrant pain that radiates to the back or right shoulder. The excretion of bile pigments by the kidneys makes urine very dark. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. The client develops a fever and may have a palpable abdominal mass.

A 70-year-old client is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which gerontologic consideration associated with the pancreas? Decreases in the physiologic function of major organs Increases in the bicarbonate output by the kidneys Increases in the rate of pancreatic secretion Development of local complications

Decreases in the physiologic function of major organs Explanation: Acute pancreatitis affects people of all ages, but the mortality rate associated with acute pancreatitis increases with advancing age. The pattern of complications changes with age. Younger clients tend to develop local complications; the incidence of multiple organ failure increases with age, possibly as a result of progressive decreases in physiologic function of major organs with increasing age.

Which condition in a client with pancreatitis makes it necessary for the nurse to check fluid intake and output, check hourly urine output, and monitor electrolyte levels? Frequent vomiting, leading to loss of fluid volume Dry mouth, which makes the client thirsty Acetone in the urine High glucose concentration in the blood

Frequent vomiting, leading to loss of fluid volume Explanation: Fluid and electrolyte disturbances are common complications because of nausea, vomiting, movement of fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever, and the use of gastric suction. The nurse assesses the client's fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the client daily and carefully measures fluid intake and output, including urine output, nasogastric secretions, and diarrhea.

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? Hepatitis B is transmitted primarily by the oral-fecal route. Hepatitis A is frequently spread by sexual contact. Hepatitis C increases a person's risk for liver cancer. Infection with hepatitis G is similar to hepatitis A.

Hepatitis C increases a person's risk for liver cancer. Explanation: Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.

While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the liklihood of liver problems? Select all that apply. Jaundice Petechiae Ecchymoses Cyanosis of the lips Aphthous stomatitis

Jaundice Petechiae Ecchymoses Explanation: The skin, mucosa, and sclerae are inspected for jaundice. The nurse observes the skin for petechiae or ecchymotic areas (bruises), spider angiomas, and palmar erythema. Cyanosis of the lips is indicative of a problem with respiratory or cardiovascular dysfunction. Aphthous stomatitis is a term for mouth ulcers and is a gastrointestinal abnormal finding.

Clinical manifestations of common bile duct obstruction include all of the following except: Light-colored urine Clay-colored feces Pruritus Jaundice

Light-colored urine Explanation: The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish, like putty, or clay-colored. The symptoms may be acute or chronic. Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen, may occur. If it goes untreated jaundice and pruritus can occur.

A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder? Coagulation studies Magnetic resonance imaging Radioisotope liver scan Liver biopsy

Liver biopsy Explanation: A liver biopsy which reveals hepatic fibrosis is the most conclusive diagnostic procedure. Coagulation studies provide information about liver function but do not definitively confirm the diagnosis of cirrhosis. Magnetic resonance imaging and radioisotope liver scan help to support the diagnosis but do not confirm it. These tests provide information about the liver's enlarged size, nodular configuration, and distorted blood flow.

A client has a blockage of the passage of bile from a stone in the common bile duct. What type of jaundice does the nurse suspect this client has? Hemolytic jaundice Hepatocellular jaundice Obstructive jaundice Cirrhosis of the liver

Obstructive jaundice Explanation: Obstructive jaundice is caused by a block in the passage of bile between the liver and intestinal tract. Hemolytic jaundice is caused by excess destruction of red blood cells. Hepatocellular jaundice is caused by liver disease. Cirrhosis of the liver would be an example of hepatocellular jaundice.

A client has undergone a liver biopsy. Which postprocedure position is appropriate? On the left side Trendelenburg On the right side High Fowler's

On the right side Explanation: In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded. Positioning the client on his left side is not indicated. Positioning the client in the Trendelenburg position may be indicated if the client is in shock, but is not the position designed for the client after liver biopsy. The high Fowler position is not indicated for the client after liver biopsy.

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? Cure the cirrhosis. Treat the esophageal varices. Reduce fluid accumulation and venous pressure. Promote optimal neurologic function.

Reduce fluid accumulation and venous pressure. Explanation: Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.

Clients with chronic liver dysfunction have problems with insufficient vitamin intake. Which may occur as a result of vitamin C deficiency? Night blindness Hypoprothrombinemia Scurvy Beriberi

Scurvy Explanation: Scurvy may result from a vitamin C deficiency. Night blindness, hypoprothrombinemia, and beriberi do not result from a vitamin C deficiency.

The nurse is admitting a patient to the intensive care unit with a diagnosis of acute pancreatitis. What does the nurse expect was the reason the patient came to the hospital? Severe abdominal pain Fever Jaundice Mental agitation

Severe abdominal pain Explanation: Severe abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas.

Gynecomastia is a common side effect of which of the following diuretics? Spironolactone Furosemide Vasopressin Nitroglycerin (IV)

Spironolactone Explanation: Gynecomastia is a common side effect caused by spironolactone. Vasopressin is used for bleeding esophageal varices and is not a diuretic. Nitroglycerin (IV) may be used with vasopressin to counteract the effects of vasoconstriction from the vasopressin.

The nurse is administering Cephulac (lactulose) to decrease the ammonia level in a patient who has hepatic encephalopathy. What should the nurse carefully monitor for that may indicate a medication overdose? Watery diarrhea Vomiting Ringing in the ears Asterixis

Watery diarrhea Explanation: The patient receiving lactulose is monitored closely for the development of watery diarrhea stools, because they indicate a medication overdose. Serum ammonia levels are closely monitored as well.

A client with chronic pancreatitis is treated for uncontrolled pain. Which complication does the nurse recognize is most common in the client with chronic pancreatitis? Weight loss Diarrhea Fatigue Hypertension

Weight loss Explanation: Weight loss is most common in the client with chronic pancreatitis due to decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack. The other answer choices are not the most common complications related to chronic pancreatitis.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: cirrhosis. peptic ulcer disease. appendicitis. cholelithiasis.

cirrhosis. Explanation: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

What is the recommended dietary treatment for a client with chronic cholecystitis? low-fat diet high-fiber diet low-residue diet low-protein diet

low-fat diet Explanation: The bile secreted from the gallbladder helps the body absorb and break down dietary fats. If the gallbladder is not functioning properly, then it will not secrete enough bile to help digest the dietary fat. This can lead to further complications; therefore, a diet low in fat can be used to prevent complications.

Which of the following would the nurse expect to assess in a client with hepatic encephalopathy? Increased motor activity Asterixis Negative Babinski reflex Irritability

Asterixis Explanation: Hepatic encephalopathy is manifested by numerous central nervous system effects including: disorientation, confusion, personality changes, memory loss, a flapping tremor called asterixis, a positive Babinski reflex, sulfurous breath odor (referred to as fetor hepaticus), and lethargy to deep coma.

A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood value does the nurse recognize as inadequate to sustain normal brain function? 30 mg/dL 50 mg/dL 70 mg/dL 90 mg/dL

30 mg/dL Explanation: Hyperinsulinism is caused by overproduction of insulin by the pancreatic islets. Occasionally, tumors of nonpancreatic origin produce an insulin-like material that can cause severe hypoglycemia and may be responsible for seizures coinciding with blood glucose levels that are too low to sustain normal brain function (i.e., lower than 30 mg/dL [1.6 mmol/L]) (Goldman & Schafer, 2012; McPherson & Pincus, 2011).

A client discharged after a laparoscopic cholecystectomy calls the surgeon's office reporting severe right shoulder pain 24 hours after surgery. Which statement is the correct information for the nurse to provide to this client? "This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort." "This pain is caused from your incision. Take analgesics as needed and as prescribed and report to the surgeon if pain is unrelieved even with analgesic use." "This may be the initial symptoms of an infection. You need to come to see the surgeon today for an evaluation." "This pain may be caused by a bile duct injury. You will need to go to the hospital immediately to have this evaluated."

"This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort." Explanation: If pain occurs in the right shoulder or scapular area (from migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure), the nurse may recommend using a heating pad for 15 to 20 minutes hourly, sitting up in a bed or chair, or walking.

A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor? "You must have the second one in 2 weeks and the third in 1 month." "You must have the second one in 1 month and the third in 6 months." "You must have the second one in 6 months and the third in 1 year." "You must have the second one in 1 year and the third the following year."

"You must have the second one in 1 month and the third in 6 months." Explanation: Both forms of the hepatitis B vaccine are administered intramuscularly in three doses; the second and third doses are given 1 and 6 months, respectively, after the first dose.

The nurse knows that the serum amylase concentration returns to normal within which time frame? 12 hours 24 hours 36 hours 48 hours

48 hours Explanation: Serum amylase usually returns to normal within 48 to 72 hours.

Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve? 1 to 2 3 to 5 6 to 12 13 to 18

6 to 12 Explanation: Ursodeoxycholic acid (UDCA [URSO, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. Six to 12 months of therapy are required in many clients to dissolve stones, and monitoring of the client for recurrence of symptoms or occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required during this time.

The nurse reviews the laboratory values for a patient being evaluated for alcoholic cirrhosis. The nurse is aware that a diagnostic indicator present in greater than 70% of cases is which of the following? Total bilirubin AST/ALT ratio >3.0 Alkaline phosphatase Albumin

AST/ALT ratio >3.0 Explanation: The aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio is helpful in diagnosing liver damage and is present in more than 70% of cases.

An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is: Acetaminophen Ibuprofen Dextromethorphan Benadryl

Acetaminophen Explanation: Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Other medications commonly associated with liver injury include anesthetic agents, medications used to treat rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsants, and antituberculosis agents. MAX YOU CAN TAKE PER DAY IS 4,000 MG

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal? Creatinine Urobilinogen Chloride Albumin

Albumin Explanation: Albumin is an abnormal finding in a routine urine specimen. Ascites present in liver failure contain albumin; therefore, if the bladder ruptured, ascites containing albumin would drain from the indwelling urinary catheter because the catheter is no longer contained in the bladder. Creatinine, urobilinogen, and chloride are normally found in urine.

A patient returns to the floor after a laparoscopic cholecystectomy. The nurse caring for the patient is aware that the most serious potential complication is what? Pulmonary atelectasis Decubitus ulcer Wound evisceration Bile duct injury

Bile duct injury Explanation: Careful screening of patients and identification of those at low risk for problems limits the frequency of conversion to an open abdominal procedure. With wider use of laparoscopic procedures, however, there may be an increase in the number of such conversions. The most serious complication after laparoscopic cholecystectomy is a bile duct injury.

A client who had developed jaundice 2 months earlier is brought to the ED after attending a party and developing excruciating pain that radiated over the abdomen and into the back. Upon assessment, which additional symptom would the nurse expect this client to have? Hypertension Bile-stained vomiting Warm, dry skin Weight loss

Bile-stained vomiting Explanation: Nausea and vomiting are common in acute pancreatitis. The emesis is usually gastric in origin but may also be bile stained. Fever, jaundice, mental confusion, and agitation may also occur.

A patient is brought to the emergency department by ambulance. He has hematemesis and alteration in mental status. The patient has tachycardia, cool clammy skin, and hypotension. The patient has a history of alcohol abuse. What would the nurse suspect the patient has? Hemolytic jaundice Hepatic insufficiency Bleeding esophageal varices Portal hypertension

Bleeding esophageal varices Explanation: The patient with bleeding esophageal varices may present with hematemesis, melena, or general deterioration in mental or physical status and often has a history of alcohol abuse. Signs and symptoms of shock (cool clammy skin, hypotension, tachycardia) may be present. The scenario does not describe hemolytic jaundice, hepatic insufficiency, or portal hypertension.

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately? Weight loss of 2 pounds in 3 days Change in the client's handwriting and/or cognitive performance Anorexia for more than 3 days Constipation for more than 2 days

Change in the client's handwriting and/or cognitive performance Explanation: The earliest symptoms of hepatic encephalopathy include mental status changes and motor disturbances. The client will appear confused and unkempt and have altered mood and sleep patterns. Neurologic status should be assessed frequently. Mental status is monitored by the nurse keeping the client's daily record of handwriting and arithmetic performance. The nurse should report any change in mental status immediately. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis.

A very ill client with acute cholecystitis is scheduled for surgery. The surgeon plans to create an incision in the common bile duct to remove stones. The nurse correctly documents this surgery in the electronic medical record using which term? Choledochostomy Cholecystostomy Cholecystectomy Choledochoduodenostomy

Choledochostomy Explanation: This procedure is reserved for the client with acute cholecystitis who may be too ill to undergo a surgical procedure. It involves making an incision in the common duct, usually to remove stones (choledochostomy). REMEMBER: CHOLE-DOCH-OSTOMY "CHOLE"=CHOLECYSTITIS "DOCH" SOUNDS LIKE COMMON "DUCT" "-OSTOMY"=SURGICAL OPENING

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice? Straw-colored urine Reduced hematocrit Clay-colored stools Elevated urobilinogen in the urine

Clay-colored stools Explanation: Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen.

Which type of jaundice seen in adults is the result of increased destruction of red blood cells? Hemolytic Hepatocellular Obstructive Nonobstructive

Hemolytic Explanation: Hemolytic jaundice results because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. Obstructive and hepatocellular jaundice are results of liver disease. Nonobstructive jaundice occurs with hepatitis.

A client is receiving vasopressin for the urgent management of active bleeding due to esophageal varices. What most serious complication should the nurse assess the client for after the administration? Urinary output changes Electrocardiogram changes Electrolytes level changes Liver enzyme changes

Electrocardiogram changes Explanation: Vasopressin (Pitressin) is administered during the management of an urgent situation with an acute esophageal bleed because of its vasoconstrictive properties in the splanchnic, portal, and intrahepatic vessels. This medication also causes coronary artery constriction that may dispose clients with coronary artery disease to cardiac ischemia; therefore, the nurse observes the client for evidence of chest pain, ECG changes, and vital sign changes. Vasopressin will does not infer with urinary output, electrolytes, or liver enzymes.

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct? Colonoscopy Abdominal x-ray Cholecystectomy Endoscopic retrograde cholangiopancreatography (ERCP)

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. Reference:

A group of students is reviewing information about the liver and associated disorders. The group demonstrates understanding of the information when they identify which of the following as a primary function of the liver? Breakdown amino acids Convert urea into ammonia Excrete bile Break down coagulation factors

Excrete bile Explanation: The liver forms and excretes bile, synthesizes amino acids from the breakdown of proteins, converts ammonia into urea, and synthesizes the factors needed for blood coagulation.

Which type of deficiency results in macrocytic anemia? Folic acid Vitamin C Vitamin A Vitamin K

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 has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition? Hepatic encephalopathy Portal hypertension Asterixis Cirrhosis

Hepatic encephalopathy Explanation: Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with an elevated ammonia concentration that produces changes in mental status, altered level of consciousness, and coma. Portal hypertension is an elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

A 33-year-old male patient with a history of IV heroin and cocaine use has been admitted to the medical unit for the treatment of endocarditis. The nurse should recognize that this patient is also likely to test positive for which of the following hepatitis viruses? Hepatitis A Hepatitis B Hepatitis C Hepatitis D

Hepatitis C Explanation: Transmission of hepatitis C occurs primarily through injection of drugs and through transfusion of blood products prior to 1992. Hepatitis A, B, and D are less likely to result from IV drug use.

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? Serum potassium level of 3.5 mEq/L Loss of 2.2 lb (1 kg) in 24 hours Serum sodium level of 135 mEq/L Blood pH of 7.25

Loss of 2.2 lb (1 kg) in 24 hours Explanation: Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.

A 59-year-old male patient was diagnosed with cirrhosis several years ago. After years of successful management of his chronic disease, he experienced a constellation of symptoms that eventually resulted in a diagnosis of hepatocellular carcinoma (HCC). What treatment holds the greatest potential for curing this patient's health problem? Hepatic lobectomy Radiotherapy Liver transplantation Laser ablation

Liver transplantation Explanation: In patients with HCC and cirrhosis, liver transplantation is the treatment of choice, being deemed more effective than surgery and radiotherapy.

A nurse is planning care for a client with acute pancreatitis. Which client outcome does the nurse assign as the highest priority? Developing no acute complications from the pancreatitis Maintaining normal respiratory function Maintaining satisfactory pain control Achieving adequate fluid and electrolyte balance

Maintaining normal respiratory function Explanation: Airway and breathing are always the priority assessment. Acute pancreatitis produces retroperitoneal edema, elevation of the diaphragm, pleural effusion, and inadequate lung ventilation. Intra-abdominal infection and labored breathing increase the body's metabolic demands, which further decreases pulmonary reserve and can lead to respiratory failure. Maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider? Report the condition to the physician immediately. Measure abdominal girth according to a set routine. Provide the client with nonprescription laxatives. Ask the client about food intake.

Measure abdominal girth according to a set routine. Explanation: If the abdomen appears enlarged, the nurse measures it according to a set routine. The nurse reports any change in mental status or signs of gastrointestinal bleeding immediately. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis.

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN? Auscultate the abdomen for bowel sounds every 4 hours Measure abdominal girth every shift Monitor for reports of nausea and vomiting Measure blood glucose concentration every 4 to 6 hours

Measure blood glucose concentration every 4 to 6 hours Explanation: Enteral or parenteral nutrition may be prescribed. In addition to administering enteral or parenteral nutrition, the nurse monitors the serum glucose concentration every 4 to 6 hours.

The critical care nurse is caring for a patient with cirrhosis. What is a priority nursing function when caring for a patient with cirrhosis? Monitoring the patient's oral intake Monitoring the patient's social support network Monitoring the patient for signs of hypervolemia Monitoring the patient's mental status

Monitoring the patient's mental status Explanation: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patient's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. An extensive neurologic evaluation is key to identifying progression through the four stages of encephalopathy. The nurse would monitor the oral intake and watch for signs of hypervolemia, but they are not as essential as the patient's mental status because of the encephalopathy that goes with cirrhosis. Monitoring the support network is not essential at this time.

Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit? Appendicitis Pancreatitis Cholecystitis Peptic ulcer

Pancreatitis Explanation: Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity. The other conditions are less likely to exhibit fluid volume deficit.

Which is the most common cause of esophageal varices? Jaundice Portal hypertension Ascites Asterixis

Portal hypertension Explanation: Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? Monitor pulse oximetry every hour. Withhold oral feedings for the client. Instruct the client to avoid coughing. Reposition the client every 2 hours.

Reposition the client every 2 hours. Explanation: Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient? Respiratory assessment related to increased thoracic pressure Urinary output related to increased sodium retention Peripheral vascular assessment related to immobility Skin assessment related to increase in bile salts

Respiratory assessment related to increased thoracic pressure Explanation: If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy.

A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test? Serum calcium Serum bilirubin Serum amylase Serum potassium

Serum amylase Explanation: Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation? The client's hepatic function is decreasing. The client didn't take his morning dose of lactulose (Cephulac). The client is relaxed and not in pain. The client is avoiding the nurse.

The client's hepatic function is decreasing. Explanation: The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.

A nurse practitioner treating a patient who is diagnosed with hepatitis A should provide health care information. Which of the following statements are correct for this disorder? Select all that apply. The incubation period for this virus is up to 4 months. There is a 70% chance that jaundice will occur. Transmission of the virus is possible with oral-anal contact during sex. Typically there is a spontaneous recovery. There is a 50% risk that cirrhosis will develop.

There is a 70% chance that jaundice will occur. Transmission of the virus is possible with oral-anal contact during sex. Typically there is a spontaneous recovery. Explanation: The incubation period for hepatitis A is 15 to 50 days, with an average of 28 days. The risk of cirrhosis occurs with hepatitis B.

Which of the following diagnostic studies definitely confirms the presence of ascites? Ultrasound of liver and abdomen Abdominal x-ray Colonoscopy Computed tomography of abdomen

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 of the following is the most effective strategy to prevent hepatitis B infection? Vaccine Barrier protection during intercourse Covering open sores Avoid sharing toothbrushes

Vaccine Explanation: The most effective strategy to prevent hepatitis B infection is through vaccination. Recommendations to prevent transmission of hepatitis B include vaccination of sexual contacts of individuals with chronic hepatitis, use of barrier protection during sexual intercourse, avoidance of sharing toothbrushes, razors with others, and covering open sores or skin lesions.

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices? Spironolactone Vasopressin Nitroglycerin Cimetidine

Vasopressin Explanation: Vasopressin may be the initial therapy for esophageal varices because it constricts 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.

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client? Vitamin A Thiamine Riboflavin Vitamin K

Vitamin A Explanation: Problems common to clients with severe chronic liver dysfunction result from inadequate intake of sufficient vitamins. Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency can lead to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Vitamin K deficiency can cause hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses.

A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. What is an important education topic regarding ingestion of medications? metabolism of medications need for increased drug dosages need for more frequently divided doses medications becoming ineffective in clients with liver disease

metabolism of medications Explanation: Careful evaluation of the client's response to drug therapy is important because the malfunctioning liver cannot metabolize many substances.

Which symptoms will a nurse observe most commonly in clients with pancreatitis? severe, radiating abdominal pain black, tarry stools and dark urine increased and painful urination increased appetite and weight gain

severe, radiating abdominal pain Explanation: The most common symptom in clients with pancreatitis is severe midabdominal to upper abdominal pain, radiating to both sides and straight to the back.

A client who is 24 hours post op from laparoscopic cholecystectomy calls the nurse and reports pain in the right shoulder. How should the nurse respond to the client's report of symptoms? "Apply a heating pad to your shoulder for 15 minutes hourly as needed." "Come into the emergency room as soon as possible." "Take an over the counter analgesic as needed." "Place your shoulder in a sling to avoid moving it."

"Apply a heating pad to your shoulder for 15 minutes hourly as needed." Explanation: Pain in the right shoulder may occur after laparoscopic cholecystectomy due to migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure. The nurse should instruct the client to apply a heating pad to the shoulder for 15 to 20 minutes every hour as needed for pain relief. The nurse should not instruct the client to take analgesic medication-this is a medical order performed by the health care provider only. This scenario is not life threatening and the client does not need to go to the emergency department. It is also not necessary for the client to place the shoulder in a sling as this is not an injury-related condition.

When reviewing the history of a client with pancreatic cancer, the nurse would identify which of the following as a possible risk factor? History of pancreatitis Ingestion of a low-fat diet One-time exposure to petrochemicals Ingestion of caffeinated coffee

History of pancreatitis Explanation: Pancreatitis is associated with the development of pancreatic cancer. Other factors that correlate with pancreatic cancer include diabetes mellitus, a high-fat diet, and chronic exposure to carcinogenic substances (i.e., petrochemicals). Although data are inconclusive, a relationship may exist between cigarette smoking and high coffee consumption (especially decaffeinated coffee) and the development of pancreatic carcinoma.

The nurse identifies a potential collaborative problem of electrolyte imbalance for a client with severe acute pancreatitis. Which assessment finding alerts the nurse to an electrolyte imbalance associated with acute pancreatitis? Muscle twitching and finger numbness Paralytic ileus and abdominal distention Hypotension Elevated blood glucose concentration

Muscle twitching and finger numbness Explanation: Muscle twitching and finger numbness indicate hypocalcemia, a potential complication of acute pancreatitis. Calcium may be prescribed to prevent or treat tetany, which may result from calcium losses into retroperitoneal (peripancreatic) exudate. The other data indicate other complications of acute pancreatitis but are not indicators of electrolyte imbalance.

Over the past 2 years, a 51-year-old man has been admitted to the hospital five times for problems related to alcohol abuse, including falls, acute alcohol withdrawal, and cirrhosis. The man's current admission has been precipitated by signs and symptoms of alcoholic liver disease (ALD). The care team is reasonably pleased with the patient's recovery to this point and discharge planning has begun. When organizing the patient's discharge planning, what psychosocial nursing diagnosis should be prioritized? Risk for altered family processes Risk for ineffective coping Risk for ineffective management of therapeutic regimen Risk for altered growth and development

Risk for ineffective management of therapeutic regimen Explanation: Abstinence from alcohol use is critical for patients who are to recover from ALD; a failure to adhere to this aspect of the therapeutic regimen is likely to result in death. As a result, this is prioritized over family processes, growth and development, and coping, even though each of these issues is likely relevant to the patient's circumstances.

A preoperative client scheduled to have an open cholecystectomy says to the nurse, "The doctor said that after surgery, I will have a tube in my nose that goes into my stomach. Why do I need that?" What most common reason for a client having a nasogastric tube in place after abdominal surgery should the nurse include in a response? decompression instillation gavage lavage

decompression Explanation: Negative pressure exerted through a tube inserted in the stomach removes secretions and gaseous substances from the stomach, preventing abdominal distention, nausea, and vomiting. Instillations in a nasogastric tube after surgery are done when necessary to promote patency; this is not the most common purpose of a nasogastric tube after surgery. Gavage is contraindicated after abdominal surgery until peristalsis returns. Lavage after surgery may be done to promote hemostasis in the presence of gastric bleeding, but this is not the most common purpose of a nasogastric tube after surgery.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: elevated liver enzymes and low serum protein level. subnormal serum glucose and elevated serum ammonia levels. subnormal clotting factors and platelet count. elevated blood urea nitrogen and creatinine levels and hyperglycemia.

subnormal serum glucose and elevated serum ammonia levels. Explanation: In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.