QUIZLET Ch. 50 (MED SURG) 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. black, tarry stools. circumoral pallor.

yellow sclerae.

Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit?

Pancreatitis

A nurse cares for a client with interstitial pancreatitis. What client teaching will the nurse include when planning care for the client? "Inflammation is confined to only the pancreas." "Normal function returns after about 2 weeks." "Tissue necrosis occurs within the pancreas." "Inflammation spreads to the surrounding glands."

"Tissue necrosis occurs within the pancreas."

A patient is receiving pharmacologic therapy with ursodeoxycholic acid or chenodeoxycholic-cholic acid for treatment of small gallstones. The patient asks the nurse how long the therapy will take to dissolve the stones. What is the best answer the nurse can give? 6 to 12 months 6 to 8 months 3 to 5 months 1 to 2 months

6 to 12 months

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? Imbalanced nutrition: Less than body requirements related to biliary inflammation Acute pain related to biliary spasms Deficient knowledge related to prevention of disease recurrence Anxiety related to unknown outcome of hospitalization

Acute pain related to biliary spasms

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?

Administering

Which intervention should be included in the plan of care for a client who has undergone a cholecystectomy? Clamping the T-tube immediately after surgery Assessing the color of the sclera every shift Placing the client in the semi-Fowler position immediately after surgery Placing the client on NPO (nothing by mouth) status for 2 days after surgery

Assessing the color of the sclera every shift

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

Cholelithiasis

A patient is admitted to the hospital with a possible common bile duct obstruction. What clinical manifestations does the nurse understand are indicators of this problem? (Select all that apply.) Pain in the left upper abdominal quadrant Jaundice Clay-colored feces Amber-colored urine Pruritus

Clay-colored feces Pruritus Jaundice

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

Clay-colored stools

The nurse is caring for a client with suspected chronic pancreatitis. Which diagnostic test or imaging does the nurse recognize as the most useful in diagnosing this condition? CT Ultrasound MRI ERCP

ERCP

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find? Increased serum calcium levels Decreased white blood cell count Decreased liver enzyme levels Elevated urine amylase levels

Elevated urine amylase levels

A nurse is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the: Duodenum Gallbladder Cystic duct Common bile duct

Gallbladder

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

History of pancreatitis

Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? White rice Mashed potatoes Vanilla pudding Hot roast beef sandwich with gravy

Hot roast beef sandwich with gravy

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

Measure blood glucose concentration every 4 to 6 hours rationale: 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 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? Paralytic ileus and abdominal distention Muscle twitching and finger numbness Hypotension Elevated blood glucose concentration

Muscle twitching and finger numbness

A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm the diagnosis of acute pancreatitis? Presence of blood in the client's stool and recent hypertension Presence of easy bruising and bradycardia Pain with abdominal distention and hypotension Adventitious breath sounds and hypertension

Pain with abdominal distention and hypotension

The nurse cares for a client with cholecystitis with severe biliary colic symptoms. Which nursing intervention best promotes adequate respirations in a client with these symptoms? Place the client in semi-Fowler's position. Instruct the client on the proper use of an incentive spirometer. Encourage the client to ambulate frequently. Encourage the client to deep breathe and cough.

Place the client in semi-Fowler's position.

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? Teaching about the disease and its treatment Preventing fluid volume overload Maintaining adequate nutritional status Relieving abdominal pain

Relieving abdominal pain

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? Reposition the client every 2 hours. Instruct the client to avoid coughing. Monitor pulse oximetry every hour. Withhold oral feedings for the client.

Reposition the client every 2 hours.

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

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 has developed renal failure. The patient is developing a paralytic ileus. The patient requires more pain medication. The patient has developed peritonitis.

The patient has developed peritonitis.

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 has developed peritonitis. Rationale: The patient has developed peritonitis.

The physician has written the following orders for a new client admitted with pancreatitis: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) . Which does the nurse attribute as the reason for NPO status? To drain the pancreatic bed To aid opening up of pancreatic duct To avoid inflammation of the pancreas To prevent the occurrence of fibrosis

To avoid inflammation of the pancreas

The nurse knows that the client with cholelithiasis can have a nutritional deficiency. The obstruction of bile flow due to cholelithiasis can interfere with the absorption of Vitamin B12 Vitamin A Vitamin C Vitamin B6

Vitamin A

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 reduce gastric and pancreatic secretions To depress the central nervous system and increase the pain threshold To relieve nausea and vomiting

To reduce gastric and pancreatic secretions

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? Vitamin K Potassium Vitamin B Oral bile acids

Vitamin K

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 Hypertension Fatigue

Weight loss

The digestion of carbohydrates is aided by secretin. amylase. lipase. trypsin.

amylase Amylase is secreted by the exocrine pancreas. Lipase aids in the digestion of fats. Trypsin aids in the digestion of proteins. Secretin is the major stimulus for increased bicarbonate secretion from the pancrea

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients:

cannot tolerate high-glucose concentration.

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 gavage lavage instillation

decompression

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

mg

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

Acute pain related to biliary spasms