RHCH 43 ,44 Liver, Pancreas, portal HTN, peritonitis

a patient with pancreatic cancer is admitted to the hospital for evaluation of possible treatment options. the patient asks the nurse to explain the Whipple procedure that the surgeon has described. the explanation includes the information that a Whipple procedure involves a. creating bypass around the obstruction cause by the tumor by joining the gallbladder to the jejunum b. ressection of the entire pancreas and the distal portion of the stomach, with anastomosis of the common bile duct and stomach into the duodenum c. removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with joining of the pancreatic duct, common bile duct, and stomach into the jejunum d. radical removal of the pancreas, duodenum, and spleen, and attaching the stomach to the jejunum, which requires oral supplementation of pancreatic digestive enzymes and insulin replacement therapy

c. removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with joining of the pancreatic duct, common bile duct, and stomach into the jejunum

A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply. 1. Preventing constipation. 2. Administering lactulose (Cephulac). 3. Monitoring coordination while walking. 4. Checking the pupil reaction. 5. Providing food and fluids high in carbohydrate. 6. Encouraging physical activity.

1, 2, 3, 4, 5. Constipation leads to increased ammonia production. Lactulose (Cephulac) is a hyperosmotic laxative that reduces blood ammonia by acidifying the colon contents, which retards diffusion of nonionic ammonia from the colon to the blood while promoting its migration from the blood to the colon. Hepatic encephalopathy is considered a toxic or metabolic condition that causes cerebral edema; it affects a person's coordination and pupil reaction to light and accommodation. Food and fluids high in carbohydrates should be given because the liver is not synthesizing and storing glucose. Because exercise produces ammonia as a byproduct of metabolism, physical activity should be limited, not encouraged.

The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply. 1. Administration of intravenous Octreotide (Sandostatin). 2. Endoscopy. 3. Administration of a blood product. 4. Minnesota tube insertion. 5. Transjugular intrahepatic portosystemic shunt (TIPS) procedure. 6. Immediate endotracheal intubation

1, 2, 3. The management of bleeding esophageal varices involves endoscopic therapy and drug therapy with octreotide, vasopressin, nitroglycerin, or beta blockers to lower portal hypertension and decompress the varices. I.V. access is needed for octreotide and potential blood product administration due to blood loss or altered clotting factors. A patent airway should be maintained, but intubation is not needed for clients with adequate ventilation and oxygenation. Balloon tamponade is used if variceal hemorrhage cannot be controlled by endoscopy. A TIPS procedure may be considered after a second major bleed to redirect portal blood flow away from the varices. ****

When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which of the following nursing interventions would be most appropriate for this client? Select all that apply. 1. Placing the client in a side-lying position. 2. Administering morphine sulfate for pain as needed. 3. Maintaining the client on a high-calorie, high-protein diet. 4. Monitoring the client's respiratory status. 5. Obtaining daily weights.

1, 4, 5. The client with acute pancreatitis usually experiences acute abdominal pain. Placing the client in a side-lying position relieves the tension on the abdominal area and promotes comfort. A semi Fowler's position is also appropriate. The nurse should also monitor the client's respiratory status because clients with pancreatitis are prone to develop respiratory complications. Daily weights are obtained to monitor the client's nutritional and fluid volume status. While the client will likely need opioid analgesics to treat the pain, morphine sulfate is not appropriate as it stimulates spasm of the sphincter of Oddi, thus increasing the client's discomfort. During the acute phase of the illness while the client is experiencing pain, the pancreas is rested by withholding food and drink. When the diet is reintroduced, it is a high-carbohydrate, low-fat, bland diet.

A client with a Sengstaken-Blakemore tube has a sudden drop in SpO2 and increase in respiratory rate to 40 breaths/minute. The nurse should do which of the following in order from first to last? 1. Affirm airway obstruction by the tube. 2. Remove the tube. 3. Deflate the tube by cutting with bedside scissors. 4. Apply oxygen via face mask.

1. Affirm airway obstruction by the tube. 3. Deflate the tube by cutting with bedside scis¬sors. 2. Remove the tube. 4. Apply oxygen via face mask. The nurse should first assess the client to determine if the tube is obstructing the airway; assessment is done by assessing air flow. Once obstruction is established, the tube should be deflated and then quickly removed. A set of scissors should always be at the bedside to allow for emergency deflation of the balloon. Oxygen via face mask should then be applied once the tube is removed.

A client with cirrhosis is receiving Lactulose (Cephulac). During the assessment the nurse notes increased confusion and asterixis. The nurse should: 1. Assess for GI bleeding. 2. Hold the Lactulose (Cephulac). 3. Increase protein in the diet. 4. Monitor serum bilirubin levels.

1. Assess for GI bleeding. Clients with cirrhosis can develop hepatic encephalopathy caused by increased ammonia levels. Asterixis, a flapping tremor, is a characteristic symptom of increased ammonia levels. Bacterial action on increased protein in the bowel will increase ammonia levels and cause the encephalopathy to worsen. GI bleeding and protein consumed in the diet increases protein in the intestine and can elevate ammonia levels. Lactulose is given to reduce ammonia formation in the intestine and should not be held since neurological symptoms are worsening. Bilirubin is associated with jaundice.

Which of the following dietary instructions would be appropriate for the nurse to give a client who is recovering from acute pancreatitis? 1. Avoid crash dieting. 2. Restrict carbohydrate intake. 3. Eat six small meals a day. 4. Decrease sodium in the diet.

1. Avoid crash dieting. Crash dieting or bingeing may cause an acute attack of pancreatitis and should be avoided. Carbohydrate intake should be increased because carbohydrates are less stimulating to the pancreas. There is no need to maintain a dietary pattern of six meals a day; the client can eat whenever desired. There is no need to place the client on a sodium-restricted diet because pancreatitis does not promote fluid retention.

The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing? 1. Decreased mental status. 2. Elevated blood pressure. 3. Decreased urine output. 4. Labored respirations.

1. Decreased mental status. The client should be monitored closely for changes in mental status. Ammonia has a toxic effect on central nervous system tissue and produces an altered level of consciousness, marked by drowsiness and irritability. If this process is unchecked, the client may lapse into coma. Increasing ammonia levels are not detected by changes in blood pressure, urine output, or respirations. *****

Which of the following medications would the nurse question for a client with acute pancreatitis? 1. Furosemide (Lasix) 20 mg I.V. push. 2. Imipenem (Primaxin) 500 mg I.V. 3. Morphine Sulfate 2 mg I.V. push. 4. Famotidine (Pepcid) 20 mg I.V. push.

1. Furosemide (Lasix) 20 mg I.V. push. Furosemide (Lasix) can cause pancreatitis. Additionally, hypovolemia can develop with acute pancreatitis and Lasix will further delete fluid volume. Imipenem is indicated in the treatment of acute pancreatitis with necrosis and infection. Research no longer supports Meperidine (Demerol) over other opiates. Morphine and Dilaudid are opiates of choice in acute pancreatitis to get pain under control. Famotidine is a Histamine 2 receptor antagonist used to decrease acid secretion and prevent stress or peptic ulcers.

The nurse is preparing a client for a paracentesis. The nurse should: 1. Have the client void immediately before the procedure. 2. Place the client in a side-lying position. 3. Initiate an I.V. line to administer sedatives. 4. Place the client on nothing-by-mouth (NPO) status 6 hours before the procedure.

1. Have the client void immediately before the procedure. Immediately before a paracentesis, the client should empty the bladder to prevent perforation. The client will be placed in a high Fowler's position or seated on the side of the bed for the procedure. I.V. sedatives are not usually administered. The client does not need to be NPO.

What diet should be implemented for a client who is in the early stages of cirrhosis? 1. High-calorie, high-carbohydrate. 2. High-protein, low-fat. 3. Low-fat, low-protein. 4. High-carbohydrate, low-sodium.

1. High-calorie, high-carbohydrate. For clients who have cirrhosis without complications, a high-calorie, high-carbohydrate diet is preferred to provide an adequate supply of nutrients. In the early stages of cirrhosis, there is no need to restrict fat, protein, or sodium.

A client is receiving Propantheline bromide (Pro-Banthine) in the management of acute pancreatitis. Which of the following would indicate that the nurse should withhold the medication? 1. Absent bowel sounds. 2. Increased urine output. 3. Diarrhea. 4. Decreased heart rate.

1. Propantheline is an anticholinergic, anti-spasmodic medication that decreases vagal stimulation and pancreatic secretions. It is contraindicated in paralytic ileus, therefore the nurse should be concerned with the absent bowel sounds. Side effects are urinary retention, constipation, and tachycardia.

A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition? 1. Ranson's criteria. 2. Vital signs. 3. Urine output. 4. Glasgow Coma Scale.

1. Ranson's criteria. The elevated amylase and lipase and symptoms suggest acute pancreatitis. Ranson's criteria is a clinical predictor scale used to assess the severity of acute pancreatitis and prognosis. Vital signs are used to evaluate hemodynamic stability. Urine output is monitored for assessment of fluid volume status. Glasgow Coma Scale (GCS) is a neurological scale to assess the level of consciousness.

The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms? 1. The client may be developing hypocalcemia. 2. The client is experiencing a reaction to meperidine (Demerol). 3. The client has a nutritional imbalance. 4. The client needs a muscle relaxant to help him rest.

1. The client may be developing hypocalcemia. Hypocalcemia develops in severe cases of acute pancreatitis. The exact cause is unknown. Signs and symptoms of hypocalcemia include jerking and muscle twitching, numbness of fingers and lips, and irritability. Meperidine (Demerol) may cause tremors or seizures as an adverse effect, but not muscle twitching. Muscle twitching is not caused by a nutritional deficit, nor does it indicate that the client needs a muscle relaxant.

The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician? 1. The client's daily record indicates a 3 kg weight gain over 2 days. 2. The client is complaining of nausea. 3. The client has a temperature of 99° F orally. 4. The client has fatigue.

1. The client's daily record indicates a 3 kg weight gain over 2 days. The fluid weight gain is of concern since the drug should be used with caution with impaired renal function. Dosage adjustment may be needed with renal insufficiency since the drug is excreted in the urine. Nausea, mild temperature elevation, and fatigue are symptoms that should be monitored, but are associated with hepatitis.

The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that: 1. There is a strong link between alcohol use and acute pancreatitis. 2. Alcohol intake can interfere with the tests used to diagnose pancreatitis. 3. Alcoholism is a major health problem, and all clients are questioned about alcohol intake. 4. The physician must obtain the pertinent facts, regardless of religious beliefs.

1. There is a strong link between alcohol use and acute pancreatitis. Alcoholism is a major cause of acute pancreatitis in the United States. Because some clients are reluctant to discuss alcohol use, staff may inquire about it in several ways. Generally, alcohol intake does not interfere with the tests used to diagnose pancreatitis. Recent ingestion of large amounts of alcohol, however, may cause an increased serum amylase level. Large amounts of ethyl and methyl alcohol may produce an elevated urinary amylase concentration. All clients are asked about alcohol and drug use on hospital admission, but this information is especially pertinent for clients with pancreatitis. Physicians do need to seek facts, but this can be done while respecting the client's religious beliefs. Respecting religious beliefs is important in providing holistic client care.

A client with acute pancreatitis has a blood pressure of 88/40, heart rate of 128 beats per minute, respirations of 28 per minute, and Grey Turner's sign. What action should the nurse perform first? 1. Assess the urine output. 2. Place an intravenous line. 3. Position on the left side. 4. Insert a nasogastric tube.

2. Place an intravenous line. Grey Turner's sign is a bluish discoloration in the flank area caused by retroperitoneal bleeding. The vital signs are showing hemodynamic instability. I.V. access should be obtained to provide immediate volume replacement. The urine output will provide information on the fluid status. A nasogastric tube is indicated for clients with uncontrolled nausea and vomiting or gastric distension. Repositioning the client may be considered for pain management once the client's vital signs are stable.

The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis? 1. Severity of intestinal hemorrhage. 2. Vasodilating effects of kinin peptides. 3. Tendency toward heart failure. 4. Frequent incidence of acute tubular necrosis.

2. Vasodilating effects of kinin peptides. Life-threatening shock is a potential complication of pancreatitis. Kinin peptides activated by the trapped trypsin cause vasodilation and increased capillary permeability. These effects exacerbate shock and are not easily reversed with pharmacologic agents such as vasopressors. Hemorrhage may occur into the pancreas, but not in the intestines. Systemic complications include pulmonary complications, but not heart failure or acute tubular necrosis.

Pancreatic enzyme replacements are ordered for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect? 1. Three times daily between meals. 2. With each meal and snack. 3. In the morning and at bedtime. 4. Every 4 hours, at specified times.

2. With each meal and snack. In chronic pancreatitis, destruction of pancreatic tissue requires pancreatic enzyme replacement. Pancreatic enzymes are prescribed to facilitate the digestion of proteins and fats and should be taken in conjunction with every meal and snack. Specified hours or limited times for administration are ineffective because the enzymes must be taken in conjunction with food ingestion.

A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects? 1. Constipation. 2. Hyperkalemia. 3. Irregular pulse. 4. Dysuria.

2.Hyperkalemia. Spironolactone (Aldactone) is a potassium-sparing diuretic; therefore, clients should be monitored closely for hyperkalemia. Other common adverse effects include abdominal cramping, diarrhea, dizziness, headache, and rash. Constipation and dysuria are not common adverse effects of spironolactone. An irregular pulse is not an adverse effect of spironolactone but could develop if serum potassium levels are not closely monitored.

The nurse is providing discharge instructions for a client with cirrhosis. Which of the following statements best indicates that the client has understood the teaching? 1. "I should eat a high-protein, high-carbohydrate diet to provide energy." 2. "It is safer for me to take acetaminophen (Tylenol) for pain instead of aspirin." 3. "I should avoid constipation to decrease chances of bleeding." 4. "If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured."

3. "I should avoid constipation to decrease chances of bleeding." Clients with cirrhosis should be instructed to avoid constipation and straining at stool to prevent hemorrhage. The client with cirrhosis has bleeding tendencies because of the liver's inability to produce clotting factors. A low-protein and high-carbohydrate diet is recommended. Clients with cirrhosis should not take acetaminophen (Tylenol), which is potentially hepatotoxic. Aspirin also should be avoided if esophageal varices are present. Cirrhosis is a chronic disease. *******

The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate? 1. Peripheral edema. 2. Ascites. 3. Anorexia. 4. Jaundice.

3. Anorexia. Early clinical manifestations of cirrhosis are subtle and usually include gastrointestinal symptoms, such as anorexia, nausea, vomiting, and changes in bowel patterns. These changes are caused by the liver's altered ability to metabolize carbohydrates, proteins, and fats. Peripheral edema, ascites, and jaundice are later signs of liver failure and portal hypertension. ****

The physician orders oral neomycin (Mycifradin) as well as a neomycin enema for a client with cirrhosis. The expected outcome of this therapy is to: 1. Reduce abdominal pressure. 2. Prevent straining during defecation. 3. Block ammonia formation. 4. Reduce bleeding within the intestine.

3. Block ammonia formation. Neomycin (Mycifradin) is administered to decrease the bacterial action on protein in the intestines, which results in ammonia production. This ammonia, if not detoxified by the liver, can result in hepatic encephalopathy and coma. The antibiotic does not reduce abdominal pressure, prevent straining during defecation, or decrease hemorrhaging within the intestine.

A client's serum ammonia level is elevated, and the physician orders 30 mL of lactulose (Cephulac). Which of the following is an adverse effect of this drug? 1. Increased urine output. 2. Improved level of consciousness. 3. Increased bowel movements. 4. Nausea and vomiting.

3. Increased bowel movements. Lactulose (Cephulac) increases intestinal motility, thereby trapping and expelling ammonia in the feces. An increase in the number of bowel movements is expected as an adverse effect. Lactulose does not affect urine output. Any improvements in mental status would be the result of increased ammonia elimination, not an adverse effect of the drug. Nausea and vomiting are not common adverse effects of lactulose.

The nurse should teach the client with chronic pancreatitis to monitor the effectiveness of pancreatic enzyme replacement therapy by doing which of the following? 1. Monitoring fluid intake. 2. Performing regular glucose fingerstick tests. 3. Observing stools for steatorrhea. 4. Testing urine for ketones.

3. Observing stools for steatorrhea. If the dosage and administration of pancreatic enzymes are adequate, the client's stool will be relatively normal. Any increase in odor or fat content would indicate the need for dosage adjustment. Stable body weight would be another indirect indicator. Fluid intake does not affect enzyme replacement therapy. If diabetes has developed, the client will need to monitor glucose levels. However, glucose and ketone levels are not affected by pancreatic enzyme therapy and would not indicate effectiveness of the therapy.

The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the physician of a decrease in which lab serum that is a potential precipitating factor for hepatic encephalopathy? 1. Aldosterone. 2. Creatinine. 3. Potassium. 4. Protein.

3. Potassium. Hypokalemia is a precipitating factor in hepatic encephalopathy. A decrease in creatinine results from muscle atrophy; an increase in creatinine would indicate renal insufficiency. With liver dysfunction increased aldosterone levels are seen. A decrease in serum protein will decrease colloid osmotic pressure and promote edema.

A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process? 1. "He must have been eating too many foods with salt in them. Salt pulls water with it." 2. "The swelling in his ankles must have moved up closer to his heart so the fluid circulates better." 3. "He must have forgotten to take his daily water pill." 4. "Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels."

4. "Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels." Portal hypertension and hypoalbuminemia as a result of cirrhosis cause a fluid shift into the peritoneal space causing ascites. In a cardiac or kidney problem, not cirrhosis, sodium can promote edema formation and subsequent decreased urine output. Edema does not migrate upward toward the heart to enhance its circulation. Although diuretics promote the excretion of excess fluid, occasionally forgetting or omitting a dose will not yield the ascites found in cirrhosis of the liver. *****

The client with chronic pancreatitis should be monitored closely for the development of which of the following disorders? 1. Cholelithiasis. 2. Hepatitis. 3. Irritable bowel syndrome. 4. Diabetes mellitus.

4. Diabetes mellitus. Clients with chronic pancreatitis are likely to develop diabetes as a result of the pancreatic fibrosis that occurs. The pancreas becomes unable to secrete insulin. Cholelithiasis, hepatitis, and irritable bowel syndrome are not caused by chronic pancreatitis.

The nurse should monitor the client with acute pancreatitis for which of the following complications? 1. Heart failure. 2. Duodenal ulcer. 3. Cirrhosis. 4. Pneumonia.

4. Pneumonia. The client with acute pancreatitis is prone to complications associated with the respiratory system. Pneumonia, atelectasis, and pleural effusion are examples of respiratory complications that can develop as a result of pancreatic enzyme exudate. Pancreatitis does not cause heart failure, ulcer formation, or cirrhosis.

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

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

A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Insert a urinary catheter to drainage. b. Infuse metronidazole (Flagyl) 500 mg IV. c. Send the patient for a computerized tomography scan. d. Place a nasogastric (NG) tube to intermittent low suction.

ANS: B Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.

A 49-year-old female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective? a. The patient reports no chest pain. b. Blood pressure is 140/90 mm Hg. c. Stools test negative for occult blood. d. The apical pulse rate is 68 beats/minute.

ANS: C Because the purpose of β-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.

The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is the highest priority? a. Offer psychologic support for depression. b. Offer high-calorie, high-protein dietary choices. c. Administer prescribed opioids to relieve pain as needed. d. Teach about the need to avoid scratching any pruritic areas.

ANS: C Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to teaching, or manage anxiety or depression.

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

ANS: C Esophageal varices are dilated submucosal veins. The therapeutic action of H2-receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purposes for H2-receptor blockade in this patient.

In reviewing the medical record shown in the accompanying figure for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullen's sign. Indicate the area where the nurse will assess for this change. a. 1 b. 2 c. 3 d. 4

ANS: C The area around the umbilicus should be indicated. Cullen's sign consists of ecchymosis around the umbilicus. Cullen's sign occurs because of seepage of bloody exudates from the inflamed pancreas and indicates severe acute pancreatitis.

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

ANS: C This patient's history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.

Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

ANS: D A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications.

21. The nurse will ask a 64-year-old patient being admitted with acute pancreatitis specifically about a history of a. diabetes mellitus. b. high-protein diet. c. cigarette smoking. d. alcohol consumption.

ANS: D Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.

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

ANS: D Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings should also be reported to the health care provider, they do not indicate complications that require rapid action.

A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.

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

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

ANS: D TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.

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

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

Which patient should the nurse assess first after receiving change-of-shift report? a. 60-year-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b. 50-year-old patient with familial adenomatous polyposis who has occult blood in the stool c. 40-year-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. 30-year-old patient who has abdominal distention and an apical heart rate of 136 beats/minute

ANS: D The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should also be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.

NCLEX review question A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings?

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

NCLEX review question The patient with suspected pancreatic cancer is having many diagnostic studies done. Which one can be used to establish the diagnosis of pancreatic denocarcinoma and for monitoring the response to treatment?

Cancer-associated antigen 19-9 Rationale: The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment. Although a spiral CT scan may be the initial study done and provides information on metastasis and vascular involvement, this test and the PET/CT scan or abdominal ultrasound do not provide additional information.

A patient with pancreatic cancer is admitted to the hospital for evaluation of possible treatment options. The patient asks the nurse to explain the Whipple procedure that the surgeon has described. The explanation includes the information that a Whipple procedure involves removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with joining of the pancreatic duct, the common bile duct, and the stomach into the jejunum

-The classic operation for pancreatic cancer is a radical pancreaticoduodenectomy, or Whipple procedure. This entails resection of the proximal pancreas (i.e., proximal pancreatectomy), the adjoining duodenum (i.e., duodenectomy), the distal portion of the stomach (i.e., partial gastrectomy), and the distal segment of the common bile duct. The pancreatic duct, common bile duct, and stomach are anastomosed to the jejunum-

A client is admitted with acute necrotizing pancreatitis. Lab results have been obtained and a peripheral I.V. has been inserted. Which of the following orders from a health care provider should the nurse question? 1. Infuse a 500 mL normal saline bolus. 2. Calcium gluconate 90 mg in 100 mL NS. 3. Total parenteral nutrition (TPN) at 72 mL/ hour. 4. Placement of a Foley catheter.

3. Total parenteral nutrition (TPN) at 72 mL/ hour. Clients with acute necrotizing pancreatitis should remain NPO with early enteral feeding via the jejunum to maintain bowel integrity and immune function. TPN is considered if enteral feedings are contraindicated. Access is also needed for TPN, preferably via a central line. Hemodynamic instability can result from fluid volume loss and bleeding and requires fluid and electrolyte replacement. Fat necrosis occurring with acute pancreatitis can cause hypocalcemia requiring calcium replacement. A Foley catheter provides accurate output assessment to monitor for prerenal acute renal failure that can occur from hypovolemia.

NCLEX pre-test question The nurse is caring for a group of patients. Which patient is at highest risk for pancreatic cancer?

A 72-year-old African American male who has smoked cigarettes for 50 years Rationale: Risk factors for pancreatic cancer include chronic pancreatitis, diabetes mellitus, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine. African Americans have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are two or three times more likely to develop pancreatic cancer as compared with nonsmokers. The risk is related to duration and number of cigarettes smoked.

The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is a. maintaining normal respiratory function. b. expressing satisfaction with pain control. c. developing no ongoing pancreatic disease. d. having adequate fluid and electrolyte balance.

ANS: A Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the following findings is the priority to be reported to the provider? A. History of cholelithiasis B. Serum amylase levels three times greater than the expected value C. Client report of severe pain radiating to the back that is rated at an "8" D. Hand spasms present when blood pressure is checked

B. CORRECT: The client should drink a full glass of water following administration of pancrelipase.

A nurse is reviewing the health record of a client who has pancreatitis. The physical exam report by the provider indicates the presence of Cullen's sign. Which of the following is an appropriate action by the nurse to identify this finding? A. Tap lightly at the costovertebral margin on the client's back. B. Palpate the client's right lower quadrant. C. Inspect the skin around the umbilicus. D. Auscultate the area below the client's scapula.

C. CORRECT: Cullen's sign is indicated by a bluish-grey discoloration in the periumbilical area.

A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following is an expected finding? A. Pain in right upper quadrant radiating to right shoulder B. Report of pain being worse when sitting upright C. Pain relieved with defecation D. Epigastric pain radiating to left shoulder

D. CORRECT: A client who has pancreatitis will report severe, boring epigastric pain that radiates to the back, left flank, or left shoulder.

What is the #1 cause of pancreatitis?

Gallbladder disease ?????? (alcohol abuse is #2)

The nurse explains to a patient with an episode of acute pancreatitis that the most effective means of relieving pain by suppressing pancreatic secretions is the use of: NPO status

Rationale: Pain from acute pancreatitis is aggravated by eating; NPO status will help to alleviate the pain by decreasing pancreatic secretions

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

a. checking for signs of hypocalcemia e. monitoring for infections, particularly respiratory infection

the nurse explaining to the patient with acute pancreatitis that the most common pathogenic mechanism of the disorder is a. cellular disorganization b. overproduction of enzymes c. lack of secretion of enzymes d. autodigestion of the pancreas

d. autodigestion of the pancreas

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

b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space

To prepare a 56-year-old male patient with ascites for paracentesis, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.

ANS: C The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.

A female patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough.

ANS: A There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patient's discomfort.

A 53-year-old patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Monitor the patient for shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea.

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

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

ANS: B The protein in the blood in the gastrointestinal (GI) tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode.

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62-year-old female patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium

ANS: C Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.

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

ANS: C Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.

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

ANS: C The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse checks the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.

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

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

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

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

The nurse is caring for a group of patients. Which patient is at highest risk for pancreatic cancer? A. A 38-year-old Hispanic female who is obese and has hyperinsulinemia B. A 23-year-old who has cystic fibrosis-related pancreatic enzyme insufficiency Incorrect C. A 72-year-old African American male who has smoked cigarettes for 50 years D. A 19-year-old who has a 5-year history of uncontrolled type 1 diabetes mellitus

C. A 72-year-old African American male who has smoked cigarettes for 50 years Risk factors for pancreatic cancer include chronic pancreatitis, diabetes mellitus, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine. African Americans have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are two or three times more likely to develop pancreatic cancer as compared with nonsmokers. The risk is related to duration and number of cigarettes smoked.

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

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

A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client requires further teaching? A. "I plan to eat small, frequent meals." B. "I will eat easy-to-digest foods with limited spice." C. "I will use skim milk when cooking." D. "I plan to drink regular cola."

D. CORRECT: Caffeine-free beverages are recommended for the client who has pancreatitis. Regular cola contains caffeine.

The patient with suspected pancreatic cancer is having many diagnostic studies done. Which one can be used to establish the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment? A. Spiral CT scan B. A PET/CT scan C. Abdominal ultrasound D. Cancer-associated antigen 19-9

D. Cancer-associated antigen 19-9 The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment. Although a spiral CT scan may be the initial study done and provides information on metastasis and vascular involvement, this test and the PET/CT scan or abdominal ultrasound do not provide additional information.

NCLEX review question The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care?

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

NCLEX pre-test question The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit?

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

NCLEX review question The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)? - There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. - Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. - Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity.

Rationale: The ascites related to cirrhosis are caused by decreased colloid oncotic pressure from the lack of albumin from liver inability to synthesize it and the portal hypertension that shifts the protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not directly contribute to ascites.

The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space

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

Nursing management of the patient with acute pancreatitis includes (select all that apply) checking for signs of hypocalcemia giving insulin based on a sliding scale

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