Biliary Disorders

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

Which dietary modification is used for a client diagnosed with acute pancreatitis?

Elimination of coffee A high-carbohydrate, low-fat, and low-protein diet should be implemented. Alcohol, caffeine, and spicy foods should be avoided.

Which of the following would be most appropriate for a client who is experiencing biliary colic?

Ensure that the client rests.

A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system?

Maintain the client in a semi-Fowler's position.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

Positioning the client on the side with the knees flexed 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.

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

Which condition is most likely to have a nursing diagnosis of fluid volume deficit?

pancreatitis

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?

packed red blood cells

When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions?

Frequent changes of positions

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.

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 ?

30 mg/dL

Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones ?

7 months

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal painLaboratory 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 morphine IV as ordered

A nursing student has been assigned to care for a client with pancreatic cancer. The student is aware that the risk for pancreatic cancer is most directly proportional to

Age

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?

Bile-stained vomiting 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 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

What is the most appropriate nursing diagnosis for the client with acute pancreatitis?

Deficient fluid volume

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

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?

Hot roast beef sandwich with gravy

A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority?

Impaired nutrition: less than body requirements

A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guardingthe abdomen is board-like and no bowel sounds are detected. What is the major concern for this patient?

Peritonitis has developed

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

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 avoid inflammation of the pancreas

The nurse is caring for a patient with acute pancreatitis. The patient has an order fo anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason ?

To reduce gas and pancreatic secretions

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note :

Yellow sclerae

A client with suspected biliary obstruction due to gallstones reports changes to the color of his stools. Which stool color does the nurse recognize as common to biliary obstruction?

gray

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 amylase

The nurse should assess for an important early indicator of acute pancreatitis. What prolonged and elevated level would the nurse determine is an early indicator?

serum lipase