Chapter 44

Combined with clinical manifestations, what is the laboratory finding that is most commonly used to diagnose acute pancreatitis? a. Increased serum calcium c. Increased urinary amylase b. Increased serum amylase d. Decreased serum glucose

. Although serum lipase levels and urinary amylase levels are increased, an increased serum amylase level is the criterion most commonly used to diagnose acute pancreatitis in the first 24 to 72 hours. Serum calcium levels are decreased.

A patient was diagnosed with nonalcoholic fatty liver disease (NAFLD). What treatment measures should the nurse plan to teach the patient about (select all that apply)? a. Weight loss b. Diabetes management c. Ulcerative colitis dietary changes d. Dietary management of hyperlipidemia e. Maintaining blood pressure with increased sodium and fluid intake

. a, b, d. There is no treatment for nonalcoholic fatty liver disease (NAFLD) except to control the other diseases that are frequently diagnosed in these individuals. These measures include weight loss for obesity, control of blood glucose for diabetes, control of hyperlipidemia, and treating hypertension if it is present. Ulcerative colitis is unrelated to NAFLD.

A patient with advanced cirrhosis has a nursing diagnosis of imbalanced nutrition: less than body requirements related to anorexia and inadequate food intake. What would be an appropriate midday snack for the patient? a. Peanut butter and salt-free crackers c. Popcorn with salt-free butter and herbal seasoning b. A fresh tomato sandwich with salt-free butter d. Canned chicken noodle soup with low-protein bread

. b. The patient with advanced, complicated cirrhosis requires a high-calorie, high-carbohydrate diet with moderate to low fat. Patients with cirrhosis are at risk for edema and ascites and their sodium intake may be limited. The tomato sandwich with salt-free butter best meets these requirements. Rough foods, such as popcorn, may irritate the esophagus and stomach and lead to bleeding. Peanut butter is high in sodium and fat and canned chicken noodle soup is very high in sodium

Which conditions contribute to the formation of abdominal ascites? a. Esophageal varices contribute to 80% of variceal hemorrhages b. Increased colloidal oncotic pressure caused by decreased albumin production c. Hypoaldosteronism causes increased sodium reabsorption by the renal tubules d. Blood flow through the portal system is obstructed, which causes portal hypertension

. d. Blood flow through the portal system is obstructed and causes portal hypertension that increases the blood pressure in the portal venous system. Decreased albumin production leads to decreased serum colloidal oncotic pressure that contributes to ascites. Hyperaldosteronism increases sodium and water retention and contributes to increased fluid retention, hypokalemia, and decreased urinary output. The retained fluid has low oncotic colloidal pressure and it escapes into the interstitial spaces, causing peripheral edema. Portal hypertension also contributes to esophageal varices. Reduced renal blood flow and increased serum levels of antidiuretic hormone (ADH) also contribute to impaired water excretion and ascites.

The patient experienced a blood transfusion reaction. How should the nurse explain to the patient the cause of the hemolytic jaundice that occurred? a. Results from hepatocellular disease b. Due to a malaria parasite breaking apart red blood cells (RBCs) c. Results from decreased flow of bile through the liver or biliary system d. Due to increased breakdown of RBCs that caused elevated serum unconjugated bilirubin

. d. Hemolytic jaundice from a blood transfusion reaction is from increased breakdown of RBCs producing increased unconjugated bilirubin in the blood. Hepatocellular jaundice results from hepatocellular disease. Hemolytic jaundice occurs with malaria. Obstructive jaundice is from obstructed bile flow through the liver or biliary duct system

Malnutrition can be a big problem for patients with cirrhosis. Which nursing intervention can help to improve nutrient intake? a. Oral hygiene before meals and snacks c. Improve oral intake by feeding the patient b. Provide all foods the patient likes to eat d. Limit snack offers to when the patient is hungry

Oral hygiene may improve the patient's taste sensation. Food preferences are important but some foods may be restricted if the patient is on a low-sodium diet. The patient will feel more independent with self-feeding and will be more likely to increase intake by having someone sit with the patient while the patient eats. Snacks and supplements should be available whenever the patient desires them but should not be forced on the patient.

The patient has a diagnosis of a biliary obstruction from gallstones. What type of jaundice is the patient experiencing and what serum bilirubin results would be expected? a. Hemolytic jaundice with normal conjugated bilirubin b. Posthepatic icteris with decreased unconjugated bilirubin c. Obstructive jaundice with elevated unconjugated and conjugated bilirubin d. Hepatocellular jaundice with altered conjugated bilirubin in severe disease

c. Gallstones cause obstructive or posticteric jaundice and may elevate both conjugated and unconjugated bilirubin.

Of the following characteristics, identify those that are most commonly associated with cholelithiasis (select all that apply). a. Obesity b. Age over 40 c. Multiparous female d. History of excessive alcohol intake e. Family history of gallbladder disease f. Use of estrogen or oral contraceptives

a, b, c, e, f. Incidence of cholelithiasis is higher in women, multiparous women, persons over 40 years of age, and those with family history and obesity. Postmenopausal women taking estrogen therapy have a higher incidence than women taking oral contraceptives. Alcohol intake and diet do not increase the incidence of cholelithiasis.

The nurse is instructing a patient with chronic pancreatitis on measures to prevent further attacks. What information should be provided (select all that apply)? a. Avoid nicotine. b. Eat bland foods. c. Observe stools for steatorrhea. d. Eat high-fat, low-protein, high-carbohydrate meals. e. Take prescribed pancreatic enzymes immediately following meals.

a, b, c. Measures to prevent attacks of pancreatitis are those that decrease the stimulation of the pancreas. Lower fat intake and foods that are less stimulating and irritating (bland) should be encouraged. Higher carbohydrates are less stimulating. Avoid alcohol and nicotine, since both stimulate the pancreas. Monitor for steatorrhea to determine effectiveness of the enzymes and because it may indicate worsening pancreatic function. Pancreatic enzymes should be taken with, not after, meals.

. Acalculous cholecystitis is diagnosed in an older, critically ill patient. Which factors may be associated with this condition (select all that apply)? a. Fasting b. Hypothyroidism c. Parenteral nutrition d. Prolonged immobility e. Streptococcus pneumoniae f. Absence of bile in the intestine

a, c, d. Acalculous cholecystitis is associated with prolonged immobility, fasting, prolonged parenteral nutrition, and diabetes mellitus. Hypothyroidism, Streptococcus pneumoniae, and absence of bile in the intestine are unrelated to this condition.

. A patient was diagnosed with nonalcoholic fatty liver disease (NAFLD). What treatment measures should the nurse plan to teach the patient about (select all that apply)? a. Weight loss b. Diabetes management c. Ulcerative colitis dietary changes d. Dietary management of hyperlipidemia e. Maintaining blood pressure with increased sodium and fluid intake

a, c, d. The anemia of cirrhosis is related to overactivity of the enlarged spleen that removes blood cells from circulation. Vitamin B deficiencies from altered intake and metabolism of nutrients and decreased prothrombin production can increase bleeding tendencies. The other options do not contribute to anemia in the patient with cirrhosis.

What is one of the most challenging nursing interventions to promote healing in the patient with viral hepatitis? a. Providing adequate nutritional intake b. Promoting strict bed rest during the icteric phase c. Providing pain relief without using liver-metabolized drugs d. Providing quiet diversional activities during periods of fatigue

a. Adequate nutrition is especially important in promoting regeneration of liver cells but the anorexia of viral hepatitis is often severe, requiring creative and innovative nursing interventions. Strict bed rest is not usually required, and the patient usually has only minor discomfort with hepatitis. Diversional activities may be required to promote psychologic rest but not during periods of fatigue.

What treatment for acute cholecystitis will prevent further stimulation of the gallbladder? a. NPO with NG suction c. Administration of antiemetics b. Incisional cholecystectomy d. Administration of anticholinergics

a. NPO and nasogastric (NG) suction prevent gallbladder stimulation by food or fluids moving into the duodenum. Incisional choleycystectomy removes the gallbladder, not its stimulation. Administration of antiemetics decreases nausea and vomiting but does not decrease gallbladder stimulation. Anticholinergics counteract the smooth muscle spasms of the bile ducts to decrease pain.

What must the nurse do to care for a T-tube in a patient following a cholecystectomy? a. Keep the tube supported and free of kinks. b. Attach the tube to low, continuous suction. c. Clamp the tube when ambulating the patient. d. Irrigate the tube with 10-mL sterile saline every 2 to 4 hours.

a. The T-tube drains bile from the common bile duct until swelling from trauma has subsided and bile can freely enter the duodenum. The tube is placed to gravity drainage and should be kept open and free from kinks to prevent bile from backing up into the liver. The tube is not normally irrigated.

The patient with suspected gallbladder disease is scheduled for an ultrasound of the gallbladder. What should the nurse explain to the patient about this test? a. It is noninvasive and is a very reliable method of detecting gallstones. b. It is used only when other tests cannot be used because of allergy to contrast media. c. It will outline the gallbladder and the ductal system to enable visualization of stones. d. It is an adjunct to liver function tests to determine whether the gallbladder is inflamed.

a. Ultrasonography is 90% to 95% accurate in detecting gallstones and is a noninvasive procedure. An IV cholangiogram uses radiopaque dye to outline the gallbladder and the ducts. Liver function tests will be elevated if liver damage has occurred but do not indicate gallbladder disease.

The patient being treated with diuretics for ascites from cirrhosis must be monitored for (select all that apply)? a. GI bleeding d. Body image disturbances b. Hypokalemia e. Increased clotting tendencies c. Renal function

b, c. With diuretic therapy, fluid and electrolyte balance must be monitored; serum levels of sodium, potassium, chloride, and bicarbonate must be monitored, especially hypokalemia. Renal function must be monitored with blood urea nitrogen and serum creatinine. Water excess is manifested by muscle cramping, weakness, lethargy, and confusion. GI bleeding, body image disturbances, and bleeding tendencies seen with cirrhosis are not related to diuretic therapy.

Serologic findings in viral hepatitis include both the presence of viral antigens and antibodies produced in response to the viruses. What laboratory result indicates that the nurse is immune to HBV after vaccination? a. Anti-HBcIgG c. Surface antibody Anti-HBs b. Surface antigen HBsAg d. Core antigen Anti-HBcIgM

c. Immunization to HBV after vaccination is identified with the hepatitis B surface antibody Anti-HBs. Anti-HBcIgG indicates previous or ongoing HBV infection. Surface antigen HBsAg is present in acute and chronic infection. Core antigen Anti-HBcIgM indicates acute infection and does not appear after vaccination.

A patient with an obstruction of the common bile duct has clay-colored fatty stools, among other manifestations. What is the pathophysiologic change that causes this clinical manifestation? a. Soluble bilirubin in the blood excreted into the urine b. Absence of bile salts in the intestine and duodenum, preventing fat emulsion and digestion c. Contraction of the inflamed gallbladder and obstructed ducts, stimulated by cholecystokinin when fats enter the duodenum d. Obstruction of the common duct prevents bile drainage into the duodenum, resulting in congestion of bile in the liver and subsequent absorption into the blood

b. Absence of bile salts in the intestine and duodenum lead to clay-colored stools and steatorrhea. Soluble bilirubin in the blood excreted into the urine leads to dark urine. Contraction of the inflamed gallbladder leads to pain with fatty food intake. Obstruction of the common bile duct prevents bile drainage into the duodenum, with congestion of bile in the liver. Bilirubin absorption in the blood leads to jaundice.

What test will be done before prescribing treatment for the patient with positive testing for HCV? Nursing Management: Liver, Pancreas, and Biliary Tract Problems a. Anti-HCV b. HCV genotyping c. HCV RNA quantitation d. Recombinant immunoblot assay (RIBA)

b. HCV genotyping is done to predict HCV response to drug therapy. Anti-HCV and HCV RNA quantitation are tests completed to diagnose HCV. Recombinant immunoblot assays are used to confirm anti-HCV reactivity.

Which type of hepatitis is a DNA virus, can be transmitted via exposure to infectious blood or body fluids, is required for HDV to replicate, and increases the risk of the chronic carrier for hepatocellular cancer? a. Hepatitis A (HAV) c. Hepatitis C (HCV) b. Hepatitis B (HBV) d. Hepatitis E (HEV)

b. Hepatitis B virus (HBV) is a DNA virus that is transmitted via infectious blood and body products and is required for hepatitis D virus (HDV) replication, and Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved. chronic HBV along with chronic hepatitis C virus (HCV) accounts for 80% of hepatocellular cancer cases. Hepatitis A virus (HAV), HCV, HDV, and HEV are all RNA viruses.

What is a risk factor associated with cancer of the pancreas? a. Alcohol intake b. Cigarette smoking c. Exposure to asbestosd. Increased dietary intake of spoiled milk products

b. Major risk factors for pancreatic cancer are cigarette smoking, high-fat diet, diabetes, and exposure to benzidine. Pancreatic cancer is not directly associated with alcohol intake, as pancreatitis is. Chronic pancreatitis is a risk factor for pancreatic cancer.

What laboratory test results should the nurse expect to find in a patient with cirrhosis? a. Serum albumin: 7.0 g/dL (70 g/L) b. Total bilirubin: 3.2 mg/dL (54.7 mmol/L) c. Serum cholesterol: 260 mg/dL (6.7 mmol/L) d. Aspartate aminotransferase (AST): 6.0 U/L (0.1 mkat/L)

b. Serum bilirubin, both direct and indirect, would be expected to be increased in cirrhosis. Serum albumin and cholesterol are decreased and liver enzymes, such as aspartate aminotransferase (AST) and alanine aminotransferase (ALT), are initially elevated but may be normal in end-stage liver disease.

The nurse identifies a need for further teaching when the patient with hepatitis B makes which statement? a. "I should avoid alcohol completely for as long as a year." b. "I must avoid all physical contact with my family until the jaundice is gone." c. "I should use a condom to prevent spread of the disease to my sexual partner." d. "I will need to rest several times a day, gradually increasing my activity as I tolerate it."

b. The patient with hepatitis B is infectious for 4 to 6 months and precautions to prevent transmission through percutaneous and sexual contact should be maintained until tests for HbsAg or Anti-HBcIgM are negative. Close contact does not have to be avoided but close contacts of the patient should be vaccinated. Alcohol should not be used for at least a year and rest with increasing activity during convalescence is recommended.

In discussing long-term management with the patient with alcoholic cirrhosis, what should the nurse advise the patient? a. A daily exercise regimen is important to increase the blood flow through the liver. b. Cirrhosis can be reversed if the patient follows a regimen of proper rest and nutrition. c. Abstinence from alcohol is the most important factor in improvement of the patient's condition. d. The only over-the-counter analgesic that should be used for minor aches and pains is acetaminophen.

c. Abstinence from alcohol is very important in alcoholic cirrhosis and may result in improvement if started when liver damage is limited. Although further liver damage may be reduced by rest and nutrition, most changes in the liver cannot be reversed. Exercise does not promote portal circulation and very moderate exercise is recommended. Acetaminophen should not be used by the patient with alcoholic cirrhosis because this liver is more sensitive to the hepatotoxicity of acetaminophen

A patient with chronic cholecystitis asks the nurse whether she will need to continue a low-fat diet after she has a cholecystectomy. What is the best response by the nurse? a. "A low-fat diet will prevent the development of further gallstones and should be continued." b. "Yes; because you will not have a gallbladder to store bile, you will not be able to digest fats adequately." c. "A low-fat diet is recommended for a few weeks after surgery until the intestine adjusts to receiving a continuous flow of bile." d. "Removal of the gallbladder will eliminate the source of your pain associated with fat intake, so you may eat whatever you like."

c. After removal of the gallbladder, bile drains directly from the liver into the duodenum and a low-fat diet is recommended until adjustment to this change occurs. Most patients tolerate a regular diet with moderate fats but should avoid excessive fats, as large volumes of bile previously stored in the gallbladder are not available. Steatorrhea could occur with a large fat intake.

When caring for a patient with autoimmune hepatitis, the nurse understands that what in this patient is different from the patient who has viral hepatitis? a. Does not manifest hepatomegaly or jaundice b. Experiences less liver inflammation and damage c. Is treated with corticosteroids or other immunosuppressive agents d. Is usually an older adult who has used a wide variety of prescription and over-the-counter drugs

c. Immunosuppressive agents are indicated in hepatitis associated with immune disorders to decrease liver damage caused by autoantibodies. Autoimmune hepatitis is similar to viral hepatitis in presenting signs and symptoms and may become chronic and lead to cirrhosis.

To treat a cirrhotic patient with hepatic encephalopathy, lactulose (Cephulac), rifaximin (Xifaxan), and a proton pump inhibitor are ordered. The patient's family wants to know why the laxative is ordered. What is the best explanation the nurse can give to the patient's family? a. It reduces portal venous pressure. c. It traps ammonia and eliminates it in the feces. b. It eliminates blood from the GI tract. d. It decreases bacteria to decrease ammonia formation.

c. Ammonia must be reduced to treat hepatic encephalopathy. The laxative, lactulose, decreases ammonia by trapping the ammonia and eliminating it in the feces. A β-adrenergic blocker will be used to decrease portal venous pressure and decrease variceal bleeding. The proton pump inhibitor will decrease gastric acidity but will not eliminate blood already in the GI tract. The rifaximin will decrease bacterial flora and therefore decrease ammonia formation from protein metabolism.

A patient is hospitalized with metastatic cancer of the liver. The nurse plans care for the patient based on what knowledge? a. Chemotherapy is highly successful in the treatment of liver cancer. b. The patient will undergo surgery to remove the involved portions of the liver. c. Supportive care that is appropriate for all patients with severe liver damage is indicated. d. Metastatic cancer of the liver is more responsive to treatment than primary carcinoma of the liver.

c. Because the prognosis for cancer of the liver is poor and treatment is largely palliative, supportive nursing care is appropriate. The patient exhibits clinical manifestations of liver failure, as seen in any patient with advanced liver failure. Whether the cancer is primary or metastatic, there is usually a poor response to chemotherapy and surgery is indicated in the few patients that have localization of the tumor when there is no evidence of invasion of hepatic blood vessels.

During discharge instructions for a patient following a laparoscopic cholecystectomy, what should the nurse include in the teaching? a. Keep the incision areas clean and dry for at least a week. b. Report the need to take pain medication for shoulder pain. c. Report any bile-colored or purulent drainage from the incisions. d. Expect some postoperative nausea and vomiting for a few days.

c. Bile-colored drainage or pus from any incision may indicate an infection and should be reported to the health care provider immediately. The bandages on the puncture sites should be removed the day after surgery, followed by bathing or showering. Referred shoulder pain is a common and expected problem following laparoscopic procedures, when carbon dioxide used to inflate the abdominal cavity is not readily absorbed by the body. Nausea and vomiting are not expected postoperatively and may indicate damage to other abdominal organs and should be reported to the health care provider.

Priority Decision: During the treatment of the patient with bleeding esophageal varices, what is the most important thing the nurse should do? a. Prepare the patient for immediate portal shunting surgery. b. Perform guaiac testing on all stools to detect occult blood. c. Maintain the patient's airway and prevent aspiration of blood. d. Monitor for the cardiac effects of IV vasopressin and nitroglycerin.

c. Bleeding esophageal varices are a medical emergency. During an episode of bleeding, management of the airway and prevention of aspiration of blood are critical factors. Occult blood as well as fresh blood from the GI tract would be expected. Vasopressin causes vasoconstriction, decreased heart rate, and decreased coronary blood flow. IV nitroglycerin may be given with the vasopressin to counter these side effects. Portal shunting surgery is performed for esophageal varices but not during an acute hemorrhage

What is the patient with chronic pancreatitis more likely to have than the patient with acute pancreatitis? a. The need to abstain from alcohol c. Malabsorption and diabetes mellitus b. Experience acute abdominal pain d. Require a high-carbohydrate, high-protein, low-fat diet

c. Chronic damage to the pancreas causes a deficiency of digestive enzymes and insulin resulting in malabsorption and diabetes mellitus. Abstinence from alcohol is necessary in both types of pancreatitis, as is a high-carbohydrate, high-protein, and low-fat diet. Although abdominal pain is a major manifestation of chronic pancreatitis, more commonly a constant heavy, gnawing feeling occurs.

. The patient has been newly diagnosed with Wilson's disease and D-penicillamine, a chelating agent, has been prescribed. What assessment finding should the nurse expect? a. Pruritus c. Corneal Fleischer rings b. Acute kidney injury d. Elevated serum iron levels

c. Corneal Fleischer rings, brownish red rings in the cornea near the limbus, are the hallmark of Wilson's disease. Pruritus (not seen with Wilson's disease) is commonly seen with jaundice or primary biliary cirrhosis. Renal failure associated with hepatorenal syndrome is not seen with Wilson's disease. Elevated serum iron levels are seen with hemochromatosis.

Which manifestations may be seen in the patient with cirrhosis related to esophageal varices? a. Jaundice, peripheral edema, and ascites from increased intrahepatic pressure and dysfunction b. Loss of the small bile ducts and cholestasis and cirrhosis in patients with other autoimmune disorders c. Development of collateral channels of circulation in inelastic, fragile esophageal veins as a result of portal hypertension d. Scarring and nodular changes in the liver lead to compression of the veins and sinusoids, causing resistance of blood flow through the liver from the portal vein

c. Esophageal varices occur when collateral channels of circulation develop inelastic fragile veins as a result of portal hypertension. Portal hypertension is from scarring and nodular changes in the liver leading to compression of the veins and sinusoids, causing resistance of blood flow through the liver from the portal vein. It contributes to peripheral edema and ascites. Jaundice is from the inability of the liver to conjugate bilirubin. Biliary cirrhosis causes the loss of small bile ducts and ultimate cholestasis in patients with other autoimmune disorders

During the incubation period of viral hepatitis, what should the nurse expect the patient to report? a. Pruritus and malaise b. Dark urine and easy fatigability c. Anorexia and right upper quadrant discomfort d. Constipation or diarrhea with light-colored stools

c. Incubation symptoms occur before the onset of jaundice and include a variety of gastrointestinal (GI) symptoms as well as discomfort and heaviness in the upper right quadrant of the abdomen. Pruritus, dark urine, and light-colored stools occur with the onset of jaundice in the acute phase. Easy fatigability and malaise are seen in the convalescent phase as jaundice disappears.

The family members of a patient with hepatitis A ask if there is anything that will prevent them from developing the disease. What is the best response by the nurse? a. "No immunization is available for hepatitis A, nor are you likely to get the disease." b. "All family members should receive the hepatitis A vaccine to prevent or modify the infection." c. "Those who have had household or close contact with the patient should receive immune globulin." d. "Only those individuals who have had sexual contact with the patient should receive immunization."

c. Individuals who have been exposed to hepatitis A through household contact or foodborne outbreaks should be given immune globulin within 1 to 2 weeks of exposure to prevent or modify the illness. Hepatitis A vaccine is used to provide preexposure immunity to the virus and is indicated for individuals at high risk for hepatitis A exposure. Although hepatitis A may be spread by sexual contact, the risk is higher for transmission with the oral- fecal route.

A patient diagnosed with chronic hepatitis B asks about drug therapy to treat the disease. What is the most appropriate response by the nurse? a. "Only chronic hepatitis C is treatable and primarily with antiviral agents and interferon." b. "There are no specific drug therapies that are effective for treating acute viral hepatitis." c. "Interferon combined with lamivudine (Epivir) will decrease viral load and prevent complications." d. "There are no drugs used for the treatment of viral hepatitis because of the risk of additional liver damage."

c. Nucleoside and nucleotide analogs (e.g., lamivudine), ribavirin, and pegylated interferon are used to treat chronic hepatitis B or C. Protease inhibitors are also used to treat chronic hepatitis C. No specific drugs are effective in treating acute viral hepatitis, although supportive drugs, such as antiemetics, sedatives, or antipruritics, may be used for symptom control.

What treatment measure is used in the management of the patient with acute pancreatitis? a. Surgery to remove the inflamed pancreas b. Pancreatic enzyme supplements administered with meals c. Nasogastric (NG) suction to prevent gastric contents from entering the duodenum d. Endoscopic pancreatic sphincterotomy using endoscopic retrograde cholangiopancreatography (ERCP)

c. Pancreatic rest and suppression of secretions are promoted by preventing any gastric contents from entering the duodenum, which would stimulate pancreatic activity. Surgery is not indicated for acute pancreatitis but may be used to drain abscesses or cysts. An endoscopic retrograde cholangiopancreatography (ERCP) pancreatic sphincterotomy may be performed when pancreatitis is related to gallstones. Pancreatic enzyme supplements are necessary in chronic pancreatitis if a deficiency in secretion occurs

A patient with acute pancreatitis has a nursing diagnosis of pain related to distention of the pancreas and peritoneal irritation. In addition to effective use of analgesics, what should the nurse include in this patient's plan of care? a. Provide diversional activities to distract the patient from the pain. b. Provide small, frequent meals to increase the patient's tolerance to food. c. Position the patient on the side with the head of the bed elevated 45 degrees for pain relief. d. Ambulate the patient every 3 to 4 hours to increase circulation and decrease abdominal congestion.`c. Pancreatic rest and suppression of secretions are promoted by preventing any gastric contents from entering the duodenum, which would stimulate pancreatic activity. Surgery is not indicated for acute pancreatitis but may be used to drain abscesses or cysts. An endoscopic retrograde cholangiopancreatography (ERCP) pancreatic sphincterotomy may be performed when pancreatitis is related to gallstones. Pancreatic enzyme supplements are necessary in chronic pancreatitis if a deficiency in secretion occurs

c. Positions that flex the trunk and draw the knees up to the abdomen help to relieve the pain of acute pancreatitis and positioning the patient on the side with the head elevated decreases abdominal tension. Diversional techniques are not as helpful as positioning in controlling the pain. The patient is usually NPO because food intake increases the pain and inflammation. Bed rest is indicated during the acute attack because of hypovolemia and pain.

The nurse determines that further discharge instruction is needed when the patient with acute pancreatitis makes which statement? a. "I should observe for fat in my stools." b. "I must not use alcohol to prevent future attacks of pancreatitis." c. "I shouldn't eat any salty foods or foods with high amounts of sodium." d. "I will need to continue to monitor my blood glucose levels until my pancreas is healed."

c. Sodium restriction is not indicated for patients recovering from acute pancreatitis but the stools should be observed for steatorrhea, indicating that fat digestion is impaired, and glucose levels may be monitored for indication of impaired β-cell function. Alcohol is a primary cause of pancreatitis and should not be used.

Priority Decision: The patient has hepatic encephalopathy. What is a priority nursing intervention to keep the patient safe? a. Turn the patient every 3 hours. c. Assist the patient to the bathroom. b. Encourage increasing ambulation. d. Prevent constipation to reduce ammonia production.

c. The patient may not be oriented or able to walk to the bathroom alone because of hyperreflexia, asterixis, or decreased motor coordination. Turning should be done every 2 hours to prevent skin breakdown. Activity is limited to decrease ammonia as a by-product of protein metabolism. Although constipation will be prevented, it will not keep the patient safe.

Which complication of acute pancreatitis requires prompt surgical drainage to prevent sepsis? a. Tetany b. Pseudocyst c. Pleural effusiond. Pancreatic abscess

d. A pancreatic abscess is a collection of pus that must be drained to prevent infection of adjacent organs and sepsis. Tetany from hypocalcemia is treated with IV calcium gluconate (10%). Although pseudocysts usually resolve spontaneously, they may be treated with surgical, percutaneous catheter, or endoscopic drainage to prevent perforation. Pleural effusion is treated by treating the cause (pancreatitis) and monitoring for respiratory distress and oxygen saturation.

Although HAV antigens are not tested in the blood, they stimulate specific immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies. Which antibody indicates there is acute HAV infection? a. Anti-HBc IgG c. Anti-HAV IgG b. Anti-HBc IgM d. Anti-HAV IgM

d. Anti-HAV immunoglobulin M (IgM) indicates acute HAV infection. Anti-HBc immunoglobulin G (IgG) indicates previous or ongoing infection with HBV. Anti- HBc IgM indicates acute HBV infection. Anti-HAV IgG indicates previous infection with HAV.

A patient with cirrhosis that is refractory to other treatments for esophageal varices undergoes a portacaval shunt. As a result of this procedure, what should the nurse expect the patient to experience? a. An improved survival rate c. Improved metabolism of nutrients b. Decreased serum ammonia levels d. Improved hemodynamic function and renal perfusion

d. By shunting fluid sequestered in the peritoneum into the venous system, pressure on esophageal veins is decreased and more volume is returned to the circulation, improving cardiac output and renal perfusion. However, because ammonia is diverted past the liver, hepatic encephalopathy continues. These procedures do not prolong life or promote liver function.

What manifestation in the patient does the nurse recognize as an early sign of hepatic encephalopathy? a. Manifests asterixis c. Has increasing oliguria b. Becomes unconscious d. Is irritable and lethargic

d. Early signs (grade 1) of this neurologic condition include changes in mentation (e.g., depression, apathy, irritability, confusion, agitation, drowsiness, lethargy). Loss of consciousness (grade 4) is usually preceded by asterixis (grades 2 and 3), disorientation, hyperventilation, hypothermia, and alterations in reflexes. Increasing oliguria is a sign of hepatorenal syndrome.

The patient asks why the serologic test of HBV DNA quantitation is being done. What is the best rationale for the nurse to explain the test to the patient? a. Indicates ongoing infection with HBV b. Indicates co-infection with HBV and HDV c. Indicates previous infection or immunization to HBV d. Indicates viral replication and effectiveness of therapy for chronic HBV

d. HBV DNA quantitation is the best indicator of viral replication and effectiveness of therapy for chronic HBV. HBsAg is present in acute or chronic infection. HBeAg indicates high infectivity and can also be used to determine clinical management of patients with chronic HBV. Anti-HBcIgM indicates acute infection and anti- HBcIgG indicates ongoing infection. Anti-HDV is present in past or current infection with HDV and therefore HBV. Anti-HBs indicate previous infection with HBV or immunization.

Following a needle stick, what is used as prophylaxis against HBV? a. Interferon c. Hepatitis B immune globulin (HBIG) b. HBV vaccine d. HBV vaccine and HBIG

d. HBV vaccine and hepatitis B immune globulin (HBIG) are used together prophylactically after a needle stick. Interferon is used to treat chronic HBV.

The patient returned from a 6-week mission trip to Somalia with complaints of nausea, malaise, fatigue, and achy muscles. Which type of hepatitis is this patient most likely to have contracted? a. Hepatitis B (HBV) c. Hepatitis D (HDV) b. Hepatitis C (HCV) d. Hepatitis E (HEV)

d. Hepatitis E virus (HEV) is associated with poor sanitation and contaminated water in developing countries.

In a radical pancreaticoduodenectomy (Whipple procedure) for treatment of cancer of the pancreas, what anatomic structure is completely resected that will affect the patient's nutritional status? a. Stomach b. Pancreas c. Common bile duct d. Duodenum adjoining the pancreas

d. In a Whipple procedure the head of the pancreas, gallbladder, part of the duodenum adjacent to the pancreas, and sometimes the pylorus of the stomach are removed. The duodenum is responsible for the breakdown of food in the small intestine and regulates the rate of stomach emptying, which affects the patient's nutritional status.

A patient with cirrhosis asks the nurse about the possibility of a liver transplant. What is the best response by the nurse? a. "Liver transplants are indicated only in young people with irreversible liver disease." b. "If you are interested in a transplant, you really should talk to your doctor about it." c. "Rejection is such a problem in liver transplants that it is seldom attempted in patients with cirrhosis." d. "Cirrhosis is an indication for transplantation in some cases. Have you talked to your doctor about this?"

d. Liver transplantation is indicated for patients with cirrhosis as well as for many adults and children with other irreversible liver diseases. Although health care providers make the decisions regarding the patient's qualifications for transplantation, nurses should be knowledgeable about the indications for transplantation and be able to discuss the patient's questions and concerns related to transplantation. Rejection is less of a problem in liver transplants than with other organs such as the kidney.

The patient with liver failure has had a liver transplant. What should the nurse teach the patient about care after the transplant? a. Alcohol intake is now okay. b. HBIG will be required to prevent rejection. c. Elevate the head 30 degrees to improve ventilation when sleeping. d. Monitor closely for infection because of the immunosuppressive medication.

d. Monitoring for viral, fungal, and bacterial infection after the liver transplant is essential, as only fever may be present with an infection. Alcohol will not be any better for the patient after the transplant than it was before the transplant. HBIG is given for postexposure protection from HBV. The head of the bed is elevated to improve ventilation with severe ascites.

Following a laparoscopic cholecystectomy, what should the nurse expect to be part of the plan of care? a. Return to work in 2 to 3 weeks b. Be hospitalized for 3 to 5 days postoperatively c. Have a T-tube placed in the common bile duct to provide bile drainage d. Have up to four small abdominal incisions covered with small dressings

d. The laparoscopic cholecystectomy requires one to four small abdominal incisions to visualize and remove the gallbladder and the patient has small dressings placed over these incisions. The patient with an incisional cholecystectomy is usually hospitalized for 2 to 3 days, whereas the laparoscopic procedure allows same-day or next-day discharge with return to work within 1 week. A T-tube is placed in the common bile duct after exploration of the duct during an incisional cholecystectomy.

The patient presents with jaundice and itching, steatorrhea, and liver enlargement. This patient has also had ulcerative colitis for several years. What diagnosis should the nurse expect for this patient? a. Cirrhosis c. Hepatorenal syndrome b. Acute liver failure d. Primary sclerosing cholangitis

d. The majority of patients with primary sclerosing cholangitis (PSC) also have ulcerative colitis. The manifestations are otherwise similar to cirrhosis and PSC may lead to cirrhosis, liver failure, and liver cancer

The occurrence of acute liver failure is most common in which situation? a. An individual with hepatitis A c. Antihypertensive medication use b. An individual with hepatitis C d. Use of acetaminophen with alcohol abuse

d. The most common cause of acute liver failure is drugs, usually acetaminophen in combination with alcohol abuse. HBV is the second most common cause.

When assessing a patient with acute pancreatitis, the nurse would expect to find a. hyperactive bowel sounds. c. a temperature greater than 102°F (38.9°C). b. hypertension and tachycardia. d. severe midepigastric or left upper quadrant (LUQ) pain.

d. The predominant symptom of acute pancreatitis is severe, deep abdominal pain that is usually located in the left upper quadrant (LUQ) but may be in the midepigastrium. Bowel sounds are decreased or absent, temperature is elevated only slightly, and the patient has hypovolemia and may manifest symptoms of shock.

What causes the systemic effects of viral hepatitis? a. Cholestasis b. Impaired portal circulation c. Toxins produced by the infected liver d. Activation of the complement system by antigen-antibody complexes

d. The systemic manifestations of rash, angioedema, arthritis, fever, and malaise in viral hepatitis are caused by the activation of the complement system by circulating immune complexes. Liver manifestations include jaundice from hepatic cell damage and cholestasis as well as anorexia. Impaired portal circulation usually does not occur in uncomplicated viral hepatitis but would be a liver manifestation.