Disorders of the Liver, Gallbladder, or Pancreas

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

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

A client has just been diagnosed with chronic pancreatitis. The client is underweight and in severe pain and diagnostic testing indicates that over 80% of the client's pancreas has been destroyed. The client asks the nurse why the diagnosis was not made earlier in the disease process. What would be the nurse's best response?

- "Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost." Explanation: By the time symptoms occur in chronic pancreatitis, approximately 90% of normal acinar cell function (exocrine function) has been lost. Late detection is not usually attributable to the vagueness of symptoms. The pancreas contributes continually to homeostasis and other organs are unable to perform its physiologic functions.

A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation?

- "How many alcoholic drinks do you typically consume in a week?" Explanation: Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use.

The nurse is assessing a client admited with suspected pancreatitis. Which question will the nurse prioritize when assessing this client?

- "How much alcohol do you consume in a day?" Explanation: Chronic pancreatitis is an inflammatory disorder characterized by progressive destruction of the pancreas. Alcohol consumption in Western societies is the major cause of chronic pancreatitis. Excessive and prolonged consumption of alcohol accounts for approximately 70% to 80% of all cases of chronic pancreatitis. The incidence of pancreatitis is 50 times greater in people with alcoholism than in those who do not abuse alcohol. The type of food (like fried or heavily processed foods) rather than the number of meals eaten each day may contribute to pancreatitis and subsequent flare-ups of the condition. The prescibed use of acetaminophen is not a typical risk factor in pancreatitis and is rare with cases of overdose. The amount and/or lack of exercise is not directly linked to pancreatitis. Risk factors do include obesity.

A nurse cares for a client with interstitial pancreatitis. What client teaching will the nurse include when planning care for the client?

- "Inflammation is confined to only the pancreas." Explanation: There are two forms of pancreatitis 1. inflammatory (interstitial) 2. Necrotizing. 1. Interstitial pancreatitis is characterized by diffuse enlargement of the pancreas due to inflammatory edema confined only to the pancreas itself; normal function returns after about 6 months. 2. Necrotizing pancreatitis is life-threatening and tissue necrosis occurs within the pancreas as well as the surrounding glands.

A client with chronic pancreatitis had a pancreaticojejunostomy created 3 months ago for relief of pain and to restore drainage of pancreatic secretions. The client has come to the office for a routine postsurgical appointment. The client is frustrated that the pain has not decreased. What is the most appropriate initial response by the nurse?

- "Pain relief occurs by 6 months in most clients who undergo this procedure, but some people experience a recurrence of their pain." Explanation: Pain relief from a pancreaticojejunostomy often occurs by 6 months in more than 85% of the clients who undergo this procedure, but pain returns in a substantial number of clients as the disease progresses. This client had surgery 3 months ago; the client has 3 months before optimal benefits of the procedure may be experienced. There is no obvious indication for gallbladder removal and nonadherence is not the most likely factor underlying the pain.

A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor?

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

A nurse is responsible for monitoring the diet of a client with hepatic encephalopathy. Which daily protein intake should this 185-pound (84-kilogram) male consume?

- 100 to 126 grams Explanation: Although in the past a low-protein diet was recommended, current guidance is that protein should not be restricted, as the danger of protein malnutrition and muscle wasting outweighs the risk of worsening hepatic encephalopathy. Protein intolerance is much less common than previously thought. Daily protein intake should be maintained at 1.2 to 1.5 g/kg per day. To calculate protein intake, multiply the 84 kg by the low and high ranges: (84 kg × 1.2 = 100 g; 84 kg × 1.5 = 126 g). This client would require a daily protein range from 100 to 126 grams.

A client is instructed to follow a low-fat diet after an inflammatory attack of the gallbladder. Which vitamins or other acids will the nurse recommend the client supplement due to the client's dietary restrictions? Select all that apply. - A - D - K - Essential fatty acids - Folic acid

- A - D - K - Essential fatty acids Explanation: A low-fat diet should be supplemented with vitamins A, D, K, and essential fatty acids. These vitamins are fat-soluble and will need to be administered if the client does not have adequate fat intake. Folic acid is not a fat-soluble vitamin.

The nurse is educating a patient with cirrhosis about the importance of maintaining a low-sodium diet. What food item would be permitted on a low-sodium diet?

- A pear Explanation: The goal of treatment for the patient with ascites, a complication of cirrhosis, is a negative sodium balance to reduce fluid retention. Table salt, salty foods, salted butter and margarine, and all canned and frozen foods that are not specifically prepared for low-sodium (2-g sodium) diets should be avoided (Dudek, 2010). Peanut butter, a hot dog, and ham are all high in sodium. A pear is not.

A client with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this client's treatment, the nurse should anticipate what intervention?

- A regimen of antiviral medications Explanation: There is no benefit from rest, diet, or vitamin supplements in HCV treatment. Studies have demonstrated that antiviral agents are most effective. Immune globulins and FFP are not indicated.

What health promotion teaching should the nurse prioritize to prevent drug-induced hepatitis?

- Adhere to dosing recommendations of over-the-counter analgesics. Explanation: Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client?

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

A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan?

- Administration of diuretics as prescribed Explanation: Use of diuretics along with sodium restriction is successful in 90% of clients with ascites. Beta-blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B12 injections are not necessary.

A client reporting shortness of breath is admitted with a diagnosis of cirrhosis. A nursing assessment reveals an enlarged abdomen with striae, an umbilical hernia, and 4+ pitting edema of the feet and legs. What is the most important data for the nurse to monitor?

- Albumin Explanation: With the movement of albumin from the serum to the peritoneal cavity, the osmotic pressure of the serum decreases. This, combined with increased portal pressure, results in movement of fluid into the peritoneal cavity. The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of ascites and edema.

What intervention does the nurse anticipate providing for the patient with ascites that will help correct the decrease in effective arterial blood volume that leads to sodium retention?

- Albumin infusion Explanation: Albumin infusions help to correct decreases in effective arterial blood volume that lead to sodium retention. The use of this colloid reduces the incidence of: - postparacentesis circulatory dysfunction with renal dysfunction - hyponatremia - rapid reaccumulation of ascites associated with decreased effective arterial volume.

A client with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the client's family how to safely perform which of the following actions?

- Assessing the patency of the drainage catheter Explanation: Families should be taught to provide basic catheter care, including assessment of patency. Antibiotics are not instilled into the catheter and aspiration using a syringe is contraindicated. The family would not independently remove the catheter; this would be done by a member of the care team when deemed necessary.

Which of the following terms describes the involuntary flapping movements of the hands associated with metabolic liver dysfunction?

- Asterixis Explanation: Asterixis refers to involuntary flapping movements of the hands associated with metabolic liver dysfunction. Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise. Ascites refers to accumulation of serous fluid within the peritoneal cavity. Dialysis refers to a form of filtration to separate crystalloid from colloid substances

A client returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the client for signs and symptoms of what serious potential complication of this surgery?

- Bile duct injury Explanation: The most serious complication after laparoscopic cholecystectomy is a bile duct injury. Clients do not face a risk of diabetic coma. A decubitus ulcer is unlikely because immobility is not expected. Evisceration is highly unlikely, due to the laparoscopic approach.

A client with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the client's prioritization for receiving a donor liver be determined?

- By objectively determining the client's medical need Explanation: The client would undergo a classification of the degree of medical need through an objective determination known as the Model of End-Stage Liver Disease (MELD) classification, which stratifies the level of illness of those awaiting a liver transplant. This algorithm considers multiple variables, not solely age, prognosis, potential for adherence, and the rejection of alternative options.

The nurse is caring for a client with a biliary disorder who has an elevated amylase level. If this elevation correlates to dysfunction, which body process does the nurse recognize may be impaired?

- Carbohydrate digestion Explanation: Amylase is a pancreatic enzyme involved in the breakdown and digestion of carbohydrates. Trypsin aids in the digestion of proteins. Lipase aids in the digestion of fats.

A client with calculi in the gallbladder is said to have

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

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?

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

Which is a clinical manifestation of cholelithiasis?

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

The nurse is caring for a client recovering from acute pancreatitis. Which menu item should the nurse remove from the client's breakfast tray?

- Coffee Explanation: Post-acute management of the client with acute pancreatitis includes the introduction of solid food. Oral feedings that are low in fat and protein are gradually initiated. Caffeine is eliminated from the diet and therefore coffee, which contains caffeine, should be removed from the client's breakfast tray. Even decaffeinated coffee has a small amount of caffeine but could serve as a compromise for chronic coffee drinkers. The other food items are appropriate for the client.

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

A group of nurses have attended an in-service on the prevention of occupationally acquired diseases that affect health care providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace?

- Disposing of sharps appropriately and not recapping needles Explanation: HCV is bloodborne. Consequently, prevention of needlestick injuries is paramount. Hand hygiene, immunizations and appropriate use of masks are important aspects of overall infection control, but these actions do not directly mitigate the risk of HCV.

A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurse's most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse's best response to this assessment finding?

- Document the presence of normal bile output. Explanation: Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.

A client has been admitted to the hospital for the treatment of chronic pancreatitis. The client has been stabilized and the nurse is now planning health promotion and educational interventions. Which of the following should the nurse prioritize?

- Educating the client about postdischarge lifestyle modifications Explanation: The client's lifestyle (especially regarding alcohol use) is a major determinant of the course of chronic pancreatitis. The disease is not often managed by surgery and blood sugar monitoring is not necessarily indicated for every client after hospital treatment. Transplantation is not an option.

The mode of transmission of hepatitis A virus (HAV) includes which of the following?

- Fecal-oral Explanation: The mode of transmission of hepatitis A virus (HAV) occurs through fecal-oral route, primarily through person to person contact and/or ingestion of fecal contaminated food or water. Hepatitis B virus (HBV) is transmitted primarily through blood. HBV can be found in blood, saliva, semen, and can be transmitted through mucous membranes and breaks in the skin.

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus?

- Following proper hand-washing techniques Explanation: Avoiding contact with the hepatitis E virus through good hygiene, including hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecal-oral route, principally through contaminated water in areas with poor sanitation.

A client with pancreatic cancer has been scheduled for a pancreaticoduodenectomy (Whipple procedure). During health education, the client should be informed that this procedure will involve the removal of which of the following? Select all that apply. - Gallbladder - Part of the stomach - Duodenum - Part of the common bile duct - Part of the rectum

- Gallbladder - Part of the stomach - Duodenum - Part of the common bile duct Explanation: - A pancreaticoduodenectomy (Whipple procedure or resection) is used for potentially resectable cancer of the head of the pancreas. This procedure involves removal of the: - gallbladder - portion of the stomach - duodenum - proximal jejunum - head of the pancreas - distal common bile duct. The rectum is not affected.

A client has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study?

- Have the client refrain from food and fluids after midnight. Explanation: An ultrasound of the gallbladder is most accurate if the client fasts overnight, so that the gallbladder is distended. Contrast and radioactive agents are not used when performing ultrasonography of the gallbladder, as an ultrasound is based on reflected sound waves.

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

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

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations?

- Hepatic encephalopathy Explanation: The earliest symptoms of hepatic encephalopathy include : - minor mental changes - motor disturbances - confused - appearance unkempt - alterations in mood and sleep patterns. - sleep during the day and have restlessness and insomnia at night. As hepatic encephalopathy progresses, the client may become difficult to awaken and completely disoriented with respect to time and place. With further progression, the client lapses into frank coma and may have seizures. Simple tasks, such as handwriting, become difficult.

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include?

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

A client has been diagnosed with pancreatic cancer and has been admitted for care. Following initial treatment, the nurse should be aware that the client is most likely to require which of the following situations?

- Hospice care Explanation: Pancreatic carcinoma has only a low survival rate regardless of the stage of disease at diagnosis or treatment. As a result, there is a higher likelihood that the client will require hospice care than physical therapy and rehabilitation.

A client has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this client?

- IV hydromorphone Explanation: The pain of acute pancreatitis is often very severe and pain relief may require parenteral opioids such as: - morphine - fentanyl - hydromorphone. There is no clinical evidence to support the use of meperidine for pain relief in pancreatitis. Opioids are preferred over NSAIDs.

A nurse on a solid organ transplant unit is planning the care of a client who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority?

- Implementation of infection-control measures Explanation: Infection control is paramount following liver transplantation. This is a priority over skin integrity and psychosocial status, even though these are valid areas of assessment and intervention. Antiretrovirals are not indicated.

When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?

- Irritability and drowsiness Explanation: Although all the options are associated with hepatitis B, the onset of irritability and drowsiness suggests a decrease in hepatic function. To detect signs and symptoms of disease progression, the nurse should observe for: - disorientation - behavioral changes - decreasing level of consciousness and should monitor the results of liver function tests, including the blood ammonia level. If hepatic function is decreased, the nurse should take safety precautions.

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

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

Diagnostic testing has revealed that a client's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this client's plan of care will focus on what intervention?

- Lobectomy Explanation: Surgical resection is the treatment of choice when HCC is confined to one lobe of the liver and the function of the remaining liver is considered adequate for postoperative recovery. Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While cryosurgery and liver transplantation are other surgical options for management of liver cancer, these procedures are not performed at the same frequency as a lobectomy. Laser hyperthermia is a nonsurgical treatment for liver cancer.

Which of the following is commonly associated with acute episodes of pancreatitis?

- Long-term use of alcohol Explanation: Long-term use of alcohol is commonly associated with acute episodes of pancreatitis, but the patient usually has had undiagnosed chronic pancreatitis before the first episode of acute pancreatitis. Less common causes of pancreatitis include bacterial or viral infection.

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?

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

A 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. Explanation: The nurse maintains the client in the semi-Fowler's position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. Respiratory distress and hypoxia are common, and the client may develop: - diffuse pulmonary infiltrates - dyspnea - tachypnea - abnormal blood gas values. The client who has undergone surgery may have multiple drains or an open surgical incision and is at risk for skin breakdown and infection. Oral food or fluid intake is not permitted; therefore, enteral or parenteral feedings may be prescribed.

A home health nurse is caring for a client discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the client who has had pancreatic surgery?

- Malabsorption and hyperglycemia Explanation: The nurse arrives at this diagnosis based on the complications of malabsorption and hyperglycemia. These complications often lead to the need for dietary modifications. Pancreatic enzyme replacement, a low-fat diet, and vitamin supplementation often are also required to meet the client's nutritional needs and restrictions. Electrolyte imbalances often accompany pancreatic disorders and surgery, but the electrolyte levels are more often deficient than excessive. Hemorrhage is a complication related to surgery, but not specific to the nutritionally based nursing diagnosis. Weight loss is a common complication, but hypoglycemia is less likely.

An adult client has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this client's plan of care?

- Measure the client's abdominal girth daily. Explanation: Due to the risk of ascites, the nurse should monitor the client's abdominal girth. There is no specific need to avoid the use of opioids or to monitor for dysphagia, and activity is usually limited.

Which of the following would be included as a postoperative intervention for the patient undergoing a laparoscopic cholecystectomy?

- Observe color of sclera Explanation: - The nurse should be particularly observant of the color of the sclera. - After recovery from anesthesia, the patient is placed in the low Fowler's position. - Water and other fluids may be administered within hours after laparoscopic procedures. - A soft diet is started after bowel sounds return.

A client has undergone a liver biopsy. After the procedure, the nurse should place the client in which position?

- On the right side Explanation: Immediately after the biopsy, assist the client to turn on to the right side; place a pillow under the costal margin, and caution the client to remain in this position. In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded. Positioning the client on the left side is not indicated. Positioning the client in the Trendelenburg position may be indicated if the client is in shock, but it is not the position designed for the client after liver biopsy. The high Fowler position is not indicated for the client after liver biopsy.

Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis?

- Pancreatic necrosis Explanation: Pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Shock and multiple organ failure may occur with acute pancreatitis. Tetany is not a major cause of morbidity and mortality in clients with acute pancreatitis.

The nurse is caring for a client with acute pancreatitis who is admitted to the intensive care unit to monitor for pulmonary complications. What is the nurse's understanding of the pathophysiology of pulmonary complications related to pancreatitis?

- Pancreatitis can elevate the diaphragm and alter the breathing pattern. Explanation: - Aggressive pulmonary care is required for clients with acute pancreatitis. Pancreatitis can elevate the diaphragm and alter the breathing pattern of clients. Pancreatitis can cause retention of pulmonary secretions but does not thicken the secretions. Acute pancreatitis does not alter the hemoglobin.

A nurse is performing an admission assessment of a client with a diagnosis of cirrhosis. What technique should the nurse use to palpate the client's liver?

- Place hand under right lower rib cage and press down lightly with the other hand. Explanation: To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant.

Which is the most common cause of esophageal varices?

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

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

- Purpura and petechiae Explanation: A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

Which liver function study is used to show the size of the liver and hepatic blood flow and obstruction?

- Radioisotope liver scan Explanation: A radioisotope liver scan assesses liver size and hepatic blood flow and obstruction. Magnetic resonance imaging is used to identify normal structures and abnormalities of the liver and biliary tree. Angiography is used to visualize hepatic circulation and detect the presence and nature of hepatic masses. Electroencephalography is used to detect abnormalities that occur with hepatic coma.

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

A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response?

- Report this finding to the primary provider due to the possibility of hepatic encephalopathy. Explanation: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the client's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly

A nurse is assessing a client who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the client's pain, the nurse should anticipate that it may radiate to what region?

- Right shoulder Explanation: The client may have biliary colic with excruciating upper right abdominal pain that radiates to the back or right shoulder. Pain from cholecystitis does not typically radiate to the left upper chest, inguinal area, neck, or jaw.

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

- Scurvy Explanation: Scurvy may result from a vitamin C deficiency

A nurse is teaching a client about the cause of acute pancreatitis. The nurse evaluates the teaching as effective when the client correctly identifies which condition as a cause of acute pancreatitis?

- Self-digestion of the pancreas by its own proteolytic enzymes Explanation: Self-digestion of the pancreas by its own proteolytic enzymes, principally trypsin, causes acute pancreatitis. Of clients with acute pancreatitis, 80% had undiagnosed chronic pancreatitis. Gallstones enter the common bile duct and lodge at the ampulla of Vater, obstructing the flow of pancreatic juice or causing a reflux of bile from the common bile duct into the pancreatic duct, thus activating the powerful enzymes within the pancreas. Normally, these remain in an inactive form until the pancreatic secretions reach the lumen of the duodenum. Activation of the enzymes can lead to vasodilation, increased vascular permeability, necrosis, erosion, and hemorrhage.

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

A 37-year-old client presents at the emergency department (ED) reporting nausea and vomiting and severe abdominal pain. The client's abdomen is rigid, and there is bruising to the client's flank. The client's spouse states that the client was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the client for what health problem?

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

A client has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize what topic?

- Signs and symptoms of intra-abdominal complications Explanation: Because of the early discharge following laparoscopic cholecystectomy, the client needs thorough education in the signs and symptoms of complications. Fluid balance is not typically a problem in the recovery period after laparoscopic cholecystectomy. There is no need for blood glucose monitoring or pancreatic enzymes.

A client with liver cirrhosis develops ascites. Which medication will the nurse prepare teaching for this client?

- Spironolactone Explanation: The use of diuretic agents along with sodium restriction is successful in 90% of clients with ascites. Spironolactone, an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. When used with other diuretic agents, spironolactone helps prevent potassium loss. Oral diuretic agents such as furosemide may be added but should be used cautiously because long-term use may induce severe hyponatremia (sodium depletion). Acetazolamide and ammonium chloride are contraindicated because of the possibility of precipitating hepatic encephalopathy and coma.

A nurse is caring for a client with hepatic encephalopathy. The nurse's assessment reveals that the client exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy?

- Stage 3 Explanation: Clients in the 3rd stage of hepatic encephalopathy exhibit the following symptoms: - stuporous - difficult to arouse - sleep most of the time - exhibits marked confusion - ncoherent in speech - asterixis - increased deep tendon reflexes - rigidity of extremities - marked EEG abnormalities. Clients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3, and clients in stage 4 are comatose. In stage 4, there is an absence of asterixis, absence of deep tendon reflexes, flaccidity of extremities, and EEG abnormalities. Just a Coma

A client is admitted to the unit with acute cholecystitis. The health care provider has stated that surgery will be scheduled in 4 days. The client asks why the surgery is being put off for a week when he has a "sick gallbladder." What rationale would underlie the nurse's response?

- Surgery is delayed until the acute symptoms subside. Explanation: Unless the client's condition deteriorates, surgical intervention is delayed just until the acute symptoms subside (usually within a few days). There is no need to delay surgery pending an improvement in nutritional status, and deciding on a laparoscopic approach is not a lengthy process.

A client with acute pancreatitis reports muscle cramping in the lower extremities. What pathophysiology concept represents the reason the client is reporting this?

- Tetany related to hypocalcemia Explanation: A client with acute pancreatitis who reports muscle cramping or pain should be suspected of having hypocalcemia and tetany of the muscles. Hypocalcemia may occur in acute pancreatitis because, when auto digestion of the pancreas occurs, calcium binds to fatty acids and calcium is decreased in the blood. This is a potentially life-threatening complication of pancreatitis and needs to be immediately addressed.

A client who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize?

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

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?

- The client's hepatic function is decreasing. Explanation: The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon.

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from:

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

A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

- Two to three soft bowel movements daily Explanation: Lactulose is given to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the client's appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.

Which of the following is the most effective strategy to prevent hepatitis B infection?

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

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?

- Vasopressin Explanation: Vasopressin may be the initial therapy for esophageal varices because it produces constriction of the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Spironolactone and cimetidine do not decrease portal hypertension.

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

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

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

- Weight loss Explanation: Weight loss is most common in the client with chronic pancreatitis due to decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack.

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

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

The nurse's review of a client's most recent laboratory results indicates a bilirubin level of 3.0 mg/dL (51 mmol/L). The nurse assesses the client for:

- jaundice. Explanation: Jaundice becomes clinically evident when the serum bilirubin level exceeds 2.0 mg/dL (34 mmol/L). Elevated bilirubin levels are not associated with hypokalemia, malnutrition or bleeding, though these complications may result from the underlying liver disorder.

A physician has ordered a liver biopsy for a client with cirrhosis whose condition has recently deteriorated. The nurse reviews the client's recent laboratory findings and recognizes that the client is at risk for complications due to:

- low platelet count. Explanation: Prolonged prothrombin time (PT) and low platelet count place the client at high risk for hemorrhage. The client may receive intravenous (IV) administration of vitamin K or infusions of platelets before liver biopsy to reduce the risk of bleeding.

What is the recommended dietary treatment for a client with chronic cholecystitis?

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

A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. What is an important education topic regarding ingestion of medications?

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

A client who has undergone surgery for a liver disorder is at risk for fluid loss. To determine the presence of decreased intravascular volume in the client, the nurse should closely monitor the client's:

- serum sodium levels. Explanation: To determine the presence of decreased intravascular volume, the nurse should closely monitor the client's serum sodium levels. Changes in potassium, hemoglobin and temperature are not normally indicative.

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

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

A client has been admitted to the critical care unit with a diagnosis of toxic hepatitis. When planning the client's care, the nurse should be aware of what potential clinical course of this health problem? Place the following events in the correct sequence.1. Fever rises. 2. Hematemesis. 3. Clotting abnormalities. 4. Vascular collapse. 5. Coma.

1, 2, 3, 4, 5 Explanation: Recovery from acute toxic hepatitis is rapid if the hepatotoxin is identified early and removed or if exposure to the agent has been limited. Recovery is unlikely if there is a prolonged period between exposure and onset of symptoms. There are no effective antidotes. The fever rises; the client becomes toxic and prostrated. Vomiting may be persistent, with the emesis containing blood. Clotting abnormalities may be severe, and hemorrhages may appear under the skin. The severe GI symptoms may lead to vascular collapse. Delirium, coma, and seizures develop, and within a few days the client may die of fulminant hepatic failure unless he or she receives a liver transplant.

A client with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the client will undergo what intervention?

Laparoscopic cholecystectomy Explanation: Most of the nonsurgical approaches, including lithotripsy and dissolution of gallstones, provide only temporary solutions to gallstone problems and are infrequently used. Cholecystectomy is the preferred treatment (permanent)

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

Pancreatitis Explanation: - Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. Appendicitis, cholecystitis, and gastric ulcer are less likely to exhibit fluid volume deficit.

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply.

People who are at high occupational risk for contracting hepatitis B, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. The consistent use of standard precautions is also highly beneficial. Vitamin supplementation is unrelated to an individual's risk of HBV.

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

- 6 to 12 months Explanation: Six to 12 months of therapy with UDCA is recommended in clients to dissolve the stones.

The single modality of pharmacologic therapy for chronic type B viral hepatitis is:

- Alpha-interferon Explanation: Alpha-interferon is a biologic response modifier that is highly effective for treatment of hepatitis B. The other antiviral agents are effective but not the preferred single-agent therapy.

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 Explanation: Frequent changes of position are necessary to prevent atelectasis and pooling of respiratory secretions.

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN?

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

During chronic pancreatitis, the patient's stool may become frothy and foul-smelling. This would be documented as which of the following?

- Steatorrhea Explanation: The stool becomes frequent, frothy, and foul-smelling because of impaired fat digestion, which results in stools with a high fat content.