Hinkle Ch. 50

The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client?

Assisting the client to turn, cough, and deep breathe every 2 hours Assessment should focus on the client's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation.

Which foods should be avoided following acute gallbladder inflammation?

Cheese The client should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the client that fatty foods may induce an episode of cholecystitis. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea may be consumed as tolerated.

Which is the most common report by clients with pancreatitis?

Severe, radiating abdominal pain Clients with pancreatitis most commonly report severe mid- to upper-abdominal pain, radiating to both sides and straight to the back. The client may describe the stools as being frothy and foul smelling, not black or tarry. The client's urine may be dark. The client will not experience increased or painful urination, increased appetite, or weight gain.

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find?

Elevated urine amylase levels Elevated serum and urine amylase, lipase, and liver enzyme levels accompany significant pancreatitis. If the common bile duct is obstructed, the bilirubin level is above normal. Blood glucose levels and white blood cell counts can be elevated. Serum electrolyte levels (calcium, potassium, and magnesium) are low.

Which nursing action is most appropriate for a client hospitalized with acute pancreatitis?

Withholding all oral intake, as ordered, to decrease pancreatic secretions The nurse should withhold all oral intake to suppress pancreatic secretions, which may worsen pancreatitis. Typically, this client requires a nasogastric tube to decompress the stomach and GI tract. Although pancreatitis may cause considerable pain, it's treated with I.M. meperidine (Demerol), not morphine, which may worsen pain by inducing spasms of the pancreatic and biliary ducts.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery?

Vitamin K Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low.

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 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 nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?

"Maintain a high-carbohydrate, low-fat diet."

A client has a nasogastric (NG) tube for suction and is NPO after a pancreaticoduodenectomy. Which explanation made by the nurse is the major purpose of this treatment?

"The tube allows the gastrointestinal tract to rest." An NG tube with suction and parenteral nutrition allow the gastrointestinal tract to rest while promoting adequate nutrition.

When caring for the patient with acute pancreatitis, the nurse must consider pain relief measures. What nursing interventions could the nurse provide? (Select all that apply.)

- Encouraging bed rest to decrease the metabolic rate - Withholding oral feedings to limit the release of secretin - Administering parenteral opioid analgesics as ordered

A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood value does the nurse recognize as inadequate to sustain normal brain function?

30 mg/dL

The nurse knows that the serum amylase concentration returns to normal within which time frame?

48-72 hours

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

Acute pain related to biliary spasms The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

A nurse is caring for a client diagnosed with cholelithiasis. Which of the following would be most appropriate for a client who is experiencing biliary colic?

Administer analgesics

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 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.

Clinical manifestations of common bile duct obstruction include all of the following except: Amber-colored urine Clay-colored feces Pruritus Jaundice

Amber-colored urine The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish, like putty, or clay-colored. The symptoms may be acute or chronic. Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen, may occur. If it goes untreated jaundice and pruritus can occur.

A client who had developed jaundice 2 months earlier is brought to the ED after attending a party and developing excruciating pain that radiated over the abdomen and into the back. Upon assessment, which additional symptom would the nurse expect this client to have?

Bile-stained vomiting Nausea and vomiting are common in acute pancreatitis. The emesis is usually gastric in origin but may also be bile stained. Fever, jaundice, mental confusion, and agitation may also occur.

Which is a clinical manifestation of cholelithiasis?

Clay-colored stools 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.

A 70-year-old client is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which gerontologic consideration associated with the pancreas?

Decreases in the physiologic function of major organs

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

Deficient fluid volume

Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes melitus. Which of the following explains the cause of this secondary diabetes?

Dysfunction of the pancreatic islet cells

When caring for the patient with acute pancreatitis, the nurse must consider pain relief measures. What nursing interventions could the nurse provide?

Encouraging bed rest to decrease the metabolic rate Withholding oral feedings to limit the release of secretin Administering parenteral opioid analgesics as ordered

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

Ensure that the client rests.

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

Which condition in a client with pancreatitis makes it necessary for the nurse to check fluid intake and output, check hourly urine output, and monitor electrolyte levels?

Frequent vomiting, leading to loss of fluid volume Fluid and electrolyte disturbances are common complications because of nausea, vomiting, movement of fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever, and the use of gastric suction. The nurse assesses the client's fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the client daily and carefully measures fluid intake and output, including urine output, nasogastric secretions, and diarrhea.

Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?

Hot roast beef sandwich with gravy

A nurse is planning care for a client with acute pancreatitis. Which client outcome does the nurse assign as the highest priority?

Maintaining normal respiratory function

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

The nurse identifies a potential collaborative problem of electrolyte imbalance for a client with severe acute pancreatitis. Which assessment finding alerts the nurse to an electrolyte imbalance associated with acute pancreatitis?

Muscle twitching and finger numbness Muscle twitching and finger numbness indicate hypocalcemia, a potential complication of acute pancreatitis. Calcium may be prescribed to prevent or treat tetany, which may result from calcium losses into retroperitoneal (peripancreatic) exudate.

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

Pancreatic necrosis 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.

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

Pancreatitis 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.

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

Positioning the client on the side with the knees flexed The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles.

A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm his diagnosis?

Recent weight loss and temperature elevation Assessment findings associated with pancreatitis include recent weight loss and temperature elevation. Inflammation of the pancreas causes a response that elevates temperature and leads to abdominal pain that typically occurs with eating. Nausea and vomiting may occur as a result of pancreatic tissue damage that's caused by the activation of pancreatic enzymes. The client may experience weight loss because of the lost desire to eat.

A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate?

Reserving an antecubital site for a peripherally inserted central catheter (PICC) Pancreatitis treatment typically involves resting the GI tract by maintaining nothing-by-mouth status. The nurse should reserve the antecubital site for a PICC, which enables the client to receive long-term total parenteral nutrition. Clients in the acute stages of pancreatitis also require large volumes of I.V. fluids to compensate for fluid loss.

A client is diagnosed with gallstones in the bile ducts. The nurse knows to review the results of blood work for a

Serum bilirubin level greater than 1.0 mg/dL Jaundice occurs in a few clients with gallbladder disease, usually with obstruction of the common bile duct. If the flow of bile is impeded (eg, by gallstones in the bile ducts), bilirubin does not enter the intestine. As a result, blood levels of bilirubin increase.

`The nurse is admitting a patient to the intensive care unit with a diagnosis of acute pancreatitis. What does the nurse expect was the reason the patient came to the hospital?

Severe abdominal pain Severe abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas.

A client who has been having recurrent attacks of severe abdominal pain over the past few months informs the physician about a 25-pound weight loss in the past year. The nurse attributes which factor as the most likely cause of this weight loss?

Skipping meals out of fear of painful attacks Weight loss is a major problem in chronic pancreatitis. More than 80% of clients experience significant weight loss, which is usually caused by decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack.

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

The nurse knows that the client with cholelithiasis can have a nutritional deficiency. The obstruction of bile flow due to cholelitiasis can interfere with the absorption of

Vitamin A

What is a major concern for the nurse when caring for a patient with chronic pancreatitis?

Weight loss Weight loss is a major problem in chronic pancreatitis. More than 80% of patients experience significant weight loss, which is usually caused by decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack

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

Yellow sclerae

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

cannot tolerate a high glucose concentration.

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

gallbladder

A patient has been admitted to the intensive care unit with a diagnosis of acute pancreatitis. Which of the following laboratory values will the nurse prioritize when gauging the course of his disease? Select all that apply.

Amylase Lipase White blood cells (WBCs)

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 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 patient is diagnosed with gallstones in the bile ducts. What laboratory results should the nurse review?

Serum bilirubin level greater than 1.0 mg/dL

A nurse is caring for a client in the emergency department who is complaining of severe abdominal pain. The client is diagnosed with acute pancreatitis. Which laboratory value requires immediate intervention?

Troponin of 2.3 mcg/L An elevated troponin level indicates myocardial damage and needs immediate further investigation

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

The patient has developed peritonitis. Abdominal guarding is present. A rigid or boardlike abdomen may develop and is generally an ominous sign, usually indicating peritonitis

A client discharged after a laparoscopic cholecystectomy calls the surgeon's office reporting severe right shoulder pain 24 hours after surgery. Which statement is the correct information for the nurse to provide to this client?

This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort