Med Surg Chap 44 Nursing management: Liver, Pancreas, biliary tract problems

The nurse recalls that hepatic coma results primarily from accumulation of which substance in the blood? 1 Sodium 2 Calcium 3 Ammonia 4 Potassium

A high ammonia level in the blood is a late manifestation of liver failure, which results in hepatic coma, causing neurological dysfunction and brain damage. Sodium, calcium, and potassium are not directly affected by liver dysfunction or hepatic coma. Text Reference - p. 1021 3

When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include? 1 A lower-fat diet may be tolerated better for several weeks 2 Do not return to work or normal activities for three weeks 3 Bile-colored drainage probably will drain from the incision 4 Keep the bandages on and the puncture site dry until it heals

Although the usual diet can be resumed, a low-fat diet usually is better tolerated for several weeks following surgery. Normal activities can be resumed gradually as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery and the patient can shower. 1

A female patient expresses her concern about becoming pregnant while her partner is on ribavirin (Rebetol) therapy for chronic hepatitis C. What should the nurse advise the patient? 1 She can plan pregnancy now. 2 She should avoid getting pregnant now. 3 She should not get pregnant with this partner ever. 4 She should avoid any sexual intercourse after conception.

Any woman who is on ribavirin or whose male partner is on ribavirin should avoid pregnancy during treatment. The pregnancy can be planned after the treatment is complete. She can get pregnant with this partner, but not while on treatment. Avoiding intercourse after conception is not necessary. 2

A patient has an increased ammonia level associated with hepatic encephalopathy. What assessment finding does the nurse expect? 1 Aphasia t2 Asterixis 3 Hyperactivity 4 Acute dementia

Asterixis is a twitching spasm of the hands and wrists seen in patients with increased ammonia levels in conditions such as hepatic encephalopathy. Aphasia, hyperactivity, and acute dementia are manifestations not associated with hepatic encephalopathy. Besides asterixis, an increased serum ammonia level causes sedation and confusion that progress to a comatose state. Text Reference - p. 1021 2

The nurse, assessing a patient with hepatitis A, expects which common clinical manifestations? Select all that apply. 1 Fatigue 2 Jaundice 3 Anorexia 4 Constipation 5 Hypotension 6 Excessive thirst

Because of inflammation, the liver is unable to clear free bilirubin from the blood, resulting in jaundice. However, jaundice may appear at any time during the course of the disease, even as a late sign. Because of insufficient metabolism of toxins by the liver, fatigue and anorexia may be experienced. Diarrhea with clay-colored stools and fever are also associated manifestations of hepatitis. Extremes in blood pressure, constipation, and excessive thirst are not common clinical manifestations of hepatitis. Text Reference - p. 1009 1,2,3

The nurse is admitting a patient with cirrhosis. The nurse checks the patient's history for which most frequent risk factor associated with cirrhosis? 1 Polypharmacy 2 Intravenous drug abuse 3 Hepatitis A 4 Alcohol abuse

Cirrhosis is highly correlated with alcohol abuse. Polypharmacy, drug abuse, and hepatitis A are not linked to cirrhosis. Text Reference - p. 1017 4

A patient with cirrhosis of the liver is admitted to the hospital. What complications of cirrhosis is the nurse likely to find in the patient? Select all that apply. 1 Edema of the feet 2 Difficulty breathing 3 Blood in the stools or black stools 4 Disorientation and lethargy 5 Severe pain in the chest with a cold sweat

Complications of cirrhosis of the liver include peripheral edema, gastric varices, and hepatic encephalopathy. Peripheral edema presents itself as swelling/edema of the feet. Gastric varices bleed easily. This bleeding can be presented as blood in vomiting or blood in the stool. Hepatic encephalopathy presents as disorientation, altered mental status, sleep disturbances, and lethargy. Cirrhosis doesn't lead to pain in the chest with a cold sweat or difficulty in breathing. Text Reference - p. 1024 1,3,4

The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? 1 The patient has completed a college education. 2 The patient has been able to stop smoking cigarettes. 3 The patient has well controlled type 1 diabetes mellitus. 4 The chest x-ray showed another lung cancer lesion.

Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course. It does not matter if the patient has a college education. The fact that the patient has quit smoking is not a contraindication for liver transplant. The patient is a well-controlled diabetic, which is not a contraindication. Text Reference - p. 1028 4

A nurse is attending to a patient suffering from cirrhosis of the liver. What clinical manifestations should the nurse expect to find upon physical examination? Select all that apply. 1 White patches on skin 2 Deposits of dark pigments 3 Small areas of bleeding into the skin 4 Vascular lesions formed by small blood vessels 5 Small dilated blood vessels with spiderlike branches

Ecchymoses are small areas of bleeding into the skin or mucous membrane forming blue or purple patches. Because there is decreased synthesis of prothrombin in the liver, the bleeding and clotting time may be deranged. Telangiectasia is a vascular lesion formed by a group of small blood vessels. Spider angioma is also seen in cirrhosis of the liver. Vitiligo (white patches of skin) develops from destruction of melanocytes and is not related to cirrhosis. Melanosis is the deposit of dark pigment unrelated to cirrhosis. 3,4,5

The nurse provides discharge instructions to a patient with newly diagnosed cirrhosis. Which statement made by the patient indicates the need for further teaching? 1 "I should take frequent rest periods." 2 "I can eat anything that appeals to me." 3 "I can do without my glass of wine with dinner." 4 "I should take only medications that have been prescribed."

Even though a low-protein diet has been questioned in the treatment of patients with cirrhosis, it remains in use. In light of this, it is incorrect for the patient to say that he may eat anything. Patients with cirrhosis must also avoid alcohol. Frequent rest and limitation of medications to those that have been prescribed are appropriate resolutions in a newly diagnosed case of cirrhosis and therefore do not indicate the need for further teaching. Text Reference - p. 1022 2

A patient underwent pancreaticoduodenectomy (Whipple procedure) for pancreatic cancer. What are the instructions that the nurse should include when giving dietary advice to this patient? Select all that apply. 1 Consume a low-fat diet. 2 Consume a low-carbohydrate diet. 3 Consume a high-calorie diet. 4 Consume a diet high in proteins. 5 Patient may resume normal diet without any restrictions.

Having a low-fat, high-carbohydrate, and high-protein diet is essential. The diet should be low in fat to decrease the work load of the liver and promote healing. A high-calorie diet should be provided, as more energy is required. High-calorie meals are needed for energy and to promote the use of protein for tissue repair. A high-protein diet is required for tissue building. The diet should be high in carbohydrates to provide the required energy. The patient should not resume a normal diet and should follow the restrictions as advised. Text Reference - p. 1036 1,3,4

The nurse finds that a patient admitted to the hospital with cirrhosis of the liver is disoriented, lethargic, and drowsy and has abnormal reflexes. Based on the patient's signs and symptoms, the nurse understands that the patient is in grade ___ hepatic encephalopathy. Fill in the blank using a whole number.

Hepatic encephalopathy has 0 to 4 grades based on three factors: level of consciousness, intellectual function, and neurological findings. Grade 2 is characterized by lethargy, drowsiness, and inappropriate behavior (level of consciousness); disorientation (intellectual function); and asterixis and abnormal reflexes (neurological findings). Grade 1 is characterized by a short attention span, mild confusion, and depression. Grade 3 is characterized by loss of meaningful conversation, marked confusion, and incomprehensible speech. Grade 4 is characterized by a complete lack of intellectual function. Grade 0 is characterized by insomnia, sleep disturbances, and a subtle change in computational skills. Text Reference - p. 1021 2

A patient with hepatitis A asks whether other family members are at risk for "catching" the disease. The nurse's response will be based on the knowledge that hepatitis A is transmitted primarily: 1 During sexual intercourse 2 By contact with infected body secretions 3 Through fecal contamination of food or water 4 Through kissing that involves contact with mucous membranes

Hepatitis A is primarily transmitted through ingestion of organisms on fecally contaminated hands, food, or water. Care should be taken in the handling of food and water, as well as contaminated items such as bed linens, bedpans, and toilets. Hand hygiene and personal protective equipment such as gloves are important in preventing the spread of infection for hospital personnel. In the home, hand hygiene and good personal hygiene are important in decreasing the risk of transmission. Sexual intercourse, contact with infected body secretions, and contact through mucous membranes all present higher risk for hepatitis B and C than for hepatitis A. 3

What are the precautions that nurses and hospital staff should follow while handling patients suffering from hepatitis infections? Select all that apply. 1 The patient must be in a private room, and door should be closed. 2 Dispose of the needles and syringes used on the patient carefully. 3 Wear gloves while handling articles contaminated by urine or feces. 4 Always wear a mask, gown, and gloves when entering the patient's room. 5 Follow infection control precautions while injecting the patient, and avoid getting pricked by the used needle.

Hepatitis A spreads through the fecal-oral route, and hepatitis B spreads through blood. Hence the virus can spread through needles and syringes used by the patient. Also, the virus can spread while the nurse is handling the urine or fecal material of the patient; hence it is necessary to wear gloves. Hepatitis does not spread through air; hence a mask is not required. A private room is required in respiratory diseases, not in hepatitis. 2,3,5

The parent of a pediatric patient suffering from hepatitis A approaches the nurse and is worried about the spread of infection to other family members through use of the same bathroom. What should the nurse advise the patient's parent? Select all that apply. 1 Buy a separate commode for your son. 2 Clean the bathroom and commode thoroughly. 3 There is no need for concern; just use disposable toilet covers. 4 Ask your son to wash his hands thoroughly after using the bathroom. 5 Ask all other family members to wash their hands thoroughly before eating and after using the bathroom.

Hepatitis A spreads through the fecal-oral route. Transmission is prevented by maintaining hygiene. Proper hand washing is extremely important in preventing the spread of the virus. Buying a separate commode is unnecessary. Thorough cleaning of the bathroom and all the equipment is enough to limit spread of the virus. Use of disposable toilet sheets is not sufficient to prevent spread of the virus. 2,3,5

The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? 1 "If I notice a fast heart rate or irregular beats, it is normal for cirrhosis." 2 "I need to take good care of my belly and ankle skin where it is swollen." 3 "A scrotal support may be more comfortable when I have scrotal edema." 4 "I can use pillows to support my head to help me breathe when I am in bed."

If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider as this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. A scrotal support may improve comfort if there is scrotal edema. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency. Text Reference - p. 1024 1

The nurse, interviewing a patient with acute pancreatitis, expects what finding in the patient's history? 1 COPD 2 Alcohol abuse 3 Diabetes mellitus 4 Congestive heart failure

In a majority of the cases of acute pancreatitis the cause is excessive alcohol intake or biliary tract disease. Alcohol abuse can cause the small pancreatic ducts to become clogged, resulting in pancreatic inflammation. Chronic obstructive pulmonary disease, diabetes mellitus, and congestive heart failure may be comorbidities but are not themselves directly related to acute pancreatitis. Text Reference - p. 1030 2

A patient admitted to the hospital with cirrhosis of the liver suddenly starts vomiting blood. What is the priority action that the nurse should take in this situation? 1 Send for endoscopic variceal ligation. 2 Give propronalol orally. 3 Stabilize the patient and manage airway. 4 Check for signs of cirrhosis.

Individuals with cirrhosis of the liver are at risk of bleeding from esophageal and gastric varices. Hematemesis in the patient with cirrhosis of the liver is likely to be variceal bleeding. In this case, the nurse should first stabilize the patient and manage the airway. Once the patient is stable, other steps in treatment can be initiated, such as assessing further and administering necessary medications. Text Reference - p. 1025 3

The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention should the nurse expect to include in the patient's plan of care? 1 Immediately start enteral feeding to prevent malnutrition Correct2 Insert a nasogastric (NG) tube and maintain nothing by mouth (NPO) status to allow the pancreas to rest 3 Initiate early prophylactic antibiotic therapy to prevent infection Incorrect4 Administer acetaminophen (Tylenol) every four hours for pain relief

Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. Enteral feedings will be used only for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is needed only with acute necrotizing pancreatitis and signs of infection. The pain will be treated with IV morphine because of the NPO status. 2

The patient with advanced cirrhosis asks why his or her skin is so yellow. The nurse's response is based on the knowledge that 1 Decreased peristalsis in the gastrointestinal tract contributes to a buildup of bile salts 2 Jaundice results from the body's inability to conjugate and excrete bilirubin 3 A lack of clotting factors promotes the collection of blood under the skin surface 4 Decreased colloidal oncotic pressure from hypoalbuminemia causes the yellowish skin discoloration

Jaundice results from the functional derangement of liver cells and compression of bile ducts by connective tissue overgrowth. Jaundice occurs as a result of the decreased ability to conjugate and excrete bilirubin Jaundice is not caused by a build-up of bile salts, a lack of clotting factors, or decreased colloidal oncotic pressure. 2

A patient is advised to undergo laparoscopic cholecystectomy. The patient asks the nurse what exactly this procedure means. What are the points that a nurse can include in this explanation? Select all that apply. 1 Gallbladder is removed through 1-4 small punctures on the abdominal wall. 2 Gallbladder is removed through an incision made on the right subcostal region. 3 The procedure is done with a laparoscope and grasping forceps under anesthesia. 4 The patient can be discharged on the day of operation or the next and resume his work after a week. 5 The gallbladder is removed through an incision on the abdomen, and a catheter is inserted to drain any fluids or effusion.

Laparoscopic cholecystectomy involves making 1-4 punctures on the abdominal wall, and the gall bladder is removed using laparoscope and grasping forceps. This procedure is done under anesthesia. The patient can be discharged in a day or two, as the recovery is fast. This procedure does not involve incisions. Text Reference - p. 1038 1,3,4

A patient has been diagnosed with cholelithiasis. The nurse will monitor for manifestations of obstructed bile flow, including which of these? Select all that apply. 1 Jaundice 2 Steatorrhea 3 Dark, tarry stools 4 Dark, amber urine 5 Bleeding tendencies

Manifestations of obstructed bile flow in a patient with cholelithiasis include jaundice, dark, amber urine, which foams when shaken, clay-colored (not dark, tarry) stools, pruritus, intolerance for fatty foods (nausea, sensation of fullness, anorexia), bleeding tendencies, and steatorrhea. Dark, tarry stools are not a manifestation of obstructed bile flow; clay stools are. Text Reference - p. 1037 1,2,4,5

A patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge? 1 Milk thistle may affect liver enzymes and thus alter drug metabolism. 2 Milk thistle generally is safe in recommended doses for up to 10 years. 3 There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. 4 Milk thistle may elevate the serum glucose levels and thus is contraindicated in diabetes.

Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore patients will need to be monitored for drug interactions. There is good scientific evidence that there is no real benefit from using milk thistle to protect the liver cells from toxic damage in the treatment of cirrhosis. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels. 1

The nurse evaluates the effectiveness of a paracentesis in a patient who has ascites. Which measurement is most important for the nurse to note? 1 Cardiac output 2 Blood pressure 3 Abdominal girth 4 Intake and output

Paracentesis involves the removal of fluid from the abdominal cavity. A large-bore needle connected to tubing is inserted by the healthcare provider into the distended abdomen. The other end of the tubing also has a large-bore needle, which is inserted into a vacuum bottle. The vacuum bottle is then held below the level of the abdomen, facilitating gravity-flowed removal of the ascites. Several bottles of fluid can be removed, with the result measured by reduction in abdominal girth. Cardiac output may improve after paracentesis, but it is unlikely that this measurement needs to be recorded. Paracentesis has no major effect on blood pressure. Likewise, intake and output continues to be monitored to account for the paracentesis fluid but is not as informative as abdominal girth. 3

The nurse is attending to a patient with tentative diagnosis of acute pancreatitis. Which diagnostic tests should the nurse anticipate for the health care provider to prescribe to confirm the diagnosis? Select all that apply. 1 Serum amylase 2 Serum lipase 3 Computed tomography (CT) scan 4 Liver biopsy 5 Serum alpha-fetoproteins

Serum amylase and lipase levels usually increase in acute pancreatitis due to pancreatic fibrosis. CT scan is used to confirm pancreatitis and its related complications. Liver biopsy is not indicated in pancreatitis, as it is not related to liver dysfunction. Serum alpha-fetoproteins are not related to pancreatitis; they are elevated in liver cancer. 1,2,3

A patient with acute hepatitis B will be discharged tomorrow. The nurse should include which measures in the discharge teaching plan? Select all that apply. 1 Restrict fluid intake. 2 Avoid alcohol for the first three weeks. 3 Avoid foods that are very hot or very cold. 4 Be sure to allow for periods of rest during the day. 5 Participate in an exercise regimen to build stamina. 6 Eat small meals frequently rather than three times a day.

Several measures are important for ensuring that the patient with hepatitis receives adequate nutrition. The anorexia and distaste for food cause nutritional problems. Assess the patient's tolerance of specific foods and eating patterns. Small, frequent meals may be preferable to three large ones and also may help prevent nausea. Measures to stimulate the appetite, such as mouth care, antiemetics, and attractively served meals in pleasant surroundings, should be included in the nursing care plan. Drinking carbonated beverages and avoiding very hot or very cold foods may help alleviate anorexia. Rest is an important factor in promoting hepatocyte regeneration. Assess the patient's response to the rest and activity plan, and modify it accordingly. Adequate fluid intake (2500 to 3000 mL/day) is important. Restricting fluid intake and participating in exercise regimens are not appropriate measures. Patients with hepatitis need to avoid alcoholic beverages. 3,4,6

A patient with a 3-year history of liver cirrhosis is hospitalized for treatment of recently diagnosed esophageal varices. What is the most important information for the nurse to include in the teaching plan for this patient? 1 Decrease fluid intake to avoid ascites. 2 Eat foods quickly so they do not get cold and cause distress. 3 Avoid exercise because it may cause bleeding of the varices. 4 Avoid straining during defecation to keep venous pressure low.

Straining during a bowel movement increases venous pressure and could cause rupture of the varices. Fluid restrictions may be a recommendation for ascites but are not directly associated with esophageal varices. If the patient is able to eat, meals should be soft or liquid and the patient should be instructed to eat slowly and avoid extremes in food temperature to prevent irritation. Excessive exercise and activity should be avoided in a patient with esophageal varices to prevent hypertension, however, avoiding straining and other activities that cause the Valsalva maneuver is still a higher-priority recommendation. 4

A patient with hepatitis A is in the acute phase. The nurse plans care while anticipating that the patient may be experiencing which symptoms? Select all that apply. 1 Fatigue 2 Pruritus 3 Anorexia 4 Dizziness 5 Constipation

The acute phase of hepatitis usually lasts from one to four months. During the incubation period, symptoms may include malaise, anorexia and weight loss, fatigue, nausea, occasional vomiting, and abdominal (right upper quadrant) discomfort. The patient may find food repugnant, and smokers may have distaste for cigarettes. There is also a decreased sense of smell. Other symptoms may include headache, low-grade fever, arthralgias, and skin rashes. Pruritus (intense chronic itching) sometimes accompanies jaundice. The pruritus occurs as a result of the accumulation of bile salts beneath the skin. Dizziness and constipation are not symptoms of the acute phase of hepatitis A. 1,2,3

When teaching the male patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? 1 "I will use care when kissing my wife to prevent giving it to her." 2 "I will need to take adofevir (Hepsera) to prevent chronic HCV." 3 "Now that I have had HCV, I will have immunity and not get it again." 4 "I will need to be checked for chronic HCV and other liver problems."

The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with hepatitis A virus (HAV) and HBV, so the patient may be reinfected with another type of HCV. Text Reference - p. 1015 4

A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings? 1 Malnutrition 2 Osteomyelitis 3 Alcohol abuse 4 Diabetes mellitus

The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal 30-122 U/L) and serum lipase (normal 31-186 U/L) levels as shown. Malnutrition, osteomielitis, and diabetes mellitus would not contribute to these increased levels of serum amylase and serum lipase. 3