NSG 252 ICR/Inflammation

Which diet instruction would the nurse give to a patient with active hepatitis?

"Eat small meals at frequent intervals."

The nurse is providing teaching about pancreatic enzyme replacement to a patient diagnosed with chronic pancreatitis. Which statement by the patient indicates the need for further teaching?

"I will take the pancreatic enzyme half an hour before meals."

Which statement by a patient with cirrhosis indicates the need for further instruction about the disease?

"My liver is scarred, but the cells can regenerate themselves and repair the damage."

After providing discharge teaching about rehabilitation for a patient who has had a stroke, the nurse identifies that which statement demonstrates understanding of the education?

"The rehabilitation therapist will help identify changes needed at home."

After providing education for a community group about transient ischemic attacks (TIAs), the nurse identifies that which statement by a group member indicates the need for further teaching?

"There is a loss of central vision."

The nurse is caring for a patient recently diagnosed with type 1 diabetes mellitus who has had an episode of acute pancreatitis. The patient asks the nurse how he developed diabetes when the disease does not run in the family. Which response by the nurse is best?

"Type 1 diabetes can occur when the pancreas is destroyed by disease."

In which way will the nurse respond to a patient diagnosed with hepatitis A who asks the nurse how this disease may have been contracted?

"You may have consumed foods contaminated with the virus."

The nurse assesses three categories of the National Institutes of Health Stroke Scale (NIHSS) and calculates which score when a patient's findings include the inability to state the date or the location, an arm drift when elevated, and patient silence when asked to identify common items? Record your answer using a whole number. ______

6

The nurse uses the National Institutes of Health Stroke Scale (NIHSS) to assess a patient. The findings include partial hemianopia, ataxia in the right limb only, no auditory comprehension, and painful stimulation needed to make movements. The nurse adds the points for each of the four categories and records what total score? ______

7

According to the American Stroke Association, which is a contraindication for alteplase administration to a patient who presents for treatment 4 hours after the onset of symptoms of a stroke? Select all that apply. One, some, or all responses may be correct.

82 years of age History of both diabetes and stroke Use of an anticoagulant Imaging evidence of middle cerebral artery involvement

The nurse reviews the medical records of patients whose stroke symptoms began 3 hours before hospitalization. The nurse identifies that which patient is eligible for fibrinolytic therapy based on the American Stroke Association guidelines?

A patient who is 60 years old

The nursing team consists of a registered nurse (RN), a licensed practical nurse (LPN), and a nursing assistant. Which patient must be assigned to the RN?

A patient with end-stage cirrhosis who needs teaching about a low-sodium diet

Hepatitis A is most likely to be spread by which person?

A restaurant worker who serves raw oysters

Which symptom of chronic pancreatitis also occurs with acute pancreatitis?

Abdominal pain

A patient is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this patient?

Administer opioid analgesic medication.

At which time will the nurse administer a prescribed antibiotic for a patient who underwent paracentesis and is showing signs of spontaneous bacterial peritonitis (SBP)?

After a sample of fluid is sent to the laboratory for culture

The nurse will instruct a patient recently diagnosed with cirrhosis of the liver to avoid which substance to prevent further fibrosis of the liver and allow the liver to heal and regenerate? Select all that apply. One, some, or all responses may be correct.

Alcohol Cigarettes Illicit drugs Acetaminophen

The nurse is caring for a patient who has been admitted multiple times for pancreatitis. The patient has inflammation and fibrosis of the tissue and diminished pancreatic function. Which assessment finding is priority for this patient?

Alcohol consumption

Which condition is the primary risk factor for chronic calcifying pancreatitis?

Alcoholism

According to the Centers for Disease Control and Prevention (CDC), which ethnic group has the highest prevalence of stroke?

American Indians and Alaskan Natives

Which nursing intervention is important while caring for a patient who has experienced a right-hemisphere stroke?

Approach the patient from the unaffected side.

Which cause of stroke is an abnormality that occurs during embryonic development?

Arteriovenous malformation

Portal hypertension related to cirrhosis can result in which complication? Select all that apply. One, some, or all responses may be correct.

Ascites Hemorrhoids Esophageal varices

Which instruction would the nurse include when teaching a patient who has liver disease with ascites about necessary dietary changes?

Avoid using table salt.

Elevation of which laboratory value is associated with jaundice for a patient with hepatitis?

Bilirubin

Which dietary suggestion is indicated for a patient who is in the healing phase after acute pancreatitis? Select all that apply. One, some, or all responses may be correct.

Bland Foods Low-fat foods Small, frequent feedings

A transjugular intrahepatic portal-systemic shunt (TIPS) may be placed to prevent which complication for a patient with ascites?

Bleeding esophageal varices

Damage to which cranial nerve (CN) may lead to dysphagia in a patient who experiences a stroke?

CN IX

Which nursing intervention helps prevent increased intracranial pressure (ICP) after a stroke?

Careful monitoring of body temperature

Which factor increases the risk for developing pancreatic cancer? Select all that apply. One, some, or all responses may be correct.

Cirrhosis Smoking Chronic pancreatitis

Which drug is considered an antiplatelet?

Clopidogrel

Abuse of which substance is most likely to result in a hemorrhagic stroke?

Cocaine

Which assessment finding would the nurse monitor to evaluate the effectiveness of pancreatic enzyme therapy?

Consistency and number of stools

Which factor may lead to hepatic encephalopathy for a patient with cirrhosis? Select all that apply. One, some, or all responses may be correct.

Constipation Decreased fluid volume GI bleeding

The nurse is reviewing the laboratory results for a patient with acute pancreatitis. Which finding does the nurse expect to find in the report? Select all that apply. One, some, or all responses may be correct.

Decrease in albumin level Increase in serum glucose level Increase in blood urea nitrogen (BUN)

Which action will the nurse take for a patient with cirrhosis who reports having difficulty getting to sleep and staying asleep?

Discuss this early sign of serious complications with the health care provider.

The nurse will emphasize which point when instructing a patient with Laennec cirrhosis and portal hypertension?

Do not consume any alcohol.

Which instruction would the nurse include when teaching a patient with viral hepatitis about care at home? Select all that apply. One, some, or all responses may be correct.

Do not consume any alcohol. Avoid medications containing acetaminophen.

Which instruction would the nurse include when teaching a patient who has been prescribed lamivudine for treatment of chronic hepatitis B?

Do not stop taking abruptly.

When performing an abdominal assessment on a patient diagnosed with pancreatitis, the nurse notes gray-blue discoloration around the periumbilical area, a dull sound on percussion, and normal bowel sounds. Which action by the nurse is priority?

Document the findings.

The nurse suspects that a patient may have acute pancreatitis as evidenced by which group of laboratory results?

Elevated lipase, elevated white blood cell count, elevated glucose

Which laboratory finding signifies an immune response to liver disease?

Elevated serum globulin

Which initial action will the nurse take for a patient who contracted hepatitis C several years ago via IV drug use who appears angry and withdrawn and refuses to participate in self-care activities and exercise?

Encourage the patient to discuss feelings of guilt or remorse.

The nurse suspects which condition when a patient presents with symptoms of a stroke, including a slight headache, speech deficits, confusion, and blurred vision?

Formation of a blood clot

When observing personnel who are providing care for a patient with a stroke, the nurse recognizes that which action warrants immediate intervention?

Gently pulling on the patient's flaccid arm to assist the patient up in bed

When reviewing the history of a patient who has had several transient ischemic attacks, the nurse identifies that which risk factor cannot be changed even with appropriate management of care?

Head trauma

A patient with chronic pancreatitis has developed a pseudocyst that has not resolved after 8 weeks, and the health care provider plans a percutaneous drainage procedure. The patient asks the nurse why this is necessary as it does not seem to be causing problems. Which complication does the nurse explain the procedure will prevent?

Hemorrhage

When a patient's level of consciousness suddenly decreases, the nurse recalls that which condition may mimic an emergency neurologic disorder?

Hypoglycemia

The nurse questions which item that is listed on the plan of care for a patient with an acute ischemic stroke who receives a prescription for alteplase?

IV alteplase 120 mg over 60 minutes, with the initial 10% of that dose given as a bolus over the first minute

Which assessment finding is consistent with a diagnosis of viral hepatitis?

Icterus

Which finding would the nurse expect for a patient with late-stage cirrhosis? Select all that apply. One, some, or all responses may be correct.

Icterus Swollen abdomen Prolonged PTT

The presence of immunoglobulin G (IgG) hepatitis A virus (HAV) antibodies would indicate which condition?

Immunity to HAV after previous HAV infection

The nurse anticipates which outcome when a patient presents with symptoms of an embolic stroke?

Improvement over several days

Which symptoms lead the nurse to suspect that a patient has experienced a right-hemisphere stroke?

Impulsiveness and unaware of any deficit

Which physiologic change would the nurse expect for a patient with severe liver disease who has developed hepatorenal syndrome? Select all that apply. One, some, or all responses may be correct.

Increased creatinine levels Increased osmolarity of urine Increased blood urea nitrogen (BUN)

The patient presents to the emergency department with severe abdominal pain. The nurse is reviewing the patient's laboratory results. Which laboratory finding would prompt the nurse to suspect a diagnosis of acute pancreatitis? Select all that apply. One, some, or all responses may be correct.

Increased serum amylase Decreased serum calcium Increased alanine aminotransferase

A positive result from a hepatitis B surface antigen (HBsAg) test would indicate which condition for a patient who was previously treated for the hepatitis B virus (HBV)?

Infectious status of the patient

Clay-colored stools and dark urine are typically characteristic of which complication of viral hepatitis?

Intrahepatic obstruction

A patient who has had acute mid-epigastric pain for 3 days has elevated glucose, bilirubin, serum lipase, and a threefold increase in alanine aminotransferase. The serum amylase is normal. Which possible cause for this patient's pain does the nurse suspect?

It is caused by acute biliary pancreatitis.

Which assessment finding would the nurse expect for a patient with hepatitis B? Select all that apply. One, some, or all responses may be correct.

Itching Tea-colored urine Right upper quadrant tenderness

Which symptom presents in a patient with acute pancreatitis and indicates complications? Select all that apply. One, some, or all responses may be correct.

Jaundice Darkened urine Clay-colored stools

Which enzyme is responsible for the release of vasoactive peptides, bradykinin, and a plasma kinin?

Kallikrein

Which nursing intervention takes priority in a patient with dysphagia?

Keep the patient on strict NPO status until the ability to swallow is verified.

A patient with hepatic encephalopathy may require which pharmacologic therapy to help decrease serum ammonia levels?

Lactulose

Which medication may cause intestinal bloating and cramping for a patient who is being treated for hepatic encephalopathy?

Lactulose

The nurse suspects a stroke in which area of the brain when a patient presents to the emergency department with aphasia and right-sided hemiplegia?

Left cerebral hemisphere

Which enzyme is involved in enzymatic fat necrosis of the endocrine and exocrine cells of the pancreas?

Lipase

Which nursing intervention would help prevent bile leakage and abscess formation after liver transplantation?

Maintaining the T-tube in a dependent position

When providing community education, the nurse would emphasize that which group should receive immunization for hepatitis B?

Men who prefer sex with men

The nurse suspects which type of stroke when a patient presents with perpetual, spatial, and visual field deficits?

Middle cerebral artery stroke

Which institutional measure should hospitals take to prevent the transmission of hepatitis B (HBV) to health care workers? Select all that apply. One, some, or all responses may be correct.

Needlesticks are the leading cause of HBV exposure among health care workers, so eliminating needles would make a huge effect on preventing transmission of the disease. For postexposure prevention of hepatitis A, the employees should be instructed to seek medical attention immediately for Ig administration. Employees, especially those who are at an increased risk, should be provided with information about the hepatitis B vaccination; this will also prevent hepatitis D by preventing hepatitis B. Hospitals should use Standard Precautions to prevent the transmission of disease between patients or between patients and health care staff. All cases of hepatitis should be reported to the local health department.

The brain must receive a constant flow of which substance for normal function? Select all that apply. One, some, or all responses may be correct.

Oxygen Glucose

A patient has been diagnosed with stage IV metastatic pancreatic cancer. Which management strategy is typical for this type of cancer?

Palliative

A patient reports severe mid-epigastric pain radiating to the left flank and back. The nurse notes generalized jaundice and a gray-blue discoloration of the patient's abdomen and periumbilical area. The nurse suspects which cause of acute pain in this patient?

Pancreatitis

Which nursing assessment is priority for a patient with severe acute pancreatitis?

Perfusion and other signs of shock

Which person has the greatest risk for developing hepatitis A?

Person who consumes raw oysters

When caring for a patient with end-stage liver disease that has resulted in ascites, the registered nurse (RN) can delegate which action to assistive personnel (AP)?

Placing the patient in a semi-Fowler position

The nurse is caring for a patient with acute pancreatitis. The patient is reporting shortness of breath and orthopnea. The patient's vital signs are blood pressure 140/80 mm Hg, pulse 110 beats/min, oxygen saturation 90% on room air, and temperature 99.8°F (37.6°C). Which complication does the nurse suspect?

Pleural effusion

Lactulose may be prescribed for which purpose for a patient with cirrhosis?

Promote GI excretion of ammonia

A patient has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the patient about this therapy, the nurse advises the patient not to mix enzyme preparations with foods containing which element?

Protein

The nurse recognizes which condition when a patient experiences difficulty understanding spoken and written words and uses language that is meaningless?

Receptive aphasia

When caring for a patient who is receiving IV fibrinolytic therapy to treat a stroke, the nurse recognizes that which assessment finding indicates the need to discontinue the infusion?

Report of severe headache

If a health care worker believes that he or she may have been exposed to hepatitis A, which immediate action will help prevent disease development?

Request an injection of immunoglobulin.

A patient is diagnosed with acute pancreatitis. Which test is a sensitive indicator of biliary obstruction in this disorder?

Serum alanine aminotransferase

A patient who has undergone an open Whipple procedure for pancreatic cancer has a heart rate of 110 beats/min, blood pressure of 90/62 mm Hg, and urine output less than 1 mL/kg/hr. The nurse notifies the surgeon to report which postoperative complication?

Shock

In the health record of a patient newly diagnosed with pancreatic cancer, which clue would the nurse consider a risk factor?

Smoking

Which precaution is necessary to implement for a patient with hepatitis A?

Standard Precautions

Which assessment finding would indicate acute graft rejection for a patient who underwent a liver transplantation surgery and is receiving cyclosporine?

Tachycardia

Which statement describes the symptoms of a transient ischemic attack (TIA)?

They typically resolve within 30 to 60 minutes.

Supplementation with which vitamin may be needed for a patient with cirrhosis if the patient is at risk for alcohol withdrawal?

Thiamine

As part of the pathophysiologic process during acute pancreatitis, proteolysis results in which effect?

Thrombosis and gangrene of the pancreas

Which neurologic event does the nurse suspect when the laboratory results of a patient who sustained a stroke show protein in the cerebrospinal fluid (CSF)?

Thrombotic stroke

A patient who has acute pancreatitis is prescribed famotidine. The nurse explains that this drug is given for which purpose?

To decrease gastric acid secretion that often occurs with pancreatitis

The nurse recognizes that which patient assessment finding is consistent with a stroke in the right hemisphere?

Unawareness of any deficit

Which type of stroke has a key feature of coma?

Vertebrobasilar artery stroke

Which symptom presents with a transient ischemic attack (TIA)? Select all that apply. One, some, or all responses may be correct.

Vertigo Aphasia Blurred Vision

After receiving a change-of-shift report, which patient does the nurse plan to assess first?

Young-adult patient with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min

Which patient condition would cause the nurse to question the use of neomycin for a patient with hepatic encephalopathy?

kidney failure

Which term will the nurse use to document round, pinpoint, red-purple lesions for a patient with possible liver dysfunction?

petechiae

Which primary deficit does the nurse expect to find in a patient who is diagnosed with a stroke in the right cerebral hemisphere?

proprioception