50 chapter - exam 1
A patient is diagnosed with gallstones in the bile ducts. What laboratory results should the nurse review? Serum ammonia concentration of 90 mg/dL Serum albumin concentration of 4.0 g/dL Serum bilirubin level greater than 1.0 mg/dL Serum globulin concentration of 2.0 g/dL
Serum bilirubin level greater than 1.0 mg/dL Explanation: If the flow of bile is impeded (e.g., by gallstones in the bile ducts), bilirubin does not enter the intestine. As a result, blood levels of bilirubin increase.
A patient discharged following a laparoscopic cholecystectomy calls the surgeon's office complaining of severe right shoulder pain 24 hours after surgery. Which of the following statements is the correct information for the nurse to provide to this patient? 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. This pain is caused from your incision. Take analgesics as needed and as prescribed and report to surgeon if pain is unrelieved even with analgesic use. This may be the beginning symptoms of an infection. You need to come to see the surgeon today for an evaluation. This pain may be caused by a bile duct injury. You will need to go to the hospital immediately to have this evaluated.
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. Explanation: If pain occurs in the right shoulder or scapular area (from migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure), the nurse may recommend using a heating pad for 15 to 20 minutes hourly, sitting up in a bed or chair, or walking.
Which of the following is clinical manifestation of cholelithiasis? Epigastric distress prior to a meal Clay-colored stools Upper left quadrant abdominal pain Nonpalpable abdominal mass
Clay-colored stools Explanation: The patient 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 patient develops a fever and may have a palpable abdominal mass.
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 Ingestion of foods high in sugar Inability for the liver to reabsorb serum glucose Renal failure
Dysfunction of the pancreatic islet cells Explanation: Diabetes mellitus resulting from dysfunction of the pancreatic islet cells is treated with diet, insulin, or oral antidiabetic agents. The hazard of severe hypoglycemia with alcohol consumption is stressed to the client and family. When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. A standard treatment with pancreatitis is to make the client NPO. The dysfunction is related to the pancreas, not the liver
Which condition is most likely to have a nursing diagnosis of fluid volume deficit? Appendicitis Pancreatitis Cholecystitis Gastric ulcer
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 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? Increased serum calcium levels Elevated urine amylase levels Decreased liver enzyme levels Decreased white blood cell count
Elevated urine amylase levels Explanation: 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 dietary modification is utilized for a patient diagnosed with acute pancreatitis? High-protein diet Elimination of coffee Low-carbohydrate diet High-fat diet
Elimination of coffee Explanation: A high-carbohydrate, low-fat, and low-protein diet should be implemented. Alcohol, caffeine, and spicy foods should be avoided.
A 70-year-old patient 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 of the following gerontologic considerations associated with the pancreas? Decreases in the physiologic function of major organs Increases in the bicarbonate output by the kidneys Increases in the rate of pancreatic secretion Development of local complications
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 patients 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.
Which of the following conditions in a patient with pancreatitis makes it necessary for the nurse to check fluid intake and output, hourly urine output, and monitor electrolyte levels? Frequent vomiting leading to loss of fluid volume Dry mouth, which makes the patient thirsty Acetone in the urine High glucose levels in the blood
Frequent vomiting leading to loss of fluid volume Explanation: 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 patient's fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the patient daily and carefully measures fluid intake and output, including urine output, nasogastric secretions, and diarrhea
A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? Monitor pulse oximetry every hour. Withhold analgesics unless necessary. Instruct the client to cough only when necessary. Use incentive spirometry every hour.
Use incentive spirometry every hour. Explanation: The nurse instructs the client in techniques of coughing and deep breathing and in the use of incentive spirometry to improve respiratory function. The nurse assists the client to perform these activities every hour. Repositioning the client every 2 hours minimizes the risk of atelectasis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring pulse oximetry helps show changes in respiratory status and promotes early intervention, but it would do little to minimize the risk of atelectasis. Withholding analgesics is not an appropriate intervention due to the severe pain associated with pancreatitis.
A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct? "Maintain a high-fat diet and drink at least 3 L of fluid a day." "Maintain a high-sodium, high-calorie diet." "Maintain a high-carbohydrate, low-fat diet." "Maintain a high-fat, high-carbohydrate diet."
"Maintain a high-carbohydrate, low-fat diet." Explanation: A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake isn't necessary because chronic pancreatitis isn't associated with hyponatremia or fluid loss.
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? Increased serum calcium levels Elevated urine amylase levels Decreased liver enzyme levels Decreased white blood cell count
Elevated urine amylase levels Explanation: 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 of the following is a gerontological consideration associated with the pancreas? Increase in fibrous material Increased bicarbonate output Increased rate of pancreatic secretion Increased calcium absorption
Increase in fibrous material Explanation: An increase in fibrous material and some fatty deposition occurs in the normal pancreas of people older than 70 years of age. There is a decreased rate of pancreatic secretion and decreased bicarbonate output in older adults. Decreased calcium absorption may also occur.
From the following profiles of clients, which client would be most likely to undergo the diagnostic test of cholecystography? Steven, suspected of having a tumor in the colon Andrew, suspected of having esophageal abnormalities Mark, suspected of having stones in the gallbladder Sandra, suspected of having lesions in the liver
Mark, suspected of having stones in the gallbladder
The nurse identifies a potential collaborative problem of electrolyte imbalance for a patient with severe acute pancreatitis. Which of the following assessment findings would alert the nurse to an electrolyte imbalance associated with acute pancreatitis? Muscle twitching and finger numbness Paralytic ileus and abdominal distention Hypotension Elevated blood glucose levels
Muscle twitching and finger numbness Explanation: 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. The other data indicate other complications of acute pancreatitis, but are not indicators of electrolyte imbalance.
A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should the nurse administer to the client before surgery? Packed red blood cells Vitamin C Potassium Oral bile acids
Packed red blood cells Explanation: Preoperative preparation includes adequate hydration, correction of prothrombin deficiency with vitamin K, and treatment of anemia to minimize postoperative complications. Parenteral nutrition and blood component therapy are frequently required. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin C has no implications in the surgery.
Which of the following is the major cause of morbidity and mortality in patients with acute pancreatitis? Shock Pancreatic necrosis MODS Tetany
Pancreatic necrosis Explanation: Pancreatic necrosis is a major cause of morbidity and mortality in patients with acute pancreatitis. Shock and multiple organ failure may occur with acute pancreatitis. Tetany is not a major cause of morbidity and mortality in patients with acute pancreatitis.
One difference between cholesterol stones (left) and the stones on the right are that the ones on the right account for only 10% to 25% of cases of stones in the United States. What is the name of the stones on the right? Pigment Pearl Patterned Pixelated
Pigment Explanation: There are two major types of gallstones: those composed predominantly of pigment and those composed primarily of cholesterol. Pigment stones probably form when unconjugated pigments in the bile precipitate to form stones; these stones account for 10% to 25% of cases in the United States. There are no gallstones with the names of pearl, patterned, or pixelated.
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 decrease metabolism To depress the central nervous system and increase the pain threshold To reduce gastric and pancreatic secretions To relieve nausea and vomiting
To reduce gastric and pancreatic secretions Explanation: Anticholinergic medications reduce gastric and pancreatic secretion.
A patient is admitted to the hospital with possible cholelithiasis. What diagnostic test of choice will the nurse prepare the patient for? X-ray Oral cholecystography Cholecystography Ultrasonography
Ultrasonography Explanation: Ultrasonography has replaced cholecystography (discussed later) as the diagnostic procedure of choice because it is rapid and accurate and can be used in patients with liver dysfunction and jaundice. It does not expose patients to ionizing radiation.
The nurse identifies a potential collaborative problem of electrolyte imbalance for a patient with severe acute pancreatitis. Which of the following assessment findings would alert the nurse to an electrolyte imbalance associated with acute pancreatitis? Muscle twitching and finger numbness Paralytic ileus and abdominal distention Hypotension Elevated blood glucose levels
Muscle twitching and finger numbness Explanation: 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. The other data indicate other complications of acute pancreatitis, but are not indicators of electrolyte imbalance.
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 Presence of blood in the client's stool and recent hypertension Presence of easy bruising and bradycardia Adventitious breath sounds and hypertension
Recent weight loss and temperature elevation Explanation: 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. Blood in stools and recent hypertension aren't associated with pancreatitis; fatty diarrhea and hypotension are usually present. Presence of easy bruising and bradycardia aren't found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Adventitious breath sounds and hypertension aren't associated with pancreatitis.
A patient admitted with severe epigastric abdominal pain radiating to the back is vomiting and complaining of difficulty breathing. Upon assessment, the nurse determines that the patent is experiencing tachycardia and hypotension. Which of the following actions is a priority intervention for this patient? Select all that apply. Administer pain-relieving medication. Administer a low-fat diet. Administer electrolytes. Administer plasma. Assist the patient to a semi-Fowler's position
Administer pain-relieving medication. Administer electrolytes. Administer plasma. Assist the patient to a semi-Fowler's position Explanation: The nurse promptly reports decreased BP and reduced urine output, which indicate hypovolemia and shock or renal failure. The treatment goals for acute pancreatitis focus on relieving pain, maintaining circulatory and fluid volume, and decreasing the production of pancreatic enzymes. IV fluid replacement of fluid and electrolytes should begin immediately due to loss of fluid in the body. If hypotension is evident, plasma should be administered to maintain BP within an acceptable range for the patient. Fluids are administered IV and may be accompanied by infusion of blood or blood products to maintain blood volume and to prevent or treat hypovolemic shock. Low serum calcium and magnesium levels may occur and require prompt treatment. The nurse maintains the patient in a semi-Fowler's position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. A low-fat diet, with small frequent meals, should be initiated after control of symptoms. It is not an immediate priority.
Which foods should be avoided following acute gallbladder inflammation? Cooked fruits Cheese Coffee Mashed potatoes
Cheese Explanation: The patient should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the patient 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.
A client with calculi in the gallbladder is said to have Cholecystitis Cholelithiasis Choledocholithiasis Choledochotomy
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.
Several clinical manifestations are associated with a tumor of the head of the pancreas. Choose all that apply. Clay-colored stools Dark urine Jaundice Amber-colored urine Dark-colored stools
Clay-colored stools Dark urine Jaundice Explanation: Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region obstruct the common bile duct. The obstructed flow of bile produces jaundice, clay-colored stools, and dark urine. Malabsorption of nutrients and fat-soluble vitamins may result if the tumor obstructs the entry of bile to the gastrointestinal tract. Abdominal discomfort or pain and pruritus may be noted, along with anorexia, weight loss, and malaise. If these signs and symptoms are present, cancer of the head of the pancreas is suspected.
Which of the following is clinical manifestation of cholelithiasis? Epigastric distress prior to a meal Clay-colored stools Upper left quadrant abdominal pain Nonpalpable abdominal mass
Clay-colored stools Explanation: The patient 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 patient develops a fever and may have a palpable abdominal mass.
When caring for a client with acute pancreatitis, the nurse should use which comfort measure? Administering an analgesic once per shift, as ordered, to prevent drug addiction Positioning the client on the side with the knees flexed Encouraging frequent visits from family and friends Administering frequent oral feedings
Positioning the client on the side with the knees flexed Explanation: 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. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.
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 Preventing fluid volume overload Maintaining adequate nutritional status Teaching about the disease and its treatment
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 client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? Monitor pulse oximetry every hour. Withhold oral feedings for the client. Instruct the client to avoid coughing. Reposition the client every 2 hours.
Reposition the client every 2 hours. Explanation: Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.
A nurse is teaching a patient about the cause of acute pancreatitis. The nurse evaluates the teaching as effective when the patient correctly identifies which of the following conditions as a cause of acute pancreatitis? Fibrosis and atrophy of the pancreatic gland Calcification of the pancreatic duct leading to its blockage Self-digestion of the pancreas by its own proteolytic enzymes Use of loop diuretics to increase the incidence of 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 patients 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 patient comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out possible acute pancreatitis. The nurse would expect the diagnosis to be confirmed with which of the following elevated laboratory tests? Serum calcium Serum bilirubin Serum amylase Serum potassium
Serum amylase Explanation: Serum amylase and lipase levels are used in making the diagnosis of acute pancreatitis. Serum amylase and lipase levels are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated for a longer period, often days longer than amylase. Urinary amylase levels also become elevated and remain elevated longer than serum amylase levels.
The physician has written the following orders: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) for a new patient admitted with pancreatitis. The nurse attributes which of the following as the cause for NPO status? To drain the pancreatic bed To aid opening up of pancreatic duct To prevent the occurrence of fibrosis To avoid inflammation of the pancreas
To avoid inflammation of the pancreas Explanation: Pancreatic secretion is increased by food and fluid intake and may cause inflammation of the pancreas.
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 Vitamin B6 Vitamin B12 Vitamin C
Vitamin A Explanation: Obstruction of bile flow interferes with absorption of the fat-soluble vitamins A, D, E, and K. Clients may exhibit deficiencies of these vitamins if biliary obstruction has been prolonged. Vitamins B6, B12, and C are not fat soluable.
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? Potassium Vitamin K Vitamin B Oral bile acids
Vitamin K Explanation: 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. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.
