CH 43 Disorders of the Biliary Tract, Disorders of the Pancreas, and Disorders of the Liver

Which tests might be ordered for patients admitted with symptoms of cholecystitis? Select all that apply.

Abdominal ultrasound Endoscopic retrograde cholangiopancreatography (ERCP) Abdominal ultrasound and ERCP are commonly ordered for diagnosis of suspected cholecystitis. Stool samples are not generally ordered in instances of cholecystitis. Serum α-fetoprotein is used in the diagnosis of liver cancer, generally coupled with ultrasound. Secretin stimulation tests are used in the diagnosis of chronic pancreatitis.

Which risk factor is most commonly associated with cirrhosis?

Alcohol abuse Cirrhosis is highly correlated with alcohol abuse and chronic hepatitis C. Polypharmacy, drug abuse, and hepatitis A are not linked to cirrhosis.

Which finding in the patient's history increases the risk for acute pancreatitis?

Alcohol abuse 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. Emphysema, diabetes mellitus, and congestive heart failure may be co-morbidities but are not themselves directly related to acute pancreatitis.

A high blood level of which substance causes hepatic coma?

Ammonia A high ammonia level in the blood is a late manifestation of liver failure that results in hepatic coma, causing neurologic dysfunction and brain damage. Sodium, calcium, and potassium levels do not cause hepatic coma.

The health care provider prescribes lactulose for a patient with hepatic encephalopathy. Which data would the nurse monitor for effectiveness of this medication?

Ammonia levels Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy. Lactulose does not decrease liver enzymes. Lactulose causes diarrhea as a side effect, but that is not the intended effect. Lactulose does not relieve abdominal pain.

The nurse provides information to a student nurse about endoscopic retrograde cholangiopancreatography (ERCP). Which statement made by the student nurse indicates the need for further teaching?

"Oral dissolution therapy is used along with the procedure." Oral dissolution therapy is used along with extracorporeal shock-wave lithotripsy (ESWL) for facilitating removal of disintegrated gallstones. It is not used with ERCP. ERCP allows visualization of the biliary system and pancreatic duct. Attachments such as the electrodiathermy knife are used to cut up a gallstone, and a catheter with a wire basket can be used to retrieve a gallstone.

Which intervention would the nurse include for a patient who is undergoing radiation therapy for pancreatic cancer?

Providing brightly colored and attractive food Patients undergoing radiation therapy experience loss of appetite. Serving brightly colored and attractive food may increase the patient's appetite. Giving low-fiber foods can result in constipation in the patient. Radiation therapy causes skin irritation, which should be brought to the health care provider's notice. Increasing dairy products in the diet may not improve the patient's appetite.

For which purpose would a patient with pancreatic cancer receive radiation therapy?

Relieve pain Radiation therapy alone for pancreatic cancer has little effect on survival but may be effective for pain relief. Radiation therapy does not reduce ascites, increase survival time, or inhibit tumor metastasis to other areas of the body.

Which vitamin supplements would the nurse anticipate administering for a patient with a biliary obstruction? Select all that apply.

Vitamins A, D, E, K Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat soluble and thus would need to be supplemented in a patient with biliary obstruction. Vitamin B is water soluble and would not be recommended for a patient with biliary obstruction.

A patient with acute hepatitis B will be discharged tomorrow. Which measures will the nurse include in the discharge teaching plan? Select all that apply.

Allow for periods of rest during the day. Avoid foods that are very hot or very cold. Eat small meals frequently rather than three larger meals a day. Rest is an important factor in promoting hepatocyte regeneration. Several measures are important for ensuring that the patient with hepatitis receives adequate nutrition. Drinking carbonated beverages and avoiding very hot or very cold foods may help alleviate anorexia. The anorexia and distaste for food cause nutritional problems. Small, frequent meals may be preferable to three large ones and may also help prevent nausea. 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 forever.

Which hepatitis virus is transmitted from mother to fetus?

Hepatitis B The hepatitis B virus is transmitted perinatally from mother to fetus. Studies show that most mother-to-child hepatitis B virus (HBV) transmission occurs during or shortly before delivery. The hepatitis A virus is transmitted through the fecal-oral route by consuming foods or drinks contaminated with the hepatitis A virus. The hepatitis C virus is transmitted by sharing contaminated needles. The hepatitis E virus is also transmitted by the fecal-oral route.

Which type of sample would the nurse collect to determine whether the patient has steatorrhea?

Stool Steatorrhea is manifested by fatty and foul-smelling stools. Therefore a stool sample is used to diagnose steatorrhea in patients with pancreatitis. Urine, blood, and sputum samples are not helpful in determining steatorrhea. They are helpful in determining abnormalities in the kidney, blood, and digestive system.

The nurse is teaching a student nurse about postoperative care for a patient who has undergone laparoscopic cholecystectomy. Which statements made by the student nurse indicate the need for further teaching? Select all that apply.

"I will need to administer narcotics for pain control." "The patient will use a bedside commode for the first 24 hours after surgery." "The patient will need to return to the office in 10 days for removal of stitches." Postoperative pain can usually be controlled with over-the-counter pain relievers. Patients who have undergone laparoscopic cholecystectomy can usually walk to the bathroom, so there is no need for a bedside commode. With laparoscopic cholecystectomy, there are small incisions that are covered by small adhesive bandages that can be removed in about five days. The stitches dissolve over time. A cholecystectomy may result in changes in prothrombin time and may cause bleeding. Therefore the nurse should monitor for bleeding. Deep-breathing exercises should be encouraged to prevent postoperative pneumonia and to help relieve the patient's discomfort.

Which statement from a male patient with acute hepatitis C virus (HCV) indicates understanding of health promotion?

"I will need to be checked for chronic HCV and other liver problems." The majority of patients who acquire HCV develop chronic infection, which may lead to cirrhosis or liver cancer. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adefovir is taken for severe hepatitis B virus (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. HCV is not transmitted via saliva but percutaneously and via high-risk sexual activity exposure. 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.

The patient with cirrhosis is learning self-care. Which statement indicates that the patient needs more teaching?

"If I notice a fast heart rate or irregular beats, that is normal for cirrhosis." 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 because this is not normal for cirrhosis and is potentially dangerous. A scrotal support may improve comfort if there is scrotal edema. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency.

Which enzyme is responsible for autodigestion of the pancreas and leads to bleeding in a patient with acute pancreatitis?

Activated trypsin In acute pancreatitis, trypsin that is present in the pancreas autodigests the pancreas, resulting in bleeding. Enterokinase converts inactivated trypsinogen produced by the pancreas into activated trypsin. Alkaline phosphatase and alanine aminotransferase are liver enzymes and do not play a role in pancreatitis.

The nurse is preparing education for a group of student nurses about endoscopic retrograde cholangiopancreatography (ERCP). Which information would the nurse include in the teaching? Select all that apply.

An endoscope is passed into the duodenum. The endoscope leaves the stone in the duodenum. The stent associated with ERCP can be removed after a few months. ERCP involves the passage of an endoscope into the duodenum and allows visualization of the biliary system. An endoscope used in ERCP has an electrodiathermy knife attached to it, which cuts the stone and leaves it in the duodenum for easy elimination through the stool. The stent associated with ERCP can be removed or changed after a few months. ERCP does not extend to the colon. A colonoscopy would be used for visualization of the colon. Cholecystostomy is the surgical procedure that creates a stoma in the gallbladder.

A patient with cirrhosis of the liver is admitted to the hospital. Which hematologic symptoms are likely in this patient? Select all that apply.

Anemia Leukopenia Thrombocytopenia Hematologic problems include thrombocytopenia, leukopenia, anemia, and coagulation disorders. Anemia, leukopenia, and thrombocytopenia are probably caused by the splenomegaly that results from the backup of blood from the portal vein into the spleen (portal hypertension). Overactivity of the enlarged spleen results in increased removal of blood cells from circulation. Anemia is also due to inadequate red blood cell (RBC) production and survival, poor diet, poor absorption of folic acid, and bleeding from varices. Leukemia and polycythemia vera are not caused by cirrhosis.

Which guidance would the nurse provide to a patient diagnosed with cirrhosis whose abdomen is distended and has a visible fluid wave? Select all that apply.

Avoid alcohol. Restrict sodium in the diet. Take lactulose as directed. Expect urinary frequency with spironolactone. Management of cirrhosis focuses on slowing the progression of disease while preventing or treating complications. Abdominal distension and a visible fluid wave are signs of ascites, a complication of cirrhosis and an indication of disease progression. Cessation of alcohol consumption will prevent further damage to the liver. Sodium restriction is a hallmark of ascites management and can help prevent the reaccumulation of fluid. Lactulose Lactulose is used to treat hepatic encephalopathy and manage ammonia levels. Frequent loose stools result, and patients very often need to be encouraged to take the medication as directed. Spironolactone is an aldosterone antagonist and potassium-sparing diuretic that is frequently used to help manage ascites. The nurse will discuss the therapeutic effect with the patient, which is increased urination. Referral to nephrology is not likely to be necessary at this point as there is nothing to suggest impaired kidney function.

Which dietary advice will the nurse give a patient after a cholecystectomy? Select all that apply.

Eat a high-fiber diet. Have small but frequent meals. Avoid or keep fats to a minimum. Having a high-fiber diet helps in the smoother passage of stools and prevents constipation. Having small and frequent meals helps digestion and prevents nausea. Fats are harder to digest. After cholecystectomy, it is essential that the patient has an adequate intake of water, around 2500 to 3000 mL per day. The patient should not have the usual foods that he or she used to consume; modifications are needed to facilitate easy digestion of food in the absence of the gallbladder.

A patient is in the acute phase of hepatitis A. Which symptoms is the patient likely to be experiencing? Select all that apply.

Fatigue Pruritus A 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 visual disturbances are not symptoms of the acute phase of hepatitis A.

A patient with type 2 diabetes mellitus has been diagnosed with non-alcoholic fatty liver disease (NAFLD). Which information would the nurse include in the teaching plan?

Following measures to gain tighter glucose control NAFLD can progress to liver cirrhosis. There is no definitive treatment, and therapy is directed at reduction of risk factors, which include treatment of diabetes, reduction in body weight, and elimination of harmful medications. For those who are overweight, weight reduction is important. Weight loss improves insulin sensitivity and reduces liver enzyme levels. NAFLD does not show up positive on a genetic test. It is not recommended to eliminate carbohydrates from the diet. NAFLD is not caused by alcohol, and the question does not imply that the patient drinks.

Which aspect would the nurse monitor for in a patient who has cholecystitis?

Gums for bleeding Cholecystitis is associated with decreased production of prothrombin, a clotting factor, thereby putting the patient at risk of bleeding. Common bleeding sites are mucous membranes of the gums, mouth, and nose, as well as injection sites. A patient with cholecystitis does not show alterations in blood glucose levels. Asterixis is a finding common in hepatic encephalopathy and would not be expected with cholecystitis. A patient with cholecystitis does not show alterations in serum creatinine levels.

A patient with a history of alcohol abuse reports dull abdominal pain, yellowing eyes, nausea, and vomiting for three weeks. The laboratory report reveals that the patient has elevated serum levels of the liver enzymes and an increased level of serum α-fetoprotein. Which condition would the nurse suspect?

Hepatocellular cancer The nurse suspects that the patient has hepatocellular cancer. Abdominal pain, jaundice, nausea, and vomiting are the clinical manifestations of hepatocellular cancer, and an elevated level of serum α-fetoprotein is used as a marker for liver cancer. Patients with cirrhosis have elevated levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Jaundice, encephalopathy, and coagulation abnormalities are the clinical manifestations of acute liver failure. Hepatic encephalopathy causes impaired consciousness and changes in neurologic and mental behavior. Patients with hepatic encephalopathy have increased levels of ammonia in their blood.

Which clinical manifestations are seen with chronic hepatitis? Select all that apply.

Hepatomegaly Elevated liver enzymes Chronic hepatitis is manifested by hepatomegaly and elevated liver enzymes, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Fever, nausea, vomiting, and decreased sense of taste are associated with acute hepatitis.

The nurse is planning discharge teaching for a patient after a laser laparoscopic cholecystectomy. Which patient statements indicate understanding of the discharge teaching? Select all that apply.

I can have normal food that is low in fat. I may have mild shoulder pain for a week. After the procedure, the diet should be high in fiber and low in fat. Having mild shoulder pain after cholecystectomy is common due to diaphragmatic irritation. After cholecystectomy, it is essential that the patient doesn't lift heavy weights for weeks so that abdominal pressure doesn't increase. The patient can bathe and shower normally after a couple of days. The patient doesn't need to follow a liquid diet.

Which information would the nurse include when teaching a student nurse about an open cholecystectomy?

Insertion of a T-tube following surgery Open cholecystectomy involves removal of the gallbladder through an abdominal incision. The T-tube facilitates drainage from the common bile duct into an external collection device. The T-tube is then discontinued, and the insertion point heals spontaneously. Radiofrequency ablation involves insertion of a needle into the core of the tumor and is performed on patients with liver cancer. The Whipple procedure is used in pancreatic cancer and involves resection of the proximal pancreas and duodenum. Administration of an embolic agent through the catheter into the artery near the tumor is done in chemoembolization, which is a treatment option for patients with liver cancer.

A patient has been diagnosed with cholelithiasis. Which findings would indicate possible obstructed bile flow? Select all that apply.

Jaundice Steatorrhea Dark-amber urine Bleeding tendencies Manifestations of obstructed bile flow in a patient with cholelithiasis include jaundice, dark-amber urine that 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.

A patient with advanced cirrhosis asks why the skin is so yellow. Which information would the nurse use to provide a response?

Jaundice results from the body's inability to conjugate and excrete bilirubin. 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 lack of clotting factors, an excess of bile salts, or decreased colloidal oncotic pressure.

Which postoperative care would the nurse perform for a patient after a cholecystectomy? Select all that apply.

Maintain a low-fat diet. Monitor for any bleeding. Place the patient in the Sims' position. After cholecystectomy, it is important to follow dietary restrictions. A diet low in fat decreases the workload of the liver. Bleeding is a complication after the procedure; hence the nurse should monitor for it. It is important to position the patient in the Sims' position to facilitate gas pockets moving away from the diaphragm. Encourage deep breathing along with movement and ambulation to help to expand the lungs and promote ventilation. The patient need not be put in the Trendelenburg position; it will cause abdominal discomfort and does not contribute to recovery.

A patient with type 2 diabetes and cirrhosis asks the nurse whether it would be okay to take silymarin (milk thistle) to help minimize liver damage. Which information provides a rationale for the nurse's response?

Milk thistle may affect liver enzymes and alter drug metabolism. Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore patients will need to be monitored for drug interactions. It is noted to be safe for up to six years, not 10 years. 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 may lower, not elevate, blood glucose levels.

A patient with cholecystitis receives a prescription for cholestyramine in powdered form. Which medication instruction would the nurse provide?

Mix the medication with four to six ounces of milk. Cholestyramine is an antihistamine that effectively treats pruritus. The powdered form of cholestyramine should be mixed with four to six ounces of milk to ensure adequate absorption. Cholestyramine can be taken along with fruit juices and water. The powdered form of cholestyramine medication should be taken by mixing with milk or juice, not directly from the container.

A patient with gallbladder disease has frequent episodes of severe vomiting. Which interventions would the nurse include in the patient's plan of care? Select all that apply.

Monitor vital signs. Perform gastric decompression. Place the patient on a low-fat diet. The nurse should monitor for the patient's vital signs to reduce the risk of any complications. It may be necessary to insert a nasogastric tube and use gastric decompression for patients with severe nausea and vomiting. For patients with less severe nausea and vomiting, antiemetics are usually adequate. Because the patient is vomiting frequently, the nurse should rinse the patient's mouth every two hours to provide comfort. Consuming fat may stimulate the gallbladder; the patient should be placed on a low-fat diet.

A patient with acute pancreatitis reports severe abdominal pain. Which medication would the nurse anticipate administering to alleviate the pain?

Morphine Morphine is an opioid analgesic that relieves acute, severe pain. Omeprazole is an antacid that decreases gastric acid secretion. Pancrelipase is a synthetic product used for pancreatic enzyme replacement in patients with chronic pancreatitis. Acetazolamide is a diuretic and is not effective in relieving pain.

A patient returns to the surgical center for his postoperative visit 10 days after a cholecystectomy. The patient's wife asks whether she should be concerned about having cholelithiasis as well. Which information about risk factors would the nurse consider in providing a response?

Obesity increases the risk, especially in women. Obesity causes increased secretion of cholesterol in bile, increasing the prevalence of cholelithiasis. Pregnancy is a high-risk factor for cholelithiasis, and multiparous women have the greatest risk of all. Cholelithiasis is more common in women than in men. Gender differences in the incidence of cholelithiasis decrease after 50 years of age.

The nurse is providing immediate postprocedural care to a patient who underwent endoscopic retrograde cholangiopancreatography (ERCP). Which actions would the nurse take? Select all that apply.

Observing for signs of bleeding Maintaining the patient on bed rest Observing for any change in body temperature Patients who undergo ERCP are at risk of developing infection, bleeding, and pancreatitis. Therefore the nurse should observe for signs of bleeding, encourage bed rest, and monitor for changes in body temperature. Gag reflex is absent after the surgery, and the nurse should wait for the gag reflex to return before providing food or fluids.

Insertion of a T-tube following surgery

Open cholecystectomy involves removal of the gallbladder through an abdominal incision. The T-tube facilitates drainage from the common bile duct into an external collection device. The T-tube is then discontinued, and the insertion point heals spontaneously. Radiofrequency ablation involves insertion of a needle into the core of the tumor and is performed on patients with liver cancer. The Whipple procedure is used in pancreatic cancer and involves resection of the proximal pancreas and duodenum. Administration of an embolic agent through the catheter into the artery near the tumor is done in chemoembolization, which is a treatment option for patients with liver cancer.

Which item reported in a patient's history increases the risk of developing cholelithiasis?

Oral contraceptive use Oral contraceptives affect cholesterol production, thereby resulting in gallbladder cholesterol saturation, which causes gallbladder diseases such as cholelithiasis. Antibiotics, vasodilators, and anticholinergics do not affect cholesterol production and metabolism.

Which condition is associated with the accumulation of fluid, pancreatic enzymes, tissue debris, and inflammatory exudates?

Pancreatic pseudocyst A pancreatic pseudocyst is an accumulation of fluid, pancreatic enzymes, tissue debris, and inflammatory exudates surrounded by a wall. Biliary sludge is a mixture of cholesterol crystals and calcium salts. Biliary atresia is a congenital condition in which the bile duct is closed or absent. Pancreatic abscess is a collection of pus resulting from necrosis of the pancreas.

Which factors can lead to a patient developing ascites? Select all that apply.

Portal hypertension Hyperaldosteronism Decreased serum colloidal oncotic pressure Portal hypertension causes an increase in resistance to blood flow in the liver leading to ascites. Hyperaldosteronism, or increased secretion of aldosterone, causes ascites. When there is decreased serum colloidal oncotic pressure, there is impairment of synthesis of albumin and loss of albumin in the peritoneal cavity, leading to ascites. Diabetes is a metabolic syndrome and does not cause ascites. Increased flow of hepatic lymph, not decreased flow, leads to ascites.

Which action would the nurse perform immediately for a patient with acute pancreatitis who develops acute respiratory distress syndrome (ARDS)?

Provide ventilatory support. Difficulty in breathing and shortness of breath are characteristics of ARDS. If ARDS develops, the patient would require ventilator support because mechanical ventilation and intubation are required to save the patient from this life-threatening condition. A chest x-ray is ordered to confirm obstructions in the respiratory tract; however, immediate action to save the patient's life does not involve performing an x-ray. Normal saline contains sodium chloride—an electrolyte solution—and will not resolve breathing difficulty. Chest compressions may further worsen the condition because severe compressions may cause lung injury.

A patient who has acute cholecystitis is fearful of undergoing surgery and wants to try conservative management. Which prescriptions would the nurse expect to see entered in the patient record? Select all that apply.

Repeat complete blood count Hydromorphone 2 mg IV every six hours PRN for pain Ondansetron 4 mg IV every six hours for nausea and vomiting Conservative management for acute cholecystitis focuses on symptom management and observation for complications. A complete blood count monitors the white blood cell count; if elevated, this could signal infection. Patients with acute cholecystitis frequently have pain and may be treated with an IV opioid such as hydromorphone, and nausea and vomiting are other common symptoms that are frequently relieved with antiemetics. A regular diet is not indicated. These patients are initially required to fast and then progress to clear liquids. Insertion of a nasogastric tube may be indicated if the patient's condition worsens or if nausea and vomiting persist after the administration of antiemetics.

The nurse is providing discharge instructions to a patient and caregiver following a laparoscopic cholecystectomy. Which measures will be included in the discharge teaching? Select all that apply.

Resume normal activities gradually within one week. Eat a low-fat diet for several weeks after the surgery. Report any bile-colored drainage or pus from any incision. After a laparoscopic cholecystectomy, the nurse should instruct the patient to gradually resume normal activities, usually within one week. The nurse should also instruct the patient to have liquids for the rest of the day and eat light meals for a few days. The amount of fat in the postoperative diet depends on the patient's tolerance of fat. A low-fat diet may be helpful if the flow of bile is reduced (usually only in the early postoperative period) or if the patient is overweight. Sometimes the patient is instructed to restrict fats for four to six weeks. Otherwise, no special dietary instructions are needed other than to eat nutritious meals and avoid excessive fat intake. The bandages are to be removed the day after the surgery. Patients need to report any bile-colored drainage or pus from any incision. Patients who undergo a laparoscopic cholecystectomy will not have a T-tube present.

A patient reports loss of appetite, nausea, vomiting and darkened urine. Laboratory test results reveal a positive hepatitis C (HCV) antibody. Which medication does the nurse anticipate will be prescribed?

Simeprevir Fatigue, loss of appetite, nausea, and vomiting are the clinical manifestations of hepatitis. A positive report for the HCV antibody confirms hepatitis C infection. Simeprevir is a protease inhibitor and is effective in the treatment of hepatitis C. Adefovir, entecavir, and tenofovir belong to the class of nucleoside and nucleotide analogs and are used in the treatment of hepatitis B infection.

Which food in the patient's diet would likely facilitate improvement in the condition of cholelithiasis?

Skim milk Skim milk is rich in calcium and low in fat. Patients with cholelithiasis should consume a diet rich in calcium and fiber and low in fat. Butter, yogurt, and cheese are rich in fats. Fat-rich foods should not be consumed by patients with biliary tract disease such as cholelithiasis or cholecystitis.

A nurse is caring for a patient who has cirrhosis of the liver. Which clinical manifestations would the nurse expect to find? Select all that apply.

Small areas of bleeding into the skin Vascular lesions formed by small blood vessels 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.

Which body substance would the nurse observe to evaluate the effectiveness of pancreatic enzyme replacement for a patient with chronic pancreatitis?

Stool Patients with pancreatitis have diminished or absent pancreatic lipases, the enzymes that break down fat. This leads to steatorrhea, which is characterized by greasy and foul-smelling stools. Therefore observing the patient's stool for steatorrhea helps to determine the effectiveness of pancreatic enzymes. The effectiveness of enzymes cannot be determined by observing the urine, saliva, or nasal secretions.

A patient is advised to undergo laparoscopic cholecystectomy. The patient asks the nurse what exactly this procedure means. Which points will the nurse include in an explanation? Select all that apply.

The gallbladder is removed through one to four small punctures on the abdominal wall. The procedure is done under anesthesia, using a laparoscope and grasping forceps. The patient can be discharged on the day of operation or the next day and resume work in a week. Laparoscopic cholecystectomy involves making one to four 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 because the recovery is fast. This procedure does not involve an abdominal incision. A T-tube may be left in place after an open cholecystectomy but is not used after a laparoscopic cholecystectomy.

Which surgical instrument is used preoperatively in a patient who will be undergoing an open cholecystectomy?

Transhepatic biliary catheter Open cholecystectomy involves the removal of the gallbladder through a right subcostal incision. A transhepatic biliary catheter can be used preoperatively in patients who will undergo an open cholecystectomy. A transhepatic biliary catheter is inserted for palliative care when inoperable liver, pancreatic, or bile duct carcinoma obstructs the bile flow. A laparoscope is an instrument inserted during laparoscopic procedures. Biliary stents and catheters with wire baskets are used during endoscopy.

A patient with hepatitis A infection is being discharged from the hospital. Which instruction would the nurse include in the discharge teaching?

Wash hands carefully after bowel movements. The mode of transmission of hepatitis A infection is the fecal-oral route. Therefore it is very important to maintain personal and environmental hygiene. The nurse should teach the patient and the family members about careful hand washing immediately after bowel movements and before eating to prevent outbreaks of hepatitis A viral infection. Not sharing toothbrushes and razors is a concern for the prevention of hepatitis B and C because they are transferred through blood contact. There is no need to isolate the patient with hepatitis A unless he or she is incontinent or maintains poor personal hygiene. Acetaminophen may cause liver damage and should be avoided in hepatic viral infection.

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill. Which response would the nurse provide?

"An injection of immunoglobulin will need to be given to prevent or minimize the effects of exposure." Immunoglobulin provides temporary (one to two months') passive immunity and is effective for preventing hepatitis A if given within two weeks after exposure. The hepatitis vaccine is used only for preexposure prophylaxis. Testing for prior exposure is not needed. Immunoglobulin may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection.

Which description of the Whipple procedure made by a patient demonstrates a need for further education?

"Complete removal of the stomach." A Whipple procedure involves removing the distal part of the stomach, which is a partial removal of stomach. Therefore the statement "Complete removal of the stomach" is incorrect. However, the procedure does involve complete removal of the duodenum (a duodenectomy), removal of the distal portion of the common bile duct, and removal of the proximal pancreas (a proximal pancreatectomy).

Which conditions may cause pancreatitis? Select all that apply.

1. Gallstones 2. Cystic fibrosis 3. Alcohol abuse Pancreatitis is an inflammation of the pancreas. Gallstones and alcohol abuse are the causes of acute pancreatitis, while cystic fibrosis can cause chronic pancreatitis. Isoniazid therapy is associated with acute liver failure. Contamination of food by feces causes hepatitis.

Which image best shows a cirrhotic liver?

1

Which substance is involved in the development of cholelithiasis?

Calcium Cholelithiasis occurs due to an imbalance in the system that maintains calcium, bile salts, and cholesterol in a solution form, thereby resulting in precipitation. Albumin, sodium, and globulin are not involved in the formation of cholelithiasis.

Which term is used for the formation of stones in the gallbladder?

Cholelithiasis Cholelithiasis is the formation of stones in the gallbladder. The pain associated with cholelithiasis is called biliary colic. Cholangitis is inflammation of bile ducts. Inflammation of the gallbladder is called cholecystitis.

A patient with cholelithiasis is experiencing severe itching. Laboratory findings reveal a 2.1 mg/dL bilirubin level. Which medication is likely to be prescribed?

Cholestyramine Bilirubin levels in a healthy individual are between 0.3 and 1.9 mg/dL. The patient's laboratory reports indicate hyperbilirubinemia, which results in jaundice. Moreover, the patient has severe itching, or pruritus. Pruritus that is accompanied by jaundice is treated with cholestyramine. Nadolol is a β-blocker used for patients with cirrhosis to reduce bleeding from varices. Lactulose is used for relieving constipation. Vasopressin is a vasoconstrictor drug that controls bleeding from the varices and maintains hemostasis.

Which assessment finding would the nurse expect when caring for a patient who has gallstones?

Clay-colored stools The presence of gallstones results in bile flow obstruction, which is manifested by fever, clay-colored stools, and dark urine. Tachycardia and hypotension are the clinical manifestations of acute pancreatitis. Hyperglycemia is seen in patients with chronic pancreatitis.

The nurse discovers a bluish discoloration of the periumbilical area on a patient who has been admitted with severe pancreatitis. How would the nurse document this finding?

Cullen's sign Bluish discoloration of the periumbilical region is called Cullen's sign and can result from seepage of blood-stained exudate from the pancreas, which may occur in severe pancreatitis. Asterixis refers to tremors, which begin upon stretching the wrist. Spider angioma is a dilated blood vessel with a red center that branches out; it is a manifestation of cirrhosis. Grey Turner's sign is a bluish discoloration of the flank region.

A patient is diagnosed with chronic cholecystitis. Which assessment finding would the nurse expect?

Flatulence Chronic cholecystitis is an obstruction of the gallbladder, which is manifested by flatulence, dyspepsia, and heartburn. Urticaria and weight loss are characteristics of acute pancreatitis. Indigestion is a manifestation of acute cholecystitis.

Which dietary recommendation would the nurse give to a patient with chronic gallbladder disease?

Include fat-soluble vitamins. Patients with chronic gallbladder diseases have a deficiency of fat-soluble vitamins. Therefore the nurse should include fat-soluble vitamins in the patient's diet plan. Dairy products are rich in saturated fats, which are contraindicated for patients with gallbladder disease because dairy stimulates the gallbladder, causing pain. A low-protein diet is given to patients with kidney disease because improper functioning of the kidneys reduces the ability to excrete the nitrogenous waste. As a result, these substances accumulate in the brain, leading to neurologic complications. Refined cereals have less fiber content. However, patients with gallbladder disease require a diet high in fiber because fiber is known to reduce the risk of developing gallstones, thereby preventing complications.

Which information would the nurse emphasize while teaching a patient ways to avoid exposure to hepatitis B infection? Select all that apply.

Use disposable needles and syringes. Avoid sharing toothbrushes and razors. Avoid unsafe sex with multiple partners, and always use condoms. Hepatitis B spreads through sexual contact and through blood. Sharing razors or toothbrushes with an infected person may introduce infection in another person's body. Similarly, a needle used by an infected person can spread the infection. Hepatitis B also spreads via sexual exposure with an infected person. Using a condom gives some protection against the spread of infection. Hepatitis B doesn't spread through water and food. Hepatitis B doesn't spread with general casual contact with people.

Which function do bile salts facilitate in the body?

Vitamin absorption Bile salts help in the absorption of vitamins and the digestion of food. Proteases are the enzymes that metabolize proteins. Glucose is metabolized by the liver, and ammonia is eliminated by the kidneys.

Which statement made by the patient indicates the need for further teaching about laparoscopic cholecystectomy?

"I will have work restrictions for six weeks after surgery." Laparoscopic cholecystectomy is a minimally invasive surgery that involves removal of the gallbladder. Postoperative pain is minimal, and the patient can resume his or her work within one week of the surgery. The procedure involves making small punctures into the abdomen through which an instrument called a laparoscope is inserted. The patient is discharged on the day of surgery or a day after it. The laparoscope has a camera attached to it, which is inserted through the punctures.

Which information would the nurse provide to the patient after a laparoscopic cholecystectomy?

A diet lower in fat may be better tolerated for several weeks. 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.

Which finding would the nurse expect in a patient who has cholecystitis?

Abdominal rigidity Physical findings in patients with cholecystitis are abdominal rigidity and tenderness in the right upper quadrant. A spider angioma is a manifestation of liver cirrhosis wherein the patient has a small, dilated blood vessel with a red center and branching of the blood vessel. Flapping tremors are seen in patients with hepatic encephalopathy, which is characterized by rapid flexion and extension movements when asked to stretch the hand. Grey Turner's sign is a manifestation of acute pancreatitis characterized by bluish discoloration of the flanks.

Which assessment finding would the nurse expect in a patient with a high ammonia level associated with hepatic encephalopathy?

Asterixis 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.

Which condition causes the formation of biliary sludge?

Bile stasis Biliary sludge is a mixture of cholesterol and bile salts and is caused by bile stasis. Ascites is associated with low serum albumin levels and liver cirrhosis. Hepatitis is inflammation of the liver; it does not cause biliary sludge. Patients with gallstones have severe pain due to the presence of stones. This pain is referred to as biliary colic.

Which term is used for the substance made of cholesterol crystals and calcium salts found in a patient with pancreatitis?

Biliary sludge Biliary sludge is a mixture of cholesterol crystals and calcium salts and is seen in patients with bile stasis. Apraxia is the inability to construct simple figures. Biliary atresia refers to congenital biliary abnormalities. Pancreatic abscess is a condition associated with the collection of pus in the pancreas.

The nurse suspects that a patient with cholelithiasis has developed choledocholithiasis. Increases in which assessment finding would support the nurse's suspicion? Select all that apply.

Bilirubin Body temperature Choledocholithiasis is manifested by jaundice caused by elevated levels of bilirubin, fever, and chills. Creatinine levels are elevated in kidney diseases. The platelet count is increased in allergic reactions, infection, and splenectomy. The alkaline phosphatase level is elevated in liver diseases.

Which assessment findings are associated with complications of cirrhosis of the liver? Select all that apply.

Black, tarry stools Pedal edema Mental staComplications of cirrhosis of the liver include peripheral edema, gastric varices, and hepatic encephalopathy. Peripheral edema presents itself as swelling/edema of the feet, or pedal edema. Hepatic encephalopathy presents as disorientation, altered mental status, sleep disturbance, and lethargy. Gastric varices bleed easily. This bleeding can present as blood in vomitus or blood in the stool. Cirrhosis doesn't typically cause chest pain, diaphoresis, or productive cough.tus changes

Which conditions may require a patient's scheduled percutaneous liver biopsy to be rescheduled? Select all that apply.

Bleeding disorder Low hemoglobin level A patient with bleeding disorder or a preprocedure low hemoglobin level may not be an appropriate candidate for liver biopsy due to the increased risk of postprocedure bleeding. A diagnosis of chronic hepatitis is not a reason to postpone a liver biopsy; in fact, it is an indication for liver biopsy. Hepatic cirrhosis or autoimmune hepatitis are not reasons to postpone a liver biopsy; the biopsy is being done to further diagnose or stage the disease.

Which finding for a patient with pancreatitis is termed Grey Turner's sign?

Bluish discoloration of the flank area The Grey Turner's sign includes a bluish discoloration, or ecchymosis, on the left or right flank area, the result of internal bleeding caused by pancreatitis. Jaundice of the sclera is associated with liver disorders and with increased serum bilirubin. Bluish discoloration of the periumbilical area is also seen in bleeding associated with pancreatitis and is known as the Cullen's sign. Left abdominal pain that occurs with movement may be seen with pancreatitis but is not associated with the Grey Turner's sign.

Which factor explains why patients with cholelithiasis experience pruritus?

Deposition of bile salts in tissues Pruritus is manifested by itching and is caused by deposition of bile salts in skin tissues. Solubility of bilirubin in the urine results in amber-colored urine that foams on shaking; it does not result in pruritus. Vitamin K is an important element in the clotting pathway. Its decreased absorption may cause clotting problems, resulting in bleeding. When bile does not flow into the duodenum, it accumulates in the systemic circulation and results in obstructive jaundice.

Which condition is associated with acalculous cholecystitis?

Diabetes mellitus Acalculous cholecystitis is an inflammatory process that occurs in the absence of obstruction and is associated with diabetes mellitus. Cholangitis and choledolithiasis are complications of cholelithiasis, not acalculous cholecystitis. Acute pancreatitis is not associated with acalculous cholecystitis.

The BP of a patient with pancreatitis dropped from 125/80 mm Hg to 90/60 mm Hg. The nurse administers isotonic fluid without an increase in the patient's BP. Which medication would the nurse anticipate will be prescribed by the health care provider?

Dopamine Acute pancreatitis is associated with hypotension. Therefore, to return the BP to normal, vasoactive drugs such as dopamine may be prescribed. These drugs increase the total vascular resistance, thereby increasing BP. Morphine is an analgesic and is used to relieve pain. Omeprazole is an antacid that reduces the production of gastric hydrochloric acid (HCl). Pancrelipase is a synthetic enzyme and is prescribed for chronic pancreatitis in which there is a deficiency of pancreatic enzymes.

A patient tells the nurse, "Gallstones were removed by passing shock waves into my gallbladder." Which procedure is the patient referring to?

Extracorporeal shock-wave lithotripsy (ESWL) ESWL is a procedure involving the use of high-energy shock waves to disintegrate gallstones. This method is used when endoscopic procedures cannot be used to remove the stones. Cholecystojejunostomy is surgical removal of the gallbladder. Pancreaticoduodenectomy is the surgical formation of a means of communication between the gallbladder and jejunum. Balloon sphincteroplasty is an adjunct procedure used with extracorporeal shock-wave lithotripsy to dilate the biliary duct.

Which dietary substance would the nurse recommend limiting for a patient with acute cholecystitis?

Fat Cholecystitis is inflammation of the gallbladder. Fats contribute to gallstone formation, worsening the inflammation; therefore patients with cholecystitis should consume a low-fat diet. A diet low in protein is given to patients with kidney or liver disease. Patients with cholecystitis should be given a diet rich in calcium and carbohydrates.

Which drug would the nurse anticipate administering to a patient to reduce gastric acid secretion?

Omeprazole Omeprazole is a proton pump inhibitor that acts by decreasing production of hydrochloric acid in the stomach. Dicyclomine is an antispasmodic used to relieve muscle spasms. Nitroglycerin is an example of a vasodilator drug that dilates the blood vessels and is used to relax the smooth muscles. Acetazolamide is a carbonic anhydrase inhibitor used to decrease the volume and concentration of bicarbonate in pancreatic secretions.

A patient who is receiving treatment for cholelithiasis experiences severe nausea and six episodes of vomiting. Which intervention would the nurse plan for the patient?

Performing gastric decompression Gastric decompression is performed to remove the gastric contents via a nasogastric tube to prevent aspiration of food contents and reduce the incidence of nausea and vomiting. Lactulose is a laxative and is used to treat constipation. Rifaximin is an antibiotic prescribed for patients with hepatic encephalopathy. Endotracheal intubation is a means of providing ventilation to the patient.

The nurse is providing care to a patient with cholecystitis who is experiencing severe nausea and vomiting. Which intervention would the nurse plan to provide?

Providing oral care every two hours Patients with cholecystitis may have severe nausea and vomiting. Therefore the nurse should give frequent oral care to the patient to provide comfort. Encouraging exercise, assisting with ambulation, and repositioning are not interventions that address the problem of severe nausea and vomiting.

The nurse is providing discharge instructions to a patient who has undergone a laparoscopic cholecystectomy. Which information would the nurse include in the teaching? Select all that apply.

Report development of jaundice. You can shower the day after surgery. Eat several small meals and snacks each day. Teach the patient signs and symptoms of obstruction to report (e.g., stool and urine changes, jaundice, itching). The patient may remove the bandages on the puncture sites the day after surgery and shower. It is helpful to eat three small meals and two or three snacks daily rather than three large meals to help reduce the flow of bile after the surgery. Eating fat-rich foods will stimulate the release of bile, so the patient should consider eating lighter meals. Return to work is generally permitted in one week; it would be dangerous to return the same day of surgery after general anesthesia.

Which change in the gallbladder is associated with acute cholecystitis?

Scarring of the wall During an acute attack of cholecystitis, the gallbladder becomes scarred. Fistulas, occlusion of the cystic duct, and inflammation of the biliary duct are complications associated with chronic cholecystitis and cholelithiasis.

A patient admitted to the hospital with cirrhosis of the liver suddenly vomits blood. Which action would the nurse take?

Stabilize the patient and manage the airway. 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. Shunting procedures may be planned after a repeated major bleeding episode.