Chapter 44: Assessment and Management of Patients with Biliary Disorders

Which condition is most likely to have a nursing diagnosis of fluid volume deficit? a) Cholecystitis b) Appendicitis c) Gastric ulcer d) Pancreatitis

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 with gallstones is diagnosed with acute pancreatitis and is requesting information about the physiology of the gallbladder. Which information will the nurse include about the function of this organ? a) Releases bile in response to cholecystokinin b) Digests carbohydrates in the jejunum c) Serves as a storage unit for glucagon d) Controls the flow of trypsin to digest proteins

Releases bile in response to cholecystokinin Explanation: The gallbladder is a pear-shaped, hollow, saclike organ that lies in a shallow depression on the inferior surface of the liver. When food enters the duodenum, the gallbladder contracts and the sphincter of Oddi relaxes. Relaxation of this sphincter allows the bile to enter the intestine. This response is mediated by secretion of the hormone cholecystokinin (CCK) from the intestinal wall. Gallstones can block the bile duct and digestive juices to the pancreas causing acute pancreatitis. The gallbladder functions as a storage depot for bile. Bile does not digest carbohydrates in the jejunum. The liver controls the flow of trypsin to digest proteins.

The nurse is caring for a client with symptoms of gallbladder disease. Which diagnostic test will the nurse anticipate preparing the client for to confirm the diagnosis? a) Cholescintigraphy b) Ultrasound c) Oral cholecystography d) Abdominal x-ray

Ultrasound Explanation: Ultrasonography is the diagnostic procedure of choice because it is rapid and accurate and can be used for clients with liver dysfunction and jaundice. Ultrasonography can detect calculi in the gallbladder or a dilated common bile duct with 90% accuracy. An abdominal x-ray may be obtained to exclude other causes of symptoms; however, only 10% to 15% of gallstones are calcified sufficiently to be visible on such x-ray studies. Cholescintigraphy is used successfully in the diagnosis of acute cholecystitis or blockage of a bile duct. Cholescintigraphy, however, is more expensive than ultrasonography, takes longer to perform, and exposes the client to radiation. It is often used when ultrasonography is not conclusive, such as in acalculous cholecystitis. Oral cholecystography is used if ultrasound equipment is not available or if the ultrasound results are inconclusive.

A nurse cares for a client with a disorder of the endocrine function of the pancreas. Which hormones or enzymes may be impacted by this disorder? Select all that apply. a) Somatostatin b) Lipase c) Insulin d) Glucagon e) Amylase

- Insulin - Glucagon - Somatostatin Explanation: Insulin, glucagon, and somatostatin are hormones released by the endocrine function of the pancreas. An impairment impacting endocrine function will impact all of these hormones. Lipase and amylase are enzymes released by the exocrine function of the pancreas and are not directly impacted by endocrine function.

A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood glucose level does the nurse recognize as inadequate to sustain normal brain function? a) 90 mg/dL b) 70 mg/dL c) 30 mg/dL d) 50 mg/dL

30 mg/dL Explanation: Hyperinsulinism is caused by overproduction of insulin by the pancreatic islets. Occasionally, tumors of nonpancreatic origin produce an insulin-like material that can cause severe hypoglycemia and may be responsible for seizures coinciding with blood glucose levels that are too low to sustain normal brain function (i.e., lower than 30 mg/dL [1.6 mmol/L]) (Goldman & Schafer, 2012; McPherson & Pincus, 2011).

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? a) Imbalanced nutrition: Less than body requirements related to biliary inflammation b) Anxiety related to unknown outcome of hospitalization c) Deficient knowledge related to prevention of disease recurrence d) Acute pain related to biliary spasms

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

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client? a) Maintaining nothing-by-mouth (NPO) status b) Administering morphine I.V. as ordered c) Placing the client in a semi-Fowler's position d) Providing mouth care

Administering morphine I.V. as ordered Explanation: The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

A client with calculi in the gallbladder is said to have a) Choledocholithiasis b) Cholelithiasis c) Choledochotomy d) Cholecystitis

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.

Which is a clinical manifestation of cholelithiasis? a) Epigastric distress before a meal b) Abdominal pain in the upper left quadrant c) Nonpalpable abdominal mass d) Clay-colored stools

Clay-colored stools Explanation: The client with gallstones has clay-colored stools and excruciating upper right quadrant pain that radiates to the back or right shoulder. The excretion of bile pigments by the kidneys makes urine very dark. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. The client develops a fever and may have a palpable abdominal mass.

The nurse is caring for a client recovering from acute pancreatitis. Which menu item should the nurse remove from the client's breakfast tray? a) Orange slices b) Coffee c) Toast d) Oatmeal

Coffee Explanation: Post-acute management of the client with acute pancreatitis includes the introduction of solid food. Oral feedings that are low in fat and protein are gradually initiated. Caffeine is eliminated from the diet and therefore coffee, which contains caffeine, should be removed from the client's breakfast tray. Even decaffeinated coffee has a small amount of caffeine but could serve as a compromise for chronic coffee drinkers. The other food items are appropriate for the client.

A 70-year-old client is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which gerontologic consideration associated with the pancreas? a) Decreases in the physiologic function of major organs b) Increases in the rate of pancreatic secretion c) Development of local complications d) Increases in the bicarbonate output by the kidneys

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 clients 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.

Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes mellitus. Which of the following explains the cause of this secondary diabetes? a) Ingestion of foods high in sugar b) Dysfunction of the pancreatic islet cells c) Renal failure d) Inability for the liver to reabsorb serum glucose

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 dietary modification is used for a client diagnosed with acute pancreatitis? a) High-fat diet b) High-protein diet c) Low-carbohydrate diet d) Elimination of coffee

Elimination of coffee Explanation: A high-carbohydrate, low-fat, and low-protein diet should be implemented. Alcohol, caffeine, and spicy foods should be avoided.

When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions? a) Suction the patient every 4 hours b) Perform chest physiotherapy c) Frequent changes of positions d) Placing the patient in the prone position

Frequent changes of positions Explanation: Frequent changes of position are necessary to prevent atelectasis and pooling of respiratory secretions.

A client with suspected biliary obstruction due to gallstones reports changes to the color of his stools. Which stool color does the nurse recognize as common to biliary obstruction? a) Black b) Red c) Gray d) Green

Gray Explanation: A gray-white stool color is common with a biliary obstruction because the stool is no longer colored with bile pigments.

Clinical manifestations of common bile duct obstruction include all of the following except: a) Clay-colored feces b) Jaundice c) Light-colored urine d) Pruritus

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

A nurse is planning care for a client with acute pancreatitis. Which client outcome does the nurse assign as the highest priority? a) Maintaining satisfactory pain control b) Achieving adequate fluid and electrolyte balance c) Developing no acute complications from the pancreatitis d) Maintaining normal respiratory function

Maintaining normal respiratory function Explanation: Airway and breathing are always the priority assessment. Acute pancreatitis produces retroperitoneal edema, elevation of the diaphragm, pleural effusion, and inadequate lung ventilation. Intra-abdominal infection and labored breathing increase the body's metabolic demands, which further decreases pulmonary reserve and can lead to respiratory failure. Maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN? a) Auscultate the abdomen for bowel sounds every 4 hours b) Monitor for reports of nausea and vomiting c) Measure blood glucose concentration every 4 to 6 hours d) Measure abdominal girth every shift

Measure blood glucose concentration every 4 to 6 hours Explanation: Enteral or parenteral nutrition may be prescribed. In addition to administering enteral or parenteral nutrition, the nurse monitors the serum glucose concentration every 4 to 6 hours.

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 the diagnosis of acute pancreatitis? a) Presence of blood in the client's stool and recent hypertension b) Adventitious breath sounds and hypertension c) Presence of easy bruising and bradycardia d) Pain with abdominal distention and hypotension

Pain with abdominal distention and hypotension Explanation: Assessment findings associated with pancreatitis include pain with abdominal distention and hypotension. 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.

Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis? a) MODS b) Tetany c) Pancreatic necrosis d) Shock

Pancreatic necrosis Explanation: Pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Shock and multiple organ failure may occur with acute pancreatitis. Tetany is not a major cause of morbidity and mortality in clients with acute pancreatitis.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure? a) Administering an analgesic once per shift, as ordered, to prevent drug addiction b) Administering frequent oral feedings c) Encouraging frequent visits from family and friends d) Positioning the client on the side with the knees flexed

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 comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test? a) Serum amylase b) Serum bilirubin c) Serum potassium d) Serum calcium

Serum amylase Explanation: Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.

The physician has written the following orders for a new client admitted with pancreatitis: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) . Which does the nurse attribute as the reason for NPO status? a) To prevent the occurrence of fibrosis b) To avoid inflammation of the pancreas c) To aid opening up of pancreatic duct d) To drain the pancreatic bed

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 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? a) To relieve nausea and vomiting b) To reduce gastric and pancreatic secretions c) To decrease metabolism d) To depress the central nervous system and increase the pain threshold

To reduce gastric and pancreatic secretions Explanation: Anticholinergic medications reduce gastric and pancreatic secretion.

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? a) Instruct the client to cough only when necessary. b) Withhold analgesics unless necessary. c) Monitor pulse oximetry every hour. d) 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.

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients: a) are at risk for hepatic encephalopathy. b) cannot tolerate high-glucose concentration. c) are at risk for gallbladder contraction. d) can digest high-fat foods.

cannot tolerate high-glucose concentration. Explanation: Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.