Lewis Chapter 43

A patient with acute hepatitis B is being discharged. The discharge teaching plan should include instructions to a. avoid alcohol for the first 3 weeks. b. use a condom during sexual intercourse. c. have family members get an injection of immunoglobulin. d. follow a low-protein, moderate-carbohydrate, moderate-fat diet.

B Hepatitis B virus may be transmitted by mucosal exposure to infected blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B.

Nursing management of the patient with acute pancreatitis includes (select all that apply) a. administering pain medication. b. checking for signs of hypocalcemia. c. providing a diet low in carbohydrates. d. giving insulin based on a sliding scale. e. monitoring for infection, particularly respiratory tract infection.

a, b, e During the acute phase, it is important to provide pain relief and monitor vital signs. Hypotension, fever, and tachypnea may compromise hemodynamic stability. Give fluids and monitor the response to therapy. Closely monitor fluid and electrolyte balances. Vomiting and gastric suction may result in decreased chloride, sodium, and potassium levels. Because hypocalcemia can occur, observe for symptoms of tetany, such as jerking, irritability, and muscular twitching. Numbness or tingling around the lips and in the fingers is an early sign of hypocalcemia. Assess the patient for Chvostek's sign or Trousseau's sign. Observe for fever and other manifestations of infection. Respiratory infections are common because the retroperitoneal fluid raises the diaphragm, causing the patient to take shallow, guarded abdominal breaths.

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements? (Select all that apply.) a. Vitamin A b. Vitamin B c. Vitamin D d. Vitamin E e. Vitamin K

a, c, d, e 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.

The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity. b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel. d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid.

b Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity and is a common manifestation of cirrhosis. With portal hypertension, proteins shift from the blood vessels through the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, those substances leak through the liver capsule into the peritoneal cavity. Osmotic pressure of the proteins pulls more fluid into the peritoneal cavity. A second mechanism of ascites formation is hypoalbuminemia, which results from the inability of the liver to synthesize albumin. Hypoalbuminemia results in decreased colloidal oncotic pressure. A third mechanism is hyperaldosteronism, which occurs when aldosterone is not metabolized by damaged hepatocytes. The increased aldosterone level causes increases in sodium reabsorption by the renal tubules. Sodium retention and an increase in antidiuretic hormone levels cause further water retention.

A patient admitted with diabetes, malnutrition, osteomyelitis, and chronic alcohol use has a serum amylase level of 480 U/L and a serum lipase level of 610 U/L. Which diagnosis does the nurse expect? a. Starvation b. Pancreatitis c. Systemic sepsis d. Diabetic ketoacidosis

b The patient with chronic alcohol use could develop pancreatitis as a complication, which would increase the serum amylase (normal, 30 to 122 U/L) and serum lipase (normal, 31 to 186 U/L) levels as shown.

The nurse caring for a patient with suspected acute cholecystitis would anticipate (select all that apply) a. ordering a low-sodium diet. b. administration of IV fluids. c. monitoring of liver function tests. d. administration of antiemetics for patients with nausea. e. insertion of an indwelling catheter to monitor urinary output.

b, c, d Priorities for patients with acute cholecystitis include pain management and control of symptoms, such as nausea. Maintaining fluid and electrolyte balance are important. IV access and fluids can help address this issue. Monitoring laboratory values, in particular liver function tests, can provide information on the severity of the acute episode.

The nurse is aware of potential complications related to cirrhosis. Which interventions would be included in a safe plan of care? (Select all that apply.) a. Provide a high-protein, low-carbohydrate diet. b. Tell the patient to use soft-bristle toothbrush and electric razor. c. Teach the patient to avoid vigorous blowing of nose and coughing. d. Apply gentle pressure for the shortest possible time after venipuncture. e. Use the smallest gauge needle possible when giving injections or drawing blood. f. Teach the patient to avoid aspirin and nonsteroidal antiinflammatory (NSAIDs).

b, c, e, f Using the smallest gauge needle for injections, using a soft bristle toothbrush and an electric razor will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding. A low-salt, low-protein, high-carbohydrate diet may be recommended.

The nurse is caring for a patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect? (Select all that apply.) a. Hematochezia b. Nausea and vomiting c. Hyperactive bowel sounds d. Left upper abdominal pain e. Ascites and peripheral edema f. Temperature 99.3° F (37.4° C)

b, d, f Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).

The nurse teaches a patient about cholestyramine to reduce pruritus caused by gallbladder disease. Which statement indicates understanding of the instructions? a. "This medication will help me digest fats and fat-soluble vitamins." b. "I will apply the medicated lotion sparingly to the areas where I itch." c. "The medication is a powder and needs to be mixed with milk or juice." d. "I should take this medication on an empty stomach at the same time each day."

c For treatment of pruritus, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in powder form and should be mixed with milk or juice before oral administration.

A patient with chronic hepatitis B is being discharged with pain medication after knee surgery. Which medication order should the nurse question? a. Tramadol b. Hydromorphone (Dilaudid) c. Hydrocodone with acetaminophen d. Oxycodone with aspirin (Percodan)

c The analgesic with acetaminophen should be questioned because this patient has chronic hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.

A patient with pancreatic cancer is admitted to the hospital for evaluation of treatment options. The patient asks the nurse to explain the Whipple procedure that the surgeon has described. The explanation includes the information that a Whipple procedure involves a. creating a bypass around the obstruction caused by the tumor by joining the gallbladder to the jejunum. b. resection of the entire pancreas and the distal part of the stomach, with anastomosis of the common bile duct and the stomach into the duodenum. c. removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with joining of the pancreatic duct, the common bile duct, and the stomach into the jejunum. d. removal of the pancreas, the duodenum, and the spleen, and attachment of the stomach to the jejunum, which requires oral supplementation of pancreatic digestive enzymes and insulin replacement therapy.

c The classic operation for pancreatic cancer is a radical pancreaticoduodenectomy, or Whipple procedure. This entails resection of the proximal pancreas (i.e., proximal pancreatectomy), the adjoining duodenum (i.e., duodenectomy), the distal part of the stomach (i.e., partial gastrectomy), and the distal segment of the common bile duct. The pancreatic duct, common bile duct, and stomach are anastomosed to the jejunum.

When teaching the patient with acute hepatitis C (HCV), which statement demonstrates understanding of the disease process? a. "I will use care when kissing my wife to prevent giving it to her." b. "I will need to take adefovir (Hepsera) to prevent chronic HCV." c. "Now that I have had HCV, I will have immunity and not get it again." d. "I will need to be monitored for chronic HCV and other liver problems."

d Many patients who acquire HCV develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva but by blood exposures such as sharing needles and high-risk sexual activity. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adefovir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. HCV is treated with oral direct-acting antivirals (DAAs). Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.

The patient with suspected pancreatic cancer is having many diagnostic studies done. Which test can be used to establish the diagnosis of pancreatic cancer and for monitoring the response to treatment? a. Spiral CT scan b. A PET/CT scan c. Abdominal ultrasound d. Cancer-associated antigen 19-9

d The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic cancer and monitoring the response to treatment. Although a spiral CT scan may be the initial study done and provides information on metastasis and vascular involvement, this test and the positron emission tomography (PET)/CT scan or abdominal ultrasonography does not provide additional information.

The nurse is caring for a group of patients. Which patient has the highest risk for developing pancreatic cancer? a. A 72-yr-old black man who has smoked cigarettes for 50 years b. A 19-yr-old patient who has a 5-year history of uncontrolled type 1 diabetes c. A 38-yr-old Hispanic woman who is obese and has hyperinsulinemia d. A 23-yr-old man who has cystic fibrosis-related pancreatic enzyme insufficiency

a Risk factors for pancreatic cancer include chronic pancreatitis, diabetes, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine. Blacks have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are 2 to 3 times more likely to develop pancreatic cancer compared with nonsmokers. The risk is related to duration and number of cigarettes smoked.

The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would best help determine if the patient has developed liver cancer? a. MRI scanning b. Serum α-fetoprotein level c. Ventilation/perfusion scan d. Abdominal girth measurement

a Hepatic ultrasonography, CT scan, and MRI scanning are used to screen for and diagnose liver cancer. Serum α-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans are used to diagnose pulmonary emboli. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.

In planning care for a patient with metastatic liver cancer, the nurse should include interventions that a. focus primarily on symptomatic and comfort measures. b. reassure the patient that chemotherapy offers a good prognosis. c. promote the patient's confidence that surgical excision of the tumor will be successful. d. provide information needed for the patient to make decisions about liver transplantation

a Nursing intervention for a patient with liver cancer focuses on keeping the patient as comfortable as possible. The prognosis for patients with liver cancer is poor. The cancer grows rapidly, and death may occur within 4 to 7 months because of hepatic encephalopathy or massive blood loss from gastrointestinal (GI) bleeding.

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

a Scientific evidence indicates there is no real benefit from milk thistle to protect liver cells from toxic damage in the treatment of chronic hepatitis C. Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore, patients will need to be monitored for drug interactions. It is generally well tolerated. It may lower, not elevate, blood glucose levels.

A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on the knowledge that a. itching is a common problem with jaundice in this phase. b. the patient is most likely to transmit the disease during this phase. c. gastrointestinal symptoms are not as severe in hepatitis A as they are in hepatitis B. d. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase.

a The acute phase of jaundice may be icteric or anicteric. Jaundice results when bilirubin diffuses into the tissues. Pruritus sometimes accompanies jaundice. Pruritus is the result of an accumulation of bile salts beneath the skin.

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

b Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks after surgery. Normal activities can be gradually resumed 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

A patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. Which intervention should the nurse include in the patient's plan of care? a. Immediately start enteral feeding to prevent malnutrition. b. Insert an NG and maintain NPO status to allow pancreas to rest. c. Initiate early prophylactic antibiotic therapy to prevent infection. d. Administer acetaminophen (Tylenol) every 4 hours for pain relief.

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

A patient has been told that she has elevated liver enzymes caused by nonalcoholic fatty liver disease (NAFLD). The nursing teaching plan should include a. having genetic testing done. b. recommending a heart-healthy diet. c. the necessity to reduce weight rapidly. d. avoiding alcohol until liver enzymes return to normal.

b Nonalcoholic fatty liver disease (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 patients who are overweight, weight reduction is important. Weight loss improves insulin sensitivity and reduces liver enzyme levels. No specific dietary therapy is recommended. However, a hearthealthy diet as recommended by the American Heart Association is appropriate.

The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What is the nurse's priority? a. Prevent all oral intake. b. Control abdominal pain. c. Provide enteral feedings. d. Avoid dietary cholesterol.

b Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelithiasis. Patients with pancreatitis may be NPO. Enteral feedings should not be needed, and avoiding dietary cholesterol is not used to treat cholelithiasis.

Teaching in relation to home management after a laparoscopic cholecystectomy should include a. keeping the bandages on the puncture sites for 48 hours. b. reporting any bile-colored drainage or pus from any incision. c. using over-the-counter antiemetics if nausea and vomiting occur. d. emptying and measuring the contents of the bile bag from the T tube every day.

b The following discharge instructions are taught to the patient and caregiver after a laparoscopic cholecystectomy. First, remove the bandages on the puncture site the day after surgery and shower. Second, notify the surgeon if any of the following signs and symptoms occur: redness, swelling, bile-colored drainage or pus from any incision; and severe abdominal pain, nausea, vomiting, fever, or chills. Third, gradually resume normal activities. Fourth, return to work within 1 week of surgery. Fifth, resume a usual diet, but a low-fat diet is usually better tolerated for several weeks after surgery.

The nurse provides discharge instructions for a patient with ascites and peripheral edema related to cirrhosis. Which patient statement indicates teaching was effective? a. "Lactulose should be taken every day to prevent constipation." b. "It is safe to take acetaminophen up to four times a day for pain." c. "Herbs and other spices should be used to season my foods instead of salt." d. "I will eat foods high in potassium while taking spironolactone (Aldactone)."

c A low-sodium diet is indicated for patients with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided because these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? a. Fluid imbalance b. Impaired tissue integrity c. Impaired nutritional status d. Ineffective breathing pattern

d Although all these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.

A patient with cholelithiasis is being prepared for surgery. Which patient assessment represents a contraindication for a cholecystectomy? a. Low-grade fever of 100° F and dehydration b. Abscess in the right upper quadrant of the abdomen c. Multiple obstructions in the cystic and common bile duct d. Activated partial thromboplastin time (aPTT) of 54 seconds

d An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration. The abscess can be assessed during surgery, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy.

A patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After a comprehensive evaluation, which finding may be a contraindication for liver transplantation? a. History of hypothyroidism b. Stopped smoking cigarettes c. Well-controlled type 1 diabetes d. Chest x-ray shows a new lung cancer lesion

d Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug or alcohol use, and the inability to comprehend or comply with the rigorous posttransplant course.

The health care provider orders lactulose for a patient with hepatic encephalopathy. Which finding indicates the medication has been effective? a. Relief of constipation b. Relief of abdominal pain c. Decreased liver enzymes d. Decreased ammonia levels

d 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. An additional finding may be an improvement in level of consciousness.

The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which person should the nurse refer for an immunoglobulin (IG) injection? a. A friend who delivers meals to the patient and family each week. b. A relative with a history of hepatitis A who visits the patient daily. c. A child living in the home who received the hepatitis A vaccine 3 months ago. d. A caregiver with no history of hepatitis A antibodies who lives in the same household with the patient.

d IG is recommended for persons who do not have anti-HAV antibodies and are exposed because of close contact with persons who have HAV or foodborne exposure. Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.

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

d If the patient with cirrhosis develops 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. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill. Which response by the nurse is most appropriate? a. "You will need to be tested first; then treatment can be determined." b. "The hepatitis vaccine will provide immunity from this and future exposures." c. "There is nothing you can do since the patient was infectious before admission." d. "An immunoglobulin injection will be given to prevent infection or limit symptoms."

d Immunoglobulin provides temporary (1 to 2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.

A patient with cirrhosis has increased abdominal girth from ascites. Which statements describe the pathophysiology of ascites? (Select all that apply.) a. Hepatocytes are unable to convert ammonia to urea. b. Osmoreceptors in the hypothalamus stimulate thirst. c. An enlarged spleen removes blood cells from the circulation. d. Portal hypertension causes leaking of protein and water into the peritoneal cavity. e. Aldosterone is released to stabilize intravascular volume by saving salt and water. f. Inability of the liver to synthesize albumin reducing intravascular oncotic pressure.

d, e, f Ascites related to cirrhosis is caused by decreased colloid oncotic pressure. The liver does not produce albumin that holds fluid in the vascular space, so fluid shifts into interstitial and third spaces. Portal hypertension causes back pressure in the vessels, shifting protein and fluids into the peritoneal cavity. Decreased intravascular volume stimulates the release of aldosterone, which increases sodium and fluid retention. Oral intake of fluids and removal of blood cells by the spleen do not directly contribute to ascites.