Adult Health Ch. 50
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?
Acute pain related to biliary spasms
The nurse is caring for a client with a biliary disorder who has an elevated amylase level. If this elevation correlates to dysfunction, which body process does the nurse recognize may be impaired?
Carbohydrate digestion
The nurse is caring for a client with suspected chronic pancreatitis. Which diagnostic test or imaging does the nurse recognize as the most useful in diagnosing this condition?
ERCP
A nurse cares for a client who is post op open cholecystectomy and has a T-tube in place. Which clinical situation will the nurse notify the health care provider about as a possible complication of the surgery?
Significantly reduced bile output from the T-tube.
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?
To avoid inflammation of the pancreas
A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery?
Vitamin K
Which is a clinical manifestation of cholelithiasis?
Clay-colored stools
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.
Insulin Glucagon Somatostatin
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?
Use incentive spirometry every hour.
Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis?
Pancreatic necrosis
A patient is diagnosed with mild acute pancreatitis. What does the nurse understand is characteristic of this disorder?
Edema and inflammation
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?
Frequent changes of positions
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?
Pain with abdominal distention and hypotension
The digestion of carbohydrates is aided by
amylase
Which condition in a client with pancreatitis makes it necessary for the nurse to check fluid intake and output, check hourly urine output, and monitor electrolyte levels?
Frequent vomiting, leading to loss of fluid volume
A client has a nasogastric (NG) tube for suction and is NPO after a pancreaticoduodenectomy. Which explanation made by the nurse is the major purpose of this treatment?
"The tube allows the gastrointestinal tract to rest."
A client discharged after a laparoscopic cholecystectomy calls the surgeon's office reporting severe right shoulder pain 24 hours after surgery. Which statement is the correct information for the nurse to provide to this client?
"This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort."
The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client?
Assisting the client to turn, cough, and deep breathe every 2 hours
A nurse discusses risk factors of cholelithiasis with a client. Which risk factors will the nurse include in the teaching? Select all that apply.
Changes in weight Obesity Diabetes Cystic fibrosis
A client with calculi in the gallbladder is said to have
Cholelithiasis
Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?
Hot roast beef sandwich with gravy
Clinical manifestations of common bile duct obstruction include all of the following except:
Light-colored urine
The nurse is caring for a client with acute pancreatitis who is admitted to the intensive care unit to monitor for pulmonary complications. What is the nurse's understanding of the pathophysiology of pulmonary complications related to pancreatitis?
Pancreatitis can elevate the diaphragm and alter the breathing pattern.
One difference between cholesterol stones (left) and the stones on the right are that the ones on the right account for only 10% to 25% of cases of stones in the United States. What is the name of the stones on the right?
Pigment
The nurse should assess for an important early indicator of acute pancreatitis. What prolonged and elevated level would the nurse determine is an early indicator?
Serum lipase
The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason?
To reduce gastric and pancreatic secretions
A client who was recently diagnosed with carcinoma of the pancreas and is having a procedure in which the head of the pancreas is removed. In addition, the surgeon will remove the duodenum and stomach, redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the middle section of the small intestine. What procedure is this client having performed?
radical pancreatoduodenectomy
A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:
yellow sclerae.
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?
30 mg/dL
Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve?
6 to 12
A patient is receiving pharmacologic therapy with ursodeoxycholic acid or chenodeoxycholic-cholic acid for treatment of small gallstones. The patient asks the nurse how long the therapy will take to dissolve the stones. What is the best answer the nurse can give?
6 to 12 months
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?
Administering morphine I.V. as ordered
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?
Decreases in the physiologic function of major organs
A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find?
Elevated urine amylase levels
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?
Gray
The nurse identifies a potential collaborative problem of electrolyte imbalance for a client with severe acute pancreatitis. Which assessment finding alerts the nurse to an electrolyte imbalance associated with acute pancreatitis?
Muscle twitching and finger numbness
Which condition is most likely to have a nursing diagnosis of fluid volume deficit?
Pancreatitis
A client is treated for gastrointestinal problems related to chronic cholecystitis. What pathophysiological process related to cholecystitis does the nurse understand is the reason behind the client's GI problems?
Reduced or absent bile as a result of obstruction impacts digestion.
A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?
Relieving abdominal pain
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?
Reposition the client every 2 hours.
A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate?
Reserving a site for a peripherally inserted central catheter (PICC)
A nurse is teaching a client about the cause of acute pancreatitis. The nurse evaluates the teaching as effective when the client correctly identifies which condition as a cause of acute pancreatitis?
Self-digestion of the pancreas by its own proteolytic enzymes
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?
Serum amylase
A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is board-like and no bowel sounds are detected. What is the major concern for this patient?
The patient has developed peritonitis.
A client with chronic pancreatitis is treated for uncontrolled pain. Which complication does the nurse recognize is most common in the client with chronic pancreatitis?
Weight loss