Chapter 44: Assessment and Management of Patients With Biliary Disorders

A nurse is preparing a client for endoscopic retrograde cholangiopancreatography (ERCP). The client asks what this test is used for. Which statements by the nurse explains how ERCP can determine the difference between pancreatitis and other biliary disorders? Select all that apply.

"It can evaluate the presence and location of ductal stones and aid in stone removal." "It can assess the anatomy of the pancreas and the pancreatic and biliary ducts." "It can detect unhealthy tissues in the pancreas and assess for abscesses and pseudocysts." ERCP can determine the difference between pancreatitis and other biliary disorders and is generally used in chronic pancreatitis. It is particularly useful in diagnosis and treatment of clients who have symptoms after biliary tract surgery, clients with intact gallbladders, and clients for whom surgery is particularly hazardous. It can be used to assist with the removal of stones. ERCP is a useful tool in providing anatomic details about the pancreas and biliary ducts. It can evaluate the presence and location of ductal stones and detect changes in the anatomy of the client with pancreatitis, such as obstruction in the pancreatic duct and tissue necrosis due to premature release of pancreatic enzymes, and assess for abscesses and pseudocysts and atrophy of the glands in the body. ERCP is rarely used in the diagnostic evaluation of acute pancreatitis because the clients is acutely ill; however, it may be valuable in treating gallstone pancreatitis.

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." Postoperative management of clients who have undergone a pancreatectomy or a pancreaticoduodenectomy is similar to the management of clients after extensive gastrointestinal or biliary surgery. An NG tube with suction and parenteral nutrition allow the gastrointestinal tract to rest while promoting adequate nutrition.

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." If pain occurs in the right shoulder or scapular area (from migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure), the nurse may recommend using a heating pad for 15 to 20 minutes hourly, sitting up in a bed or chair, or walking.

The nurse knows that the serum amylase concentration returns to normal within which time frame?

48 hours Serum amylase usually returns to normal within 48 to 72 hours.

Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones?

7 months Six to 12 months of therapy with UDCA is recommended in clients to dissolve the stones.

A client admitted with severe epigastric abdominal pain radiating to the back is vomiting and reports difficulty breathing. Upon assessment, the nurse determines that the client is experiencing tachycardia and hypotension. Which actions are priority interventions for this client? Select all that apply.

Administer pain-relieving medication Administer electrolytes Administer plasma Assist the client to a semi-Fowler position The nurse promptly reports decreased blood pressure (BP) and reduced urine output, which indicate hypovolemia and shock or renal failure. The treatment goals for acute pancreatitis focus on relieving pain, maintaining circulatory and fluid volume, and decreasing the production of pancreatic enzymes. Intravenous replacement of fluid and electrolytes should begin immediately because of the loss of fluid in the body. If hypotension is evident, plasma should be administered to maintain BP within an acceptable range. Fluids are administered intravenously and may be accompanied by infusion of blood or blood products to maintain blood volume and to prevent or treat hypovolemic shock. Low serum calcium and magnesium concentrations may occur and require prompt treatment. The nurse maintains the client in a semi-Fowler position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. A low-fat diet, with small frequent meals, should be initiated after control of symptoms; it is not an immediate priority.

27. A patient has a recent diagnosis of chronic pancreatitis and is undergoing diagnostic testing to determine pancreatic islet cell function. The nurse should anticipate what diagnostic test? A) Glucose tolerance test B) ERCP C) Pancreatic biopsy D) Abdominal ultrasonography

Ans: A Feedback: A glucose tolerance test evaluates pancreatic islet cell function and provides necessary information for making decisions about surgical resection of the pancreas. This specific clinical information is not provided by ERCP, biopsy, or ultrasound.

7. A patient has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? A) Have the patient refrain from food and fluids after midnight. B) Administer the contrast agent orally 10 to 12 hours before the study. C) Administer the radioactive agent intravenously the evening before the study. D) Encourage the intake of 64 ounces of water 8 hours before the study.

Ans: A Feedback: An ultrasound of the gallbladder is most accurate if the patient fasts overnight, so that the gallbladder is distended. Contrast and radioactive agents are not used when performing ultrasonography of the gallbladder, as an ultrasound is based on reflected sound waves.

24. An adult patient has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this patient's plan of care? A) Measure the patient's abdominal girth daily. B) Limit the use of opioid analgesics. C) Monitor the patient for signs of dysphagia. D) Encourage activity as tolerated.

Ans: A Feedback: Due to the risk of ascites, the nurse should monitor the patient's abdominal girth. There is no specific need to avoid the use of opioids or to monitor for dysphagia, and activity is usually limited.

4. A patient's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the patient's laboratory studies, what finding is most closely associated with this diagnosis? A) Increased bilirubin B) Decreased serum cholesterol C) Increased blood urea nitrogen (BUN) D) Decreased serum alkaline phosphatase level

Ans: A Feedback: If the flow of blood is impeded, bilirubin, a pigment derived from the breakdown of red blood cells, does not enter the intestines. As a result, bilirubin levels in the blood increase. Cholesterol, BUN, and alkaline phosphatase levels are not typically affected.

37. A patient with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the patient will undergo what intervention? A) Laparoscopic cholecystectomy B) Methyl tertiary butyl ether (MTBE) infusion C) Intracorporeal lithotripsy D) Extracorporeal shock wave therapy (ESWL)

Ans: A Feedback: Most of the nonsurgical approaches, including lithotripsy and dissolution of gallstones, provide only temporary solutions to gallstone problems and are infrequently used in the United States. Cholecystectomy is the preferred treatment.

36. A patient with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure? A) Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. B) Laparoscopic cholecystectomy can be performed in a clinic setting, while an open procedure requires an OR. C) A laparoscopic approach allows for the removal of the entire gallbladder. D) A laparoscopic approach can be performed under conscious sedation.

Ans: A Feedback: Open surgery has largely been replaced by laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus). As a result, surgical risks have decreased, along with the length of hospital stay and the long recovery period required after standard surgical cholecystectomy. Both approaches allow for removal of the entire gallbladder and must be performed under general anesthetic in an operating theater.

6. A 37-year-old male patient presents at the emergency department (ED) complaining of nausea and vomiting and severe abdominal pain. The patient's abdomen is rigid, and there is bruising to the patient's flank. The patient's wife states that he was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the patient for what health problem? A) Severe pancreatitis with possible peritonitis B) Acute cholecystitis C) Chronic pancreatitis D) Acute appendicitis with possible perforation

Ans: A Feedback: Severe abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care. Pain in pancreatitis is accompanied by nausea and vomiting that does not relieve the pain or nausea. Abdominal guarding is present and a rigid or board-like abdomen may be a sign of peritonitis. Ecchymosis (bruising) to the flank or around the umbilicus may indicate severe peritonitis. Pain generally occurs 24 to 48 hours after a heavy meal or alcohol ingestion. The link with alcohol intake makes pancreatitis a more likely possibility than appendicitis or cholecystitis.

19. A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A) Fried chicken B) Mashed potatoes C) Dinner roll D) Tapioca pudding

Ans: A Feedback: The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated. The patient should avoid fried foods such as fried chicken, as fatty foods may bring on an episode of cholecystitis.

23. A patient with pancreatic cancer has been scheduled for a pancreaticoduodenectomy (Whipple procedure). During health education, the patient should be informed that this procedure will involve the removal of which of the following? Select all that apply. A) Gallbladder B) Part of the stomach C) Duodenum D) Part of the common bile duct E) Part of the rectum

Ans: A, B, C, D Feedback: A pancreaticoduodenectomy (Whipple procedure or resection) is used for potentially resectable cancer of the head of the pancreas (Fig. 50-7). This procedure involves removal of the gallbladder, a portion of the stomach, duodenum, proximal jejunum, head of the pancreas, and distal common bile duct. The rectum is not affected.

3. A patient's assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment questions address likely etiologic factors? Select all that apply. A) "How many alcoholic drinks do you typically consume in a week?" B) "Have you ever been tested for diabetes?" C) "Have you ever been diagnosed with gallstones?" D) "Would you say that you eat a particularly high-fat diet?" E) "Does anyone in your family have cystic fibrosis?"

Ans: A, C Feedback: Eighty percent of patients with acute pancreatitis have biliary tract disease such as gallstones or a history of long-term alcohol abuse. Diabetes, high-fat consumption, and cystic fibrosis are not noted etiologic factors.

22. The nurse is caring for a patient who has just returned from the ERCP removal of gallstones. The nurse should monitor the patient for signs of what complications? A) Pain and peritonitis B) Bleeding and perforation C) Acidosis and hypoglycemia D) Gangrene of the gallbladder and hyperglycemia

Ans: B Feedback: Following ERCP removal of gallstones, the patient is observed closely for bleeding, perforation, and the development of pancreatitis or sepsis. Blood sugar alterations, gangrene, peritonitis, and acidosis are less likely complications.

14. A patient has had a laparoscopic cholecystectomy. The patient is now complaining of right shoulder pain. What should the nurse suggest to relieve the pain? A) Aspirin every 4 to 6 hours as ordered B) Application of heat 15 to 20 minutes each hour C) Application of an ice pack for no more than 15 minutes D) Application of liniment rub to affected area

Ans: B Feedback: If pain occurs in the right shoulder or scapular area (from migration of the CO2 used to insufflate the abdominal cavity during the procedure), the nurse may recommend use of a heating pad for 15 to 20 minutes hourly, walking, and sitting up when in bed. Aspirin would constitute a risk for bleeding.

10. A nurse is caring for a patient who has been scheduled for endoscopic retrograde cholangiopancreatography (ERCP) the following day. When providing anticipatory guidance for this patient, the nurse should describe what aspect of this diagnostic procedure? A) The need to protect the incision postprocedure B) The use of moderate sedation C) The need to infuse 50% dextrose during the procedure D) The use of general anesthesia

Ans: B Feedback: Moderate sedation, not general anesthesia, is used during ERCP. D50 is not administered and the procedure does not involve the creation of an incision.

9. A patient with chronic pancreatitis had a pancreaticojejunostomy created 3 months ago for relief of pain and to restore drainage of pancreatic secretions. The patient has come to the office for a routine postsurgical appointment. The patient is frustrated that the pain has not decreased. What is the most appropriate initial response by the nurse? A) "The majority of patients who have a pancreaticojejunostomy have their normal digestion restored but do not achieve pain relief." B) "Pain relief occurs by 6 months in most patients who undergo this procedure, but some people experience a recurrence of their pain." C) "Your physician will likely want to discuss the removal of your gallbladder to achieve pain relief." D) "You are probably not appropriately taking the medications for your pancreatitis and pain, so we will need to discuss your medication regimen in detail."

Ans: B Feedback: Pain relief from a pancreaticojejunostomy often occurs by 6 months in more than 85% of the patients who undergo this procedure, but pain returns in a substantial number of patients as the disease progresses. This patient had surgery 3 months ago; the patient has 3 months before optimal benefits of the procedure may be experienced. There is no obvious indication for gallbladder removal and nonadherence is not the most likely factor underlying the pain.

31. A patient has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this patient? A) Oral oxycodone B) IV hydromorphone (Dilaudid) C) IM meperidine (Demerol) D) Oral naproxen (Aleve)

Ans: B Feedback: The pain of acute pancreatitis is often very severe and pain relief may require parenteral opioids such as morphine, fentanyl (Sublimaze), or hydromorphone (Dilaudid). There is no clinical evidence to support the use of meperidine for pain relief in pancreatitis. Opioids are preferred over NSAIDs.

38. A nurse is caring for a patient with gallstones who has been prescribed ursodeoxycholic acid (UDCA). The patient askshow this medicine is going to help his symptoms. The nurse should be aware of what aspect of this drug's pharmacodynamics? A) It inhibits the synthesis of bile. B) It inhibits the synthesis and secretion of cholesterol. C) It inhibits the secretion of bile. D) It inhibits the synthesis and secretion of amylase.

Ans: B Feedback: UDCA acts by inhibiting the synthesis and secretion of cholesterol, thereby desaturating bile. UDCA does not directly inhibit either the synthesis or secretion of bile or amylase.

35. A patient is admitted to the unit with acute cholecystitis. The physician has noted that surgery will be scheduled in 4 days. The patient asks why the surgery is being put off for a week when he has a "sick gallbladder." What rationale would underlie the nurse's response? A) Surgery is delayed until the patient can eat a regular diet without vomiting. B) Surgery is delayed until the acute symptoms subside. C) The patient requires aggressive nutritional support prior to surgery. D) Time is needed to determine whether a laparoscopic procedure can be used.

Ans: B Feedback: Unless the patient's condition deteriorates, surgical intervention is delayed just until the acute symptoms subside (usually within a few days). There is no need to delay surgery pending an improvement in nutritional status, and deciding on a laparoscopic approach is not a lengthy process.

18. A patient with gallstones has been prescribed ursodeoxycholic acid (UDCA). The nurse understands that additional teaching is needed regarding this medication when the patient states: A) "It is important that I see my physician for scheduled follow-up appointments while taking this medication." B) "I will take this medication for 2 weeks and then gradually stop taking it." C) "If I lose weight, the dose of the medication may need to be changed." D) "This medication will help dissolve small gallstones made of cholesterol."

Ans: B Feedback: Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. This drug can reduce the size of existing stones, dissolve small stones, and prevent new stones from forming. Six to 12 months of therapy is required in many patients to dissolve stones, and monitoring of the patient is required during this time. The effective dose of medication depends on body weight.

12. A nurse is preparing a plan of care for a patient with pancreatic cysts that have necessitated drainage through the abdominal wall. What nursing diagnosis should the nurse prioritize? A) Disturbed Body Image B) Impaired Skin Integrity C) Nausea D) Risk for Deficient Fluid Volume

Ans: B Feedback: While each of the diagnoses may be applicable to a patient with pancreatic drainage, the priority nursing diagnosis is Impaired Skin Integrity. The drainage is often perfuse and destructive to tissue because of the enzyme contents. Nursing measures must focus on steps to protect the skin near the drainage site from excoriation. The application of ointments or the use of a suction apparatus protects the skin from excoriation.

11. A patient has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize which of the following topics? A) Management of fluid balance in the home setting B) The need for blood glucose monitoring for the next week C) Signs and symptoms of intra-abdominal complications D) Appropriate use of prescribed pancreatic enzymes

Ans: C Feedback: Because of the early discharge following laparoscopic cholecystectomy, the patient needs thorough education in the signs and symptoms of complications. Fluid balance is not typically a problem in the recovery period after laparoscopic cholecystectomy. There is no need for blood glucose monitoring or pancreatic enzymes.

32. A patient has just been diagnosed with chronic pancreatitis. The patient is underweight and in severe pain and diagnostic testing indicates that over 80% of the patient's pancreas has been destroyed. The patient asks the nurse why the diagnosis was not made earlier in the disease process. What would be the nurse's best response? A) "The symptoms of pancreatitis mimic those of much less serious illnesses." B) "Your body doesn't require pancreatic function until it is under great stress, so it is easy to go unnoticed." C) "Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost." D) "It's likely that your other organs were compensating for your decreased pancreatic function."

Ans: C Feedback: By the time symptoms occur in chronic pancreatitis, approximately 90% of normal acinar cell function (exocrine function) has been lost. Late detection is not usually attributable to the vagueness of symptoms. The pancreas contributes continually to homeostasis and other organs are unable to perform its physiologic functions.

25. A community health nurse is caring for a patient whose multiple health problems include chronic pancreatitis. During the most recent visit, the nurse notes that the patient is experiencing severe abdominal pain and has vomited 3 times in the past several hours. What is the nurse's most appropriate action? A) Administer a PRN dose of pancreatic enzymes as ordered. B) Teach the patient about the importance of abstaining from alcohol. C) Arrange for the patient to be transported to the hospital. D) Insert an NG tube, if available, and stay with the patient.

Ans: C Feedback: Chronic pancreatitis is characterized by recurring attacks of severe upper abdominal and back pain, accompanied by vomiting. The onset of these acute symptoms warrants hospital treatment. Pancreatic enzymes are not indicated and an NG tube would not be inserted in the home setting. Patient education is a later priority that may or may not be relevant.

34. A patient is admitted to the ICU with acute pancreatitis. The patient's family asks what causes acute pancreatitis. The critical care nurse knows that a majority of patients with acute pancreatitis have what? A) Type 1 diabetes B) An impaired immune system C) Undiagnosed chronic pancreatitis D) An amylase deficiency

Ans: C Feedback: Eighty percent of patients with acute pancreatitis have biliary tract disease or a history of long-term alcohol abuse. These patients usually have had undiagnosed chronic pancreatitis before their first episode of acute pancreatitis. Diabetes, an impaired immune function, and amylase deficiency are not specific precursors to acute pancreatitis.

5. A nurse who provides care in a walk-in clinic assesses a wide range of individuals. The nurse should identify which of the following patients as having the highest risk for chronic pancreatitis? A) A 45-year-old obese woman with a high-fat diet B) An 18-year-old man who is a weekend binge drinker C) A 39-year-old man with chronic alcoholism D) A 51-year-old woman who smokes one-and-a-half packs of cigarettes per day

Ans: C Feedback: Excessive and prolonged consumption of alcohol accounts for approximately 70% to 80% of all cases of chronic pancreatitis.

26. A student nurse is caring for a patient who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments? A) Fluid output B) Oral intake C) Blood glucose levels D) BUN and creatinine levels

Ans: C Feedback: In addition to administering enteral or parenteral nutrition, the nurse monitors serum glucose levels every 4 to 6 hours. Output should be monitored but in most cases it is not more important than serum glucose levels. A patient on parenteral nutrition would have no oral intake to monitor. Blood sugar levels are more likely to be unstable than indicators of renal function.

29. The family of a patient in the ICU diagnosed with acute pancreatitis asks the nurse why the patient has been moved to an air bed. What would be the nurse's best response? A) "Air beds allow the care team to reposition her more easily while she's on bed rest." B) "Air beds are far more comfortable than regular beds and she'll likely have to be on bed rest a long time." C) "The bed automatically moves, so she's less likely to develop pressure sores while she's in bed." D) "The bed automatically moves, so she is likely to have less pain."

Ans: C Feedback: It is important to turn the patient every 2 hours; use of specialty beds may be indicated to prevent skin breakdown. The rationale for a specialty bed is not related to repositioning, comfort, or ease of movement.

30. A patient is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in patients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication? A) Sudden increase in random blood glucose readings B) Increased abdominal girth accompanied by decreased level of consciousness C) Fever, increased heart rate and decreased blood pressure D) Abdominal pain unresponsive to analgesics

Ans: C Feedback: Pancreatic necrosis is a major cause of morbidity and mortality in patients with acute pancreatitis because of resulting hemorrhage, septic shock, and multiple organ dysfunction syndrome (MODS). Signs of shock would include hypotension, tachycardia and fever. Each of the other listed changes in status warrants intervention, but none is clearly suggestive of an onset of pancreatic necrosis.

21. A nurse is creating a care plan for a patient with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan? A) Bed rest reduces the patient's metabolism and reduces the risk of metabolic acidosis. B) Reduced activity protects the physical integrity of pancreatic cells. C) Bed rest lowers the metabolic rate and reduces enzyme production. D) Inactivity reduces caloric need and gastrointestinal motility.

Ans: C Feedback: The acutely ill patient is maintained on bed rest to decrease the metabolic rate and reduce the secretion of pancreatic and gastric enzymes. Staying in bed does not release energy from the body to fight the disease.

8. A patient who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this patient knows to immediately report what assessment finding to the physician? A) Decreased breath sounds B) Drainage of bile-colored fluid onto the abdominal dressing C) Rigidity of the abdomen D) Acute pain with movement

Ans: C Feedback: The location of the subcostal incision will likely cause the patient to take shallow breaths to prevent pain, which may result in decreased breath sounds. The nurse should remind patients to take deep breaths and cough to expand the lungs fully and prevent atelectasis. Acute pain is an expected assessment finding following surgery; analgesics should be administered for pain relief. Abdominal splinting or application of an abdominal binder may assist in reducing the pain. Bile may continue to drain from the drainage tract after surgery, which will require frequent changes of the abdominal dressing. Increased abdominal tenderness and rigidity should be reported immediately to the physician, as it may indicate bleeding from an inadvertent puncture or nicking of a major blood vessel during the surgical procedure.

39. A nurse is providing discharge education to a patient who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods? A) High-fiber foods B) Low-purine, nutrient-dense foods C) Low-fat foods high in proteins and carbohydrates D) Foods that are low-residue and low in fat

Ans: C Feedback: The nurse encourages the patient to eat a diet that is low in fats and high in carbohydrates and proteins immediately after surgery. There is no specific need to increase fiber or avoid purines. A low-residue diet is not indicated.

28. A patient has been admitted to the hospital for the treatment of chronic pancreatitis. The patient has been stabilized and the nurse is now planning health promotion and educational interventions. Which of the following should the nurse prioritize? A) Educating the patient about expectations and care following surgery B) Educating the patient about the management of blood glucose after discharge C) Educating the patient about postdischarge lifestyle modifications D) Educating the patient about the potential benefits of pancreatic transplantation

Ans: C Feedback: The patient's lifestyle (especially regarding alcohol use) is a major determinant of the course of chronic pancreatitis. The disease is not often managed by surgery and blood sugar monitoring is not necessarily indicated for every patient after hospital treatment. Transplantation is not an option.

16. A patient has been treated in the hospital for an episode of acute pancreatitis. The patient has acknowledged the role that his alcohol use played in the development of his health problem, but has not expressed specific plans for lifestyle changes after discharge. What is the nurse's most appropriate response? A) Educate the patient about the link between alcohol use and pancreatitis. B) Ensure that the patient knows the importance of attending follow-up appointments. C) Refer the patient to social work or spiritual care. D) Encourage the patient to connect with a community-based support group.

Ans: D Feedback: After the acute attack has subsided, some patients may be inclined to return to their previous drinking habits. The nurse provides specific information about resources and support groups that may be of assistance in avoiding alcohol in the future. Referral to Alcoholics Anonymous as appropriate or other support groups is essential. The patient already has an understanding of the effects of alcohol, and follow-up appointments will not necessarily result in lifestyle changes. Social work and spiritual care may or may not be beneficial.

2. A 55-year-old man has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this patient's health problem? A) "Toxins have accumulated and inflamed your pancreas." B) "Bacteria likely migrated from your intestines and became lodged in your pancreas." C) "A virus that was likely already present in your body has begun to attack your pancreatic cells." D) "The enzymes that your pancreas produces have damaged the pancreas itself."

Ans: D Feedback: Although the mechanisms causing pancreatitis are unknown, pancreatitis is commonly described as the autodigestion of the pancreas. Less commonly, toxic substances and microorganisms are implicated as the cause of pancreatitis.

40. A patient presents to the emergency department (ED) complaining of severe right upper quadrant pain. The patient states that his family doctor told him he had gallstones. The ED nurse should recognize what possible complication of gallstones? A) Acute pancreatitis B) Atrophy of the gallbladder C) Gallbladder cancer D) Gangrene of the gallbladder

Ans: D Feedback: In calculous cholecystitis, a gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur; and the blood vessels in the gallbladder are compressed, compromising its vascular supply. Gangrene of the gallbladder with perforation may result. Pancreatitis, atrophy, and cancer of the gallbladder are not plausible complications.

33. A patient has been diagnosed with pancreatic cancer and has been admitted for care. Following initial treatment, the nurse should be aware that the patient is most likely to require which of the following? A) Inpatient rehabilitation B) Rehabilitation in the home setting C) Intensive physical therapy D) Hospice care

Ans: D Feedback: Pancreatic carcinoma has only a 5% survival rate at 5 years regardless of the stage of disease at diagnosis or treatment. As a result, there is a higher likelihood that the patient will require hospice care than physical therapy and rehabilitation.

20. A nurse is assessing an elderly patient with gallstones. The nurse is aware that the patient may not exhibit typical symptoms, and that particular symptoms that may be exhibited in the elderly patient may include what? A) Fever and pain B) Chills and jaundice C) Nausea and vomiting D) Signs and symptoms of septic shock

Ans: D Feedback: The elderly patient may not exhibit the typical symptoms of fever, pain, chills jaundice, and nausea and vomiting. Symptoms of biliary tract disease in the elderly may be accompanied or preceded by those of septic shock, which include oliguria, hypotension, change in mental status, tachycardia, and tachypnea.

15. A patient returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the patient for signs and symptoms of what serious potential complication of this surgery? A) Diabetic coma B) Decubitus ulcer C) Wound evisceration D) Bile duct injury

Ans: D Feedback: The most serious complication after laparoscopic cholecystectomy is a bile duct injury. Patients do not face a risk of diabetic coma. A decubitus ulcer is unlikely because immobility is not expected. Evisceration is highly unlikely, due to the laparoscopic approach.

13. A home health nurse is caring for a patient discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the patient who has had pancreatic surgery? A) Proteinuria and hyperkalemia B) Hemorrhage and hypercalcemia C) Weight loss and hypoglycemia D) Malabsorption and hyperglycemia

Ans: D Feedback: The nurse arrives at this diagnosis based on the complications of malabsorption and hyperglycemia. These complications often lead to the need for dietary modifications. Pancreatic enzyme replacement, a low-fat diet, and vitamin supplementation often are also required to meet the patient's nutritional needs and restrictions. Electrolyte imbalances often accompany pancreatic disorders and surgery, but the electrolyte levels are more often deficient than excessive. Hemorrhage is a complication related to surgery, but not specific to the nutritionally based nursing diagnosis. Weight loss is a common complication, but hypoglycemia is less likely.

17. A patient is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention should the nurse perform in order to best address this diagnosis? A) Position the patient supine to facilitate diaphragm movement. B) Administer corticosteroids by nebulizer as ordered. C) Perform oral suctioning as needed to remove secretions. D) Maintain the patient in a semi-Fowler's position whenever possible.

Ans: D Feedback: The nurse maintains the patient in a semi-Fowler's position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. A supine position will result in increased pressure on the diaphragm and potentially decreased respiratory expansion. Steroids and oral suctioning are not indicated.

1. A nurse is assessing a patient who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the patient's pain, the nurse should anticipate that it may radiate to what region? A) Left upper chest B) Inguinal region C) Neck or jaw D) Right shoulder

Ans: D Feedback: The patient may have biliary colic with excruciating upper right abdominal pain that radiates to the back or right shoulder. Pain from cholecystitis does not typically radiate to the left upper chest, inguinal area, neck, or jaw.

Which intervention should be included in the plan of care for a client who has undergone a cholecystectomy?

Assessing the color of the sclera every shift If bile is not draining properly, an obstruction is probably causing bile to be forced back into the liver and bloodstream. Because jaundice may result, the nurse should assess the color of the sclerae.

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 Assessment should focus on the client's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation.

A client who had developed jaundice 2 months earlier is brought to the ED after attending a party and developing excruciating pain that radiated over the abdomen and into the back. Upon assessment, which additional symptom would the nurse expect this client to have?

Bile-stained vomiting Nausea and vomiting are common in acute pancreatitis. The emesis is usually gastric in origin but may also be bile stained. Fever, jaundice, mental confusion, and agitation may also occur.

Which foods should be avoided following acute gallbladder inflammation?

Cheese The client should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the client that fatty foods may induce an episode of cholecystitis. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea may be consumed as tolerated.

Which term most precisely refers to the incision of the common bile duct for removal of stones?

Choledocholithotomy Choledocholithotomy refers to incision of the common bile duct for the removal of stones (liths). Cholecystostomy refers to opening and draining the gallbladder. Choledochotomy refers to opening into the common duct. Choledochoduodenostomy refers to anastomosis of the common duct to the duodenum.

A very ill client with acute cholecystitis is scheduled for surgery. The surgeon plans to create an incision in the common bile duct to remove stones. The nurse correctly documents this surgery in the electronic medical record using which term?

Choledochostomy This procedure is reserved for the client with acute cholecystitis who may be too ill to undergo a surgical procedure. It involves making an incision in the common duct, usually to remove stones (choledochostomy).

Which is a clinical manifestation of cholelithiasis?

Clay-colored stools The client with gallstones has clay-colored stools and excruciating RUQ 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.

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 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.

Which dietary modification is used for a client diagnosed with acute pancreatitis?

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

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 Fluid and electrolyte disturbances are common complications because of nausea, vomiting, movement of fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever, and the use of gastric suction. The nurse assesses the client's fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the client daily and carefully measures fluid intake and output, including urine output, nasogastric secretions, and diarrhea.

Which is a gerontological consideration associated with the pancreas?

Increased amount of fibrous material An increase in fibrous material and some fatty deposition occurs in the normal pancreas of people older than 70 years of age. There is a decreased rate of pancreatic secretion and decreased bicarbonate output in older adults. Decreased calcium absorption may also occur.

A nurse is planning care for a client with acute pancreatitis. Which client outcome does the nurse assign as the highest priority?

Maintaining normal respiratory function 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?

Measure blood glucose concentration every 4 to 6 hours

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 Muscle twitching and finger numbness indicate hypocalcemia, a potential complication of acute pancreatitis. Calcium may be prescribed to prevent or treat tetany, which may result from calcium losses into retroperitoneal (peripancreatic) exudate. The other data indicate other complications of acute pancreatitis but are not indicators of electrolyte imbalance.

A client is admitted to the health care center with hyperglycemia, a 15-pound weight loss, and reports of vague upper and midabdominal pain that increases in intensity at night. The client' health history indicates alcoholism, smoking of a pack of cigarettes daily, and diabetes for the past 20 years. Upon examination the nurse finds swelling in the feet and abdominal ascites. Based on the clinical manifestations, which condition is the most likely diagnosis?

Pancreatic carcinoma Pain, jaundice, and weight loss are considered classic signs of pancreatic carcinoma. Other signs include rapid, profound, and progressive weight loss as well as vague upper or midabdominal pain or discomfort unrelated to any gastrointestinal function that is often difficult to describe. It is often more severe at night and is accentuated when lying supine. The formation of ascites is common. An important sign is the onset of symptoms of insulin deficiency: glucosuria, hyperglycemia, and abnormal glucose tolerance. Therefore, diabetes may be an early sign of carcinoma of the pancreas.

Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis?

Pancreatic necrosis 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.

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 Self-digestion of the pancreas by its own proteolytic enzymes, principally trypsin, causes acute pancreatitis. Of clients with acute pancreatitis, 80% had undiagnosed chronic pancreatitis. Gallstones enter the common bile duct and lodge at the ampulla of Vater, obstructing the flow of pancreatic juice or causing a reflux of bile from the common bile duct into the pancreatic duct, thus activating the powerful enzymes within the pancreas. Normally, these remain in an inactive form until the pancreatic secretions reach the lumen of the duodenum. Activation of the enzymes can lead to vasodilation, increased vascular permeability, necrosis, erosion, and hemorrhage.

A 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 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.

A nursing instructor is explaining the pathophysiology and clinical manifestations of pancreatitis to a group of nursing students. The instructor evaluates the teaching as effective when a student correctly identifies which symptom as that most commonly reported by clients with pancreatitis?

Severe, radiating abdominal pain Severe abdominal pain is the major symptom of pancreatitis that causes the client to seek medical care. The pain occurs in the midepigastrium. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas. Pain is frequently acute in onset, occurring 24 to 48 hours after a very heavy meal or alcohol ingestion; it may be diffuse and difficult to localize.

A client who has been having recurrent attacks of severe abdominal pain over the past few months informs the physician about a 25-pound weight loss in the past year. The nurse attributes which factor as the most likely cause of this weight loss?

Skipping meals out of fear of painful attacks Weight loss is a major problem in chronic pancreatitis. More than 80% of clients experience significant weight loss, which is usually caused by decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack.

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 is admitted to the health care center with severe abdominal pain rated 10 on a 1-to-10 scale, tachycardia, hypertension, and muscle spasms. The nurse immediately administers morphine sulfate 4 mg slow intravenous pyelogram (IVP), as ordered. The nurse plans for which goal after administration of this mediation?

To increase the client's pain threshold Morphine, fentanyl, and hydromorphone act by depressing the central nervous system, thereby increasing the client's pain threshold.

1. Which is the most common report by clients with pancreatitis?

a. severe, radiating abdominal pain Explanation: Clients with pancreatitis most commonly report severe mid- to upper-abdominal pain, radiating to both sides and straight to the back. The client may describe the stools as being frothy and foul smelling, not black or tarry. The client's urine may be dark. The client will not experience increased or painful urination, increased appetite, or weight gain.

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because they

cannot tolerate a high glucose concentration. Total parenteral 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 high protein intake increases risk for hepatic encephalopathy in clients with cirrhosis. Clients with pancreatitis should not be given high-fat foods because they are difficult to digest.