gall bladder disease- 114 exam 1
a client is experiencing severe upper abdominal pain and jaundice. which finding on the cholescintigraphy should indicate to the nurse that the client has cholelithiasis a. obstruction of the cystic duct by a gallstone b. viral infection of the gallbladder c. accumulation of fat in the wall of the gallbladder d. accumulation of bile in the hepatic duct
Answer: A Rationale: Cholelithiasis is almost always caused by a gallstone lodged in the cystic duct. Accumulation of bile in the hepatic duct would not lead to cholecystitis. Neither the accumulation of fat nor a viral infection leads to cholecystitis.
A client is recovering from a laparoscopic cholecystectomy. Which nursing action should the nurse use to reduce this client's risk of infection? (Select all that apply.) a. monitor vital signs including temp every 4 hours b. administer antibiotics as prescribed c. coach to take deep breath every 2 hrs while awake d. assess the abdomen every 4 hrs e. place in fowler position
Answer: A, B, C, DRationale: To reduce the risk of infection, the nurse will monitor vital signs, including temperature, every 4 hours, because changes may be the first sign of infection. Assessment of the abdomen can reveal signs of a surgical wound infection. Turning, breathing, and incentive spirometry help prevent postsurgical atelectasis and subsequent pneumonia. Antibiotics are used to control infection. Fowler position may enhance the client's comfort but will have no effect on postsurgical infection.
a client with acute cholecystitis is experiencing nausea and vomiting. which nursing action should the nurse use to address the clients nutritional status (SATA) a. counseling regarding low fat menu choices b. administering antiemetics as prescribed c. assessing height and weight d. advising to consume a low protein diet e. reviewing serum electrolytes
Answer: A, B, C, ERationale: Assessing height and weight, reviewing serum electrolytes, counseling on low-fat menu choices, and administering antiemetics as prescribed are all nursing actions that address the client's nutritional status. A high-protein, not low-protein, diet is used to treat cholecystitis.
A middle-aged female client who is obese has been experiencing right upper quadrant abdominal pain for the past several hours. For which risk factors of gallstone development should the nurse assess this client during the health history? (Select all that apply.) a. excess cholesterol b. inflammation of the gallbladder c. biliary colic d. biliary stasis e. abnormal bile composition
Answer: A, B, D, ERationale: The formation of gallstones occurs when several factors are present, including abnormal bile composition, biliary stasis, inflammation of the gallbladder, and excess cholesterol. Excess cholesterol in bile is associated with obesity, a high-calorie and high-cholesterol diet, and drugs that lower serum cholesterol levels. Biliary colic is the pain described in cholelithiasis. This pain is localized to the epigastrium and the right upper quadrant of the abdomen. Biliary colic does not lead to the formation of gallstones.
The nurse is teaching a client with cholelithiasis about a new prescription for ursodiol. Which client statement indicates to the nurse that the teaching was successful? a. if i take this for a long time it may damage my liver so i will need checkups for my liver function b. there is a good change i will experience diarrhea, so i might need my dosage reduced c. this medicine should take away the orange color from my skin d. i might have some slight diarrhea or constipation, but that is a normal side effect of the medicine
Answer: DRationale: Ursodiol is a bile acid. It is used to dissolve gallstones in clients who cannot have surgery to remove gallstones. Ursodiol is also used to prevent the formation of gallstones in clients who are overweight or who are losing weight very quickly. It works by decreasing the production of cholesterol and by dissolving the cholesterol in bile so that it cannot form stones. Ursodiol is generally well tolerated but can cause diarrhea or constipation.
The nurse evaluates a client's understanding of discharge teaching following a laparoscopic cholecystectomy. Which client statement indicates teaching has been effective? (Select all that apply.) a. i will take my medicine on an empty stomach to get the maximum benefit b. i will be sure to get up and walk every hour c. i can have some hot chocolate with my breakfast d. i will increase the protein in my diet by drinking whole milk
a b d clients from a laparoscopic cholecystectomy are often tx in day surgery, but discharge instructions should be similar to those for other clients who have had abdominal surgery. therefore they should be informed to be sure to increase their activity level when they return home. clients should take pain medicine with food to diminish irritation to the stomach lining.
A client scheduled for a cholecystectomy asks what caused the gallstones to develop. Which risk factor should the nurse list when responding to this client? (Select all that apply.) a. american indian ethnicity b. male sex c. family hx of gallstones d. obesity e. hyperlipidemia
a c d e the risk factors for developing gallbladder disorders include age, family hx, american indian ethnicity, obesity, hyperlipidemia, female, pregnancy, DM, cirrhosis, ileal disease, and sickle cell disease
A client's stool are light gray in color. The nurse should asses the client for which of the following? Select all that apply. a. Intolerance to fatty foods b. Fever c. Jaundice d. Respiratory distress e. Pain at McBurney's point f. Peptic ulcer disease
A, B, C: Bile is created in the liver, stored in the gallbladder, and released into the duodenum, giving stool its brown color. A bile duct obstruction can cause pale-colored stool. Respiratory distress is not a symptom. Pain at McBurney's point is associated with appendicitis. Bleeding ulcers produce black tarry stool.
a 40 year old client is admitted to the hospital with cholecystitis. the nurse should contact the physician to question which prescription. a. iv fluid therapy of NS solution to be infused at 100 ml hr until further prescriptions b. administer morphine sulfate 10mg IM q 4 hrs as needed for severe abdominal pain c. NPO until further orders d. insert a masogastric tube and connect to low intermittent suction
B: A nurse should question the prescription for morphine sulfate because it is believed to cause biliary spasm. The preferred opioid analgesic to treat cholecystitis is meperidine (Demerol)
the nurse is prociding dietary teaching to a client with a history of gallstones. which diet should the nurse recommend SATA a. high protein b. low sodium c. low fat d. high vitamin c e. high carbohydrate
Answer: A, C Rationale: A low-carbohydrate, low-fat, high-protein diet reduces symptoms of cholecystitis. While fasting and very low-calorie diets are contraindicated, a moderate reduction in caloric intake and increased activity levels promote weight loss.
a client with acute cholecystitis is experiencing jaundice. which should the nurse consider as the reason for the jaundice a. viral infection of the gallbladder b. obstruction of the cystic duct by a gallstone c. accumulation of bile in the hepatic duct d. accumulation of fat in the wall of the gallbladder
Answer: BRationale: When acute cholecystitis is accompanied by jaundice, partial common duct obstruction is likely, which is usually due to stones or inflammation.
A client who is morbidly obese is diagnosed with acute cholelithiasis. Which nonpharmacologic therapy should the nurse expect to be prescribed for this client? a. parenteral nutrition b. fat soluble vitamins c. bile salts d. withholding all oral intakes and inserting a nasogastric tube
Answer: DRationale: During an acute attack of cholecystitis, food should be eliminated and a nasogastric tube inserted to relieve nausea and vomiting. Parenteral nutrition is not indicated at this time. Once the client is eating again, dietary fat intake may be limited, especially if the client is obese. If bile flow is obstructed, fat-soluble vitamins (A, D, E, and K) and bile salts may need to be administered but this would be considered a pharmacologic therapy.
the nurse is teaching a client with cholelithiasis about lifestyle modification. which statement made by the client indicates that the nurses teaching has been successful? a. i will walk three times a week for twenty minutes each day b. i will eliminate salt from my diet c. i can fry food as long as i use olive oil instead of vegetable oil d. i will use more ground beef in my meal preperation
a obesity is commonly associated with development of gallbladder disease. a balanced diet and exercise will help keep clients weight within normal limits
The nurse prepares discharge teaching for a client recovering from a cholecystectomy. Which topic should the nurse include in this teaching? (Select all that apply.) A. Surgical incision care B. Manifestations of postoperative complications C. Pain control measures D. Activity level E. High-fat diet
a b c d the nurse will instruct the client on prescribed activity level, manifestations of post operative complications that must be reported, pain control measures, surgical insicion care. a low fat diet should be followed
A client with cholelithiasis is not a surgical candidate at this time. Which pharmacologic treatment should the nurse expect to be prescribed for this client? (Select all that apply.) a. ursodiol b. chenodiol c. antibiotics d. antipyretics e. cholestryamine
a b c e pharmological tx for gallstones is used for clients who refuse surgery or for whom surgery is contraindicated. medications used in the tx of gallstones include ursodiol, chenodiol, antibiotics, cholestyramine, and opiod analgesics. antipyretics are a pharmalogical tx for fever, not cholelithiasis itself
a client with right upper quadrant abdominal pain asks why so many tests are scheduled. which is the reason that the nurse should give this client SATA a. to identify possible complications b. to determine if gallstones are present c. to prevent recurrence d. to determine the location of gallstones e. to diagnose the disorder
Answer: A, B, D, E Rationale: Diagnostic tests are used to identify the presence and location of gallstones, identify possible complications of the gallstones, and help differentiate gallbladder disorders from other disease processes. Diagnostic tests do not prevent the formation of gallstones but can give information necessary for treatments that prevent recurrence.
the nurse is preparing health promotion teaching for a client with gallbladder disease. which topic should the nurse include in the teaching session? SATA a. role of a high cholesterol diet on gallstone formation b. role of hypolipidemia on gallstone formation c. importance of a low cholesterol diet d. dangers of rapid weight loss e. importance of a high fiber diet
a c d e clients should be taught about the role of obesity, hyperlipidemia, and a high cholesterol diet on gallstone formation; the importance of a high fiber, low fat, and low cholesterol diet to reduce the incidence of gallbladder disorders; and the dangers of rapid weight loss. hypolipidemia does not promote gallstone formation
A pregnant client of American Indian heritage experiences mild gastric distress and nausea after eating large meals and constant sharp abdominal pain. Which additional information should the nurse collect during the interview? (Select all that apply.) A. History of chronic diseases B. Expected due date C. Length of time the symptoms last and when they occur D. Smoking historyE. Other symptoms F. Current diet
a c e f the nurse should note current mainfestations, including right upper quadrant abdominal pain, and its relationship to meals, duration, radiation, N&V, duration of symptoms, chronic diseases, current diet, pregnancy
A client asks what causes gallstones to form. Which factor should the nurse explain as being present when these stones are formed? (Select all that apply.) a. rapid weight gain b. abnormal bile composition c. excess cholesterol d. inflammation of the bladder e. biliary stasis
b c d e gall stones are formed d/t abnormal bile composition, an inflammation of the gallbladder, biliary stasis, and excess cholesterol. rapid weight loss is a factor that also contributes to the formation of gallstones
which is a risk factor for gallbladder disease a. male gender b. hypocalcemia c. rapid weight loss d. hypolipidemia
c rapid weight loss, female, and hyperlipidemia are risk factors for gallbladder disease
The nurse is planning an educational program about development and prevention of gallstones for a community group. Which population should the nurse identify to be most at risk for developing gallstones? A. Young adult Asian American women B. Middle-aged Caucasian American men C. African American clients D. Women over the age of 40
d genetic considerations and risk factors vary depending on the nature of the inflammatory disorder. female sex, age over 40, american indians and mexican americans are most at risk
After a cholecystectomy, the client is to follow a low-fat diet. Which of the following foods would be most appropriate to include a low-fat diet? a. Cheese omlet b. Peanut butter c. Ham salad sandwich d.Roast Beef
d lean meats such as beef, lamb, veal, and well trimmed lean ham and pork are low in fat
A client has undergone a laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the discharge teaching? a. Empty the bile bag daily b. Breathe deeply into a paper bag when nauseated c. Keep adhesive dressings in place for 6 weeks d. Report bile-colored drainage from any incision
d there should be no bile colored drainage from any of the incisions after post op. a laparoscopic cholecystectomy does not involve a bile bag. breathing into a paper bag will prevent a person from passing out due to hyperventilation, does not alleviate nausea.
