IGGY CH59 Biliary & pancreas
20. A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? A. Measure intake and output every shift. B. Do not administer food or fluids by mouth. C. Administer opioid analgesic medication. D. Assist the client to assume a position of comfort.
ANS. C Administer opioid analgesic medication. Pain relief is the highest priority for the client with acute pancreatitis.Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.
5. Which diagnostic results lead the nurse to suspect that a client may have gallbladder disease? A. Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall B. Decreased WBC count, visualization of calcified gallstones, increased alkaline phosphatase C. Increased WBC count, visualization of noncalcified gallstones, edema of the gallbladder wall D. Decreased WBC count, visualization of noncalcified gallstones, increased alkaline phosphatase
ANS. A Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall An increased WBC count, calcified gallstones visualized on the abdominal X-ray, and edema of the gallbladder wall are the best diagnostic results to indicate gallbladder disease. Acute cholecystitis is seen as edema of the gallbladder wall and pericholecystic fluid. Ultrasonography of the right upper quadrant is the best diagnostic test for cholecystitis.An increased WBC count, not decreased, is evidence of inflammation. Only calcified gallstones, not noncalcified gallstones, will be visualized on abdominal X-ray. Alkaline phosphatase will be elevated if liver function is abnormal; this is not common in gallbladder disease.
10. A client who had been hospitalized with pancreatitis is being discharged with home health services. The client is severely weakened after this illness. Which nursing intervention is the highest priority in conserving the client's strength? A. Limiting the client's activities to one floor of the home B. Instructing the client to take an as-needed (PRN) sleeping medication at night C. Arranging for the client to have a nutritional consult to assess the client's diet D. Asking the health care provider for a request for PRN nasal oxygen
ANS. A Limiting the client's activities to one floor of the home Limiting the client's activities to one floor of the home is the highest priority nursing intervention. This will prevent tiring the client unnecessarily with stair climbing.A PRN sleeping medication will not increase the client's strength level or conserve strength.Arranging for a nutritional consult or placing the client on PRN nasal oxygen will not necessarily result in an increase in the client's strength level or conserve strength. No information suggests that the client has any history of breathing difficulties.
18. After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? A. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min B. Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain C. Middle-aged client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography D. Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL (13.1 mmol/L)
ANS. A Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min The nurse would first assess the young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. Airway and breathing are the two most important criteria the nurse will use to determine which client to assess first. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. Acute respiratory distress syndrome is a possible complication of acute pancreatitis.The client with cholecystitis and the client with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse's immediate attention. The older adult client's glucose level will require intervention but, again, is not a medical emergency.
19. A client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which precautionary measures does the nurse implement to prevent potential complications? Select all that apply. A. Check blood glucose often. B. Check bowel sounds and stools. C. Ensure that drainage color is clear. D. Monitor mental status. E. Place the client in the supine position.
ANS. A, B, D To prevent potential complications after a Whipple procedure, the nurse would check the client's glucose often to monitor for diabetes mellitus. Bowels sounds and stools would be checked to monitor for bowel obstruction. A change in mental status or level of consciousness could be indicative of hemorrhage.Clear, colorless, bile-tinged drainage or frank blood with increased output may indicate disruption or leakage of a site of anastomosis but is not a precautionary action for the nurse to implement. The client should be placed in semi-Fowler's and not supine position to reduce tension on the suture line and the anastomosis site and to optimize lung expansion.
9. A client has developed acute pancreatitis after also developing gallstones. Which is the highest priority nursing instruction for this client to avoid further attacks of pancreatitis? A. "You may need a surgical consult for removal of your gallbladder." B. "See your health care provider (HCP) immediately when experiencing symptoms of a gallbladder attack." C. "If you have a gallbladder attack and pain does not resolve within a few days, call your health care provider." D. "You'll need to drastically modify your alcohol intake."
ANS. B "See your health care provider (HCP) immediately when experiencing symptoms of a gallbladder attack." The highest priority nursing instruction for the client to avoid more attacks of pancreatitis is to report symptoms of gallbladder attacks immediately to the HCP.The client may not require removal of the gallbladder. That decision is made by the HCP. The client must see the provider promptly when experiencing gallbladder disease and should not wait. Because this client's acute pancreatitis is likely related to gallstones, alcohol consumption need not be restricted.
1. A client has just been diagnosed with pancreatic cancer. The client's upset spouse tells the nurse that they have recently moved to the area, have no close relatives, and are not yet affiliated with a church. What is the nurse's best response? A. "Maybe you should find a support group to join." B. "Would you like me to contact the hospital chaplain for you?" C. "Do you want me to try to find a therapist for you?" D. "Do you have any friends whom you want me to call?"
ANS. B "Would you like me to contact the hospital chaplain for you?" Suggesting to contact the hospital chaplain is the best and most appropriate response for the nurse to take when talking with the cancer client's spouse.Suggesting that the client find a support group does not assist the client and the family with the problem. It is inappropriate for the nurse to suggest that the client and the family need a therapist. The spouse has already told the nurse that they have recently moved to the area, so it is unlikely that they have already made close friends.
6. The nurse expects that which client will be discharged to the home environment first? A. Older obese adult who has had a laparoscopic cholecystectomy B. Middle-aged thin adult who has had a laparoscopic cholecystectomy C. Middle-aged thin adult with a heart murmur who has had a traditional cholecystectomy D. Older obese adult with chronic obstructive pulmonary disease (COPD) who has had a traditional cholecystectomy
ANS. B Middle-aged thin adult who has had a laparoscopic cholecystectomy A middle-aged client with a thin frame, who had a laparoscopic cholecystectomy, will be discharged first.Although the older obese client also had a laparoscopic cholecystectomy, the client's obesity and age probably will require a longer stay. A traditional cholecystectomy will always require a longer recovery time. The older obese client with a history of COPD will likely have a more lengthy recovery because of associated breathing problems.
12. The nurse suspects that which client is at highest risk for developing gallstones? A. Obese male with chronic obstructive pulmonary disease B. Obese female receiving hormone replacement therapy C. Thin male with a history of coronary artery bypass grafting D. Thin female who has recently given birth
ANS. B Obese female receiving hormone replacement therapy The client at highest risk is the obese female receiving hormone replacement therapy. Both obesity and hormone replacement therapy have been found to increase a woman's risk for developing gallstones. Other risk factors for developing gallstones are type 2 diabetes, dyslipidemia, and insulin resistance.Men are at lower risk than women for developing gallstones. Although pregnancy increases the risk for a woman to develop gallstones, a woman's thin frame lessens that risk.
14. A client has been discharged to home after being hospitalized with an acute episode of pancreatitis. The client, who is an alcoholic, is unwilling to participate in Alcoholics Anonymous (AA), and the client's spouse expresses frustration to the home health nurse regarding the client's refusal. What is the nurse's best response? A. "Your spouse will sign up for the meetings only when he is ready to deal with his problem." B. "Keep mentioning the AA meetings to your spouse on a regular basis." C. "I'll get you some information on the support group Al-Anon." D. "Tell me more about your frustration with your spouse's refusal to participate in AA."
ANS. C "I'll get you some information on the support group Al-Anon." The nurse's best response involves putting the client's spouse in contact with an Al-Anon support group. This action may help with the spouse's frustration and help both to cope with the situation.Telling the spouse that the client will sign up for AA meetings when the client is ready and telling the spouse to keep mentioning AA do not address the spouse's frustration with the client's refusal to participate in AA. Encouraging the spouse to say more about his or her frustration may allow the spouse to vent frustration, but it does not offer any options or solutions.
4. A client diagnosed with acalculous cholecystitis asks the nurse how the gallbladder inflammation developed when there is no history of gallstones. What is the nurse's best response? A. "This may be an indication that you are developing sepsis." B. "The gallstones are present, but have become fibrotic and contracted." C. "This type of gallbladder inflammation is associated with hypovolemia." D. "This may be an indication of pancreatic disease."
ANS. C "This type of gallbladder inflammation is associated with hypovolemia." The nurse's best response about acalculous cholecystitis is that "This type of gallbladder inflammation is associated with hypovolemia."Although this type of gallbladder inflammation is associated with sepsis, it is not an indicator that sepsis is developing. Fibrotic and contracted gallstones are associated with chronic cholecystitis and this scenario states that there is no history of gallstones. The presence of acalculous cholecystitis is not an indicator that pancreatic disease has developed.
17. The nurse suspects that a client may have acute pancreatitis as evidenced by which group of laboratory results? A. Deceased calcium, elevated amylase, decreased magnesium B. Elevated bilirubin, elevated alkaline phosphatase C. Elevated lipase, elevated white blood cell (WBC) count, elevated glucose D. Decreased blood urea nitrogen (BUN), elevated calcium, elevated magnesium
ANS. C Elevated lipase, elevated white blood cell (WBC) count, elevated glucose Elevated lipase, along with increased WBC and increased glucose, suggests acute pancreatitis. Also, increased are serum amylase, serum trypsin, and serum elastase.Many pancreatic and nonpancreatic disorders can cause increased serum amylase levels. Bilirubin and alkaline phosphatase levels will be increased only if pancreatitis is accompanied by biliary dysfunction. Usually, calcium and magnesium will be increased and BUN increased, not decreased, in acute pancreatitis.
3. The nurse is assessing a client who has recurrent attacks of pancreatitis and is concerned about possible alcohol abuse as an underlying cause of these attacks. To elicit this information, what will the nurse do initially? A. Ask the client about binge drinking. B. Question the client whether drinking increases on weekends. C. Provide privacy and use the CAGE questionnaire (Cut down, Annoyed by criticism, Guilt about drinking, and Eye-opener drinks) D. Ask the client's spouse to describe the client's drinking
ANS. C Provide privacy and use the CAGE questionnaire (Cut down, Annoyed by criticism, Guilt about drinking, and Eye-opener drinks) Initially, the nurse needs to provide privacy and establish a trusting relationship to help obtain information from the client about alcohol use. The CAGE questionnaire is useful as well.Topics such as binge drinking or tending to drink more on holidays or weekends may put the client on the defensive rather than provide the desired information. It has not yet been determined whether the client engages in binge drinking. Asking the client client's spouse will decrease nurse-client trust.
7. The nurse is teaching a client with gallbladder disease about diet modification. Which meal does the nurse suggest to the client? A. Steak and French fries B. Fried chicken and mashed potatoes C. Turkey sandwich on wheat bread D. Sausage and scrambled eggs
ANS. C Turkey sandwich on wheat bread Turkey is an appropriate low-fat selection for this client. High fiber, from the wheat bread, also helps reduce the risk. Typically, diets high in fat, high in calories, low in fiber, and high in refined white carbohydrates place clients at higher risk for developing gallstones.Steak, French fries, fried chicken and mashed potatoes, and sausage are too fatty. Eggs are too high in cholesterol for a client with gallbladder disease.
11. The nurse is caring for a client recently diagnosed with type 1 diabetes mellitus who has had an episode of acute pancreatitis. The client asks the nurse how he developed diabetes when the disease does not run in the family. What is the nurse's best response? A. "The diabetes could be related to your obesity." B. "Look online for general information about diabetes." C. "Do you consume alcohol on a frequent basis?" D. "Type 1 diabetes can occur when the pancreas is affected or destroyed by disease."
ANS. D "Type 1 diabetes can occur when the pancreas is affected or destroyed by disease." The nurse's best response is to tell the client that type 1 diabetes can occur when the pancreas is affected or destroyed by disease. This is the only response that accurately describes the relationship of the client's diabetes to pancreatic destruction.Type 2, not type 1, diabetes is usually related to obesity. Telling the client to look online for information is inappropriate because some information available online is incorrect at best.Many factors could produce acute pancreatitis other than alcohol consumption.
2. A client with acute cholecystitis is admitted to the medical-surgical unit. Which nursing activity associated with the client's care will be appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? A. Assessing dietary risk factors for cholecystitis B. Checking for bowel sounds and distention C. Determining precipitating factors for abdominal pain D. Obtaining the admission weight, height, and vital signs
ANS. D Obtaining the admission weight, height, and vital signs Obtaining admission height, weight, and vital signs is included in the education for UAPs and usually is included in the job description for these staff members.Assessing for risk factors, checking bowel sounds, and determining precipitating factors for abdominal pain require assessment skills. Assessment skills require broader education and are within the scope of practice of licensed nursing staff and not UAPs.
15. Which set of assessment findings indicates to the nurse that a client may have acute pancreatitis? A. Absence of jaundice, pain of gradual onset B. Absence of jaundice, pain in right abdominal quadrant C. Presence of jaundice, pain worsening when sitting up D. Presence of jaundice, pain worsening when lying supine
ANS. D Presence of jaundice, pain worsening when lying supine Pain that worsens when lying supine and the presence of jaundice are the only assessment findings indicative of acute pancreatitis.Pain associated with acute pancreatitis usually has an abrupt onset, is located in the mid-epigastric or upper left quadrant, and lessens with sitting up. Also, jaundice is present.
16. A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element? A. Carbohydrates B. High fat C. High fiber D. Protein
ANS. D Protein The nurse tells the client not to mix enzyme preparations with foods containing protein because the enzymes will dissolve the food into a watery substance. Pancreatic-enzyme replacement therapy (PERT) is the standard of care to prevent malnutrition, malabsorption, and excessive weight loss (Chart 59-3). Pancrelipase is usually prescribed in capsule or tablet form and contains varying amounts of amylase, lipase, and protease.No evidence suggests that enzyme preparations should not be mixed with carbohydrates, food with high fat content, and food with high fiber content.
13. The nurse is attempting to position a client having an acute attack of pancreatitis in the most comfortable position possible. In which position does the nurse place this client? A. Supine, with a pillow supporting the abdomen B. Up in a chair between frequent periods of ambulation C. High-Fowler's position, with pillows used as needed D. Side-lying position, with knees drawn up to the chest
ANS. D Side-lying position, with knees drawn up to the chest The side-lying position with the knees drawn up has been found to be the most comfortable possible position to relieve abdominal discomfort related to acute pancreatitis.No evidence suggests that supine position, sitting up in a chair, or high-Fowler's position has any effect on abdominal discomfort related to acute pancreatitis.
8. The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase (Cotazym). Which instruction does the nurse include when teaching the client about this medication? A. Administer pancrelipase before taking an antacid. B. Chew tablets before swallowing. C. Take pancrelipase before meals. D. Wipe your lips after taking pancrelipase.
ANS. D Wipe your lips after taking pancrelipase. The nurse will instruct the client to wipe the lips after taking pancrelipase. Pancrelipase is a pancreatic enzyme used for enzyme replacement for clients with chronic pancreatitis. To avoid skin irritation and breakdown from residual enzymes, the lips should be wiped.Pancrelipase should be administered after, and not before, antacids or histamine2 blockers are taken. It should not be chewed to minimize oral irritation and allow the drug to be released more slowly. It should be taken with meals and snacks, and not before, and followed with a glass of water.