pancreatitis 114 exam 1
a nurse is completing nutritional teaching for a client who has pancreatitis. which of the following statements by the client indicates an understanding of the teachings (SATA) a. i plan to eat small frequent meals b. i will eat easy to digest foods with limited spice c. i will use skin milk when cooking d. i plan to drink regular cola e. i will limit alcohol intake to two drinks per day
A,B C Rationale: Patients with pancreatitis should eat small, frequent, easy to digest, low-fat meals. Pt should avoid alcohol and caffeinated beverages.
the client is admitted to the medical department with a dx of r/o acute pancreatitis. what laboratory values should the nurse monitor to confirm this dx a. creatinine and BUN b. troponin and CK-MB c. serum amylase and lipase d. serum bilirubin and calcium
C.Rationale: Serum amylase levels increase within two to 12 hours of the onset of acute pancreatitis; lipase elevates and remains elevated for seven to 14 days
The client diagnosed with acute pancreatitis is being discharged home. What statement by the client indicates the teaching has been effective? a. i should decrease my intake of coffee, tea, and cola b. i will eat a low fat diet and avoid spicy food c. i will check my amylase and lipase levels daily d. i will return to work tomorrow but take it easy
B Rationale: High fat and spicy foods stimulate pancreatic enzymes. Caffeinated beverages should be avoided not decreased. There are no daily tests the client can take at home. The client will be fatigued as a result as a lowered metabolic rate and will need to rest.
the client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain? a recommend lying in the prone position with legs extended b. maintain a tripod osition over the bedside table c. place in side lying position with knees flexed d. encourage a supine position with a pillow under the knees
C Rationale: The fetal position deceases pain caused by the stretching of the peritoneum as a result of edema. The pancreas is located abdomen. Anything that causes the abdomen to be stretched will increase pain.
a nurse is assessing a client who has pancreatitis. which of the following actions should the nurse take to assess the presence of cullens sign? a. tap lightly at the costovertebral margin on the clients back b. palpate the RLQ c. inspect the skin around the umbilicus d. auscultate the area below the scapula
C.Rationale: Cullen's sign is indicated by a bluish-gray discoloration in the periumbillical area
A nurse is completing the admission assessment of a client who has acute pancreatitis. Which finding is the first priority? A) History of cholelithiasis B) Elevated serum amylase levels C) Decrease in bowel sounds upon auscultation D) Hand spasms present when blood pressure is checked
d the greatest risk to the client is ecg changes and hypotension from hypocalcemia. hand spasms when taking blood pressure is a manifestation of hypocalcemia
a nurse is completing an admission assessment of a client who has pancreatitis. which of the following findings should the nurse expect a. pain in the upper quadrant radiating to the shoulder b. report of pain being worse when sitting upright c. pain relieved with defecation d. epigastric pain radiating to the left shoulder
D.Rationale: A client with pancreatitis will report pain being worse when lying down in the fetal position, and pain that radiates to the back. left flank, or left, shoulder.
The nurse is completing discharge teaching to the client diagnosed with acute pancreatitis. What instruction should the nurse discuss with the client? a.instruct the importance to avoid all stress b. explain the correct way to take pancreatic enzymes c. instruct the client to decrease alcohol intake d. discuss the importance of stopping smoking
D.Rationale: Alcohol must be avoided completely due to its destruction of the pancreas. Stress stimulates the liver, but it is unrational to avoid all stress. Pancreatic enzymes are only needed for chronic pancreatitis. Smoking stimulates the pancreas to release pancreatic enzymes.
The client is diagnosed with acute pancreatitis. What health-care provider's admitting order should the nurse question? A. Bedrest with bathroom privileges B. Initiate IV therapy of D5W at 125 mL/hr C. Weight client daily D. Low fat, low carb diet
d bed rest decreases the metabolic rate. the client should be NPO to rest the pancreas to decrease the auto digestion of the pancreas. since the client is npo iv therapy is appropriate. weight changes will happen as a result of diet and iv fluids therfore are appropriate
a 36 year old man presents with sudden onset severe epigastric pain following an alcohol binge/ pain is referred to his back. pain is alleviated when he sits and leans forward. there is also nausea and vomiting. physical examination revealed upper abdominal tenderness, bluish discoloration around umbillicus, bowel sounds are absent. what is likely the dx? a. acute pancreatitis b. acute appendicitis c. acute cholecystitis d. acute gastroenteritis
a Sudden severe epigastric pain (following alcohol binge) that is referred to the back and relieved by sitting and leaning forward with Cullen's sign (periumbilical ecchymosis) strongly suggest acute pancreatitis.
the nurse is administering a pancreatic enzyme to the client dx with chronic pancreatitis. which statement best explains the rationale for adminsitering this medication a. it is an exogenous source of protease, amylase, and lipase b. this enzyme increases the number of bowel movements c. this medication breaks down in the stomach to help digestion d. pancreatic enzymes help break down fat in the small intestine
a pancreatic enzymes enhance the digestion of starches in the gastrointestinal tract by supplying outside source of the pancreatic enzymes. pancreatic enzymes decrease the number of bowel movements. the enzymes are enteric coated and should not be crushed because the hydrochloric acid in the stomach will destroy the enzymes, these enzymes work in the small intestine. pancreatic enzymes help breakdown carbohydrates and bile breaks down fat
nursing management of the pt with acute pancreatitis includes: SATA a. check for signs of hypocalcemia b. provide a diet low in carbohydrates c. giving insulin based on sliding scale d. observing stools for signs of steatorrhea e. monitoring for infection, particularly respiratory tract infection
a e During the acute phase, it is important to monitor vital signs. Hemodynamic stability may be compromised by hypotension, fever, and tachypnea. Injection fluids are ordered, and the response to therapy is monitored. Fluid and electrolyte balances are closely monitored. Frequent vomiting, along with gastric suction, may result in decreased levels of chloride, sodium, and potassium. Because hypocalcemia can occur in acute pancreatitis, the nurse should observe for symptoms of tetany, such as jerking, irritability, and muscular twitching. Numbness or tingling around the lips and in the fingers is an early indicator of hypocalcemia. The patient should be assessed for Chvostek's sign or Trousseau's sign. A patient with acute pancreatitis should be observed for fever and other manifestations of infection. Respiratory infections are common because the retroperitoneal fluid raises the diaphragm, which causes the patient to take shallow, guarded abdominal breaths.
the nurse is caring for a 55 year old man patient with acute pancreatitis resulting from gallstones. which clinical manifestation would the nurse expect a. hematochezia b. left upper abdominal pain c. ascites and peripheral edema d. temperature over 102
b abdominal pain is the predominant manifestation of acute pancreatitis. other manifestations include nausea and vomiting, low grade fever, hypotension, tachycardia, and jaundice. abdominal tenderness with gaurding is common. bowel sounds may be decreased or absent. ileus may occur and causes marked abdominal distention. areas of cyanosis or greenish to yellow brown discoloration of the abdominal wall may occur
The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care? A. Immediately start enteral feeding to prevent malnutrition. B. Insert an NG and maintain NPO status to allow pancreas to rest. C. Initiate early prophylactic antibiotic therapy to prevent infection. D. Administer acetaminophen (Tylenol) every 4 hours for pain relief.
b initial tx with acute pancreatitis will include an ng tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. fluid will be administered to tx and prevent shock. the pain will be tx with IV morphine because of the npo status. enteral feedings will only be used for the pt with severe acute pancreatitis in whom oral intake is not resumed. ABT is only needed with acute necrotizing pancreatitis and signs of infection
