unit5 chapter44
A client with calculi in the gallbladder is said to have
Cholelithiasis
A client with acute pancreatitis is prescribed hydromorphone 2 mg intranvenously every 4 hours as needed for severe pain. Which assessment will the nurse prioritize for this client?
Bowel sounds
A client has a tumor of the head of the pancreas. What clinical manifestations will the nurse assess? Select all that apply.
Clay-colored stools Dark urine Jaundice
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
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 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 preoperative client scheduled to have an open cholecystectomy says to the nurse, "The doctor said that after surgery, I will have a tube in my nose that goes into my stomach. Why do I need that?" What most common reason for a client having a nasogastric tube in place after abdominal surgery should the nurse include in a response?
decompression
A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?
"Maintain a high-carbohydrate, low-fat diet."
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
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 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
The nurse is caring for a client recovering from acute pancreatitis. Which menu item should the nurse remove from the client's breakfast tray?
Coffee
Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes mellitus. Which of the following explains the cause of this secondary diabetes?
Dysfunction of the pancreatic islet cells
When caring for the patient with acute pancreatitis, the nurse must consider pain relief measures. What nursing interventions could the nurse provide? (Select all that apply.)
Encouraging bed rest to decrease the metabolic rate Withholding oral feedings to limit the release of secretin Administering parenteral opioid analgesics as ordered
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 student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority? You Selected:
Impaired nutrition: less than body requirements
Clinical manifestations of common bile duct obstruction include all of the following except:
Light-colored urine
Which enzyme aids in the digestion of fats?
Lipase
Which condition is most likely to have a nursing diagnosis of fluid volume deficit?
Pancreatitis
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
When caring for a client with acute pancreatitis, the nurse should use which comfort measure?
Positioning the client on the side with the knees flexed
A client with gallstones is diagnosed with acute pancreatitis and is requesting information about the physiology of the gallbladder. Which information will the nurse include about the function of this organ?
Releases bile in response to cholecystokinin
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 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
The nurse is admitting a patient to the intensive care unit with a diagnosis of acute pancreatitis. What does the nurse expect was the reason the patient came to the hospital?
Severe abdominal pain
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.
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 statu
To avoid inflammation of the pancreas
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 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.
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
The digestion of carbohydrates is aided by
amylase.
Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients:
cannot tolerate high-glucose concentration.
A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:
yellow sclerae.
