Hinkle 44 Flashcards
(39 cards)
A nurse is assessing a client who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the client’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
Rationale: The client 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.
A client has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse explain the pathophysiology of this client’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
Rationale: 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.
A client’s abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the client’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
Rationale: 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.
A nurse who provides care in a community clinic assesses a wide range of individuals. The nurse should identify which client 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
Rationale: Excessive and prolonged consumption of alcohol accounts for most cases of chronic pancreatitis in Western societies.
A 37-year-old client presents at the emergency department (ED) reporting nausea and vomiting and severe abdominal pain. The client’s abdomen is rigid, and there is bruising to the client’s flank. The client’s spouse states that the client was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the client for what health problem?
A. Severe pancreatitis with possible peritonitis
B. Acute cholecystitis
C. Chronic pancreatitis
D. Acute appendicitis with possible perforation
ANS: A
Rationale: Severe abdominal pain is the major symptom of pancreatitis that causes the client 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.
A client 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 client 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
Rationale: An ultrasound of the gallbladder is most accurate if the client 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.
A client who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this client knows to immediately report what assessment finding to the health care provider?
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
Rationale: Increased abdominal tenderness and rigidity should be reported immediately to the health care provider, as it may indicate bleeding from an inadvertent puncture or nicking of a major blood vessel during the surgical procedure.
The location of the subcostal incision will likely cause the client to take shallow breaths to prevent pain, which may result in decreased breath sounds. The nurse should remind clients 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 given 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.
A client with chronic pancreatitis had a pancreaticojejunostomy created 3 months ago for relief of pain and to restore drainage of pancreatic secretions. The client has come to the office for a routine postsurgical appointment. The client is frustrated that the pain has not decreased. What is the most appropriate initial response by the nurse?
A. “The majority of clients who have a pancreaticojejunostomy have their normal digestion restored but do not achieve pain relief.”
B. “Pain relief occurs by 6 months in most clients who undergo this procedure, but some people experience a recurrence of their pain.”
C. “Your health care provider 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
Rationale: Pain relief from a pancreaticojejunostomy often occurs by 6 months in more than 85% of the clients who undergo this procedure, but pain returns in a substantial number of clients as the disease progresses. This client had surgery 3 months ago; the client 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.
A nurse is caring for a client who has been scheduled for endoscopic retrograde
cholangiopancreatography (ERCP) the following day. When providing anticipatory
guidance for this client, 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
Rationale: Moderate sedation, not general anesthesia, is used during ERCP. D50 is not
given and the procedure does not involve the creation of an incision.
A client has undergone a laparoscopic cholecystectomy and is being prepared for
discharge home. When providing health education, the nurse should prioritize what
topic?
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
Rationale: Because of the early discharge following laparoscopic cholecystectomy, the
client 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.
A nurse is preparing a plan of care for a client 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
Rationale: While each of the diagnoses may be applicable to a client 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.
A home health nurse is caring for a client 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 client who has had
pancreatic surgery?
A. Proteinuria and hyperkalemia
B. Hemorrhage and hypercalcemia
C. Weight loss and hypoglycemia
D. Malabsorption and hyperglycemia
ANS: D
Rationale: 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 client’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.
A client returns to the floor after a laparoscopic cholecystectomy. The nurse should
assess the client 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
Rationale: The most serious complication after laparoscopic cholecystectomy is a bile duct injury. Clients 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.
A client has had a laparoscopic cholecystectomy. The client is now reporting right
shoulder pain. What should the nurse suggest to relieve the pain?
A. Aspirin every 4 to 6 hours as prescribed
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
Rationale: 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.
A client has been treated in the hospital for an episode of acute pancreatitis. The
client 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. What is the
nurse’s most appropriate response?
A. Educate the client about the link between alcohol use and pancreatitis.
B. Ensure that the client knows the importance of attending follow-up appointments.
C. Refer the client to social work or spiritual care.
D. Encourage the client to connect with a community-based support group.
ANS: D
Rationale: After the acute attack has subsided, some clients 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 client
already has an understanding of the effects of alcohol, and follow-up appointments will
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not necessarily result in lifestyle changes. Social work and spiritual care may or may not
be beneficial.
A client is being treated for acute pain from an episode of pancreatitis. The nurse has
identified a nursing diagnosis of Ineffective Breathing Pattern related to pain secondary
to effects of surgery. Which intervention should the nurse perform in order to best
address this diagnosis?
A. Position the client supine to facilitate diaphragm movement.
B. Administer corticosteroids by nebulizer as prescribed.
C. Perform oral suctioning as needed to remove secretions.
D. Administer analgesic per orders.
ANS: D
Rationale: The client has ineffective breathing patterns due to pain. To increase the
likelihood of the client being able to perform interventions for his/her respiratory status,
it would be important to treat acute pain first. A supine position will result in increased
pressure on the diaphragm and potentially decreased respiratory expansion. Steroids
and oral suctioning are not indicated.
A client with gallstones has been prescribed ursodeoxycholic acid (UDCA). The nurse
understands that additional teaching is needed regarding this medication when the client
states:
A. “It is important that I see my health care provider 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
Rationale: 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 clients to dissolve stones, and monitoring of the client is
required during this time. The effective dose of medication depends on body weight.
A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner
tray for a client 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
Rationale: 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 client should avoid fried foods such as
fried chicken, as fatty foods may bring on an episode of cholecystitis.
A nurse is assessing an older adult client with gallstones. The nurse is aware that the
client may not exhibit typical symptoms, and that particular symptoms that may be
exhibited in the elderly client may include what examples?
A. Fever and pain
B. Chills and jaundice
C. Nausea and vomiting
D. Signs and symptoms of septic shock
ANS: D
Rationale: The elderly client 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.
A nurse is creating a care plan for a client 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 client’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
Rationale: The acutely ill client 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.
The nurse is caring for a client who has just returned from the ERCP removal of
gallstones. The nurse should monitor the client 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
Rationale: Following ERCP removal of gallstones, the client is observed closely for
bleeding, perforation, and the development of pancreatitis or sepsis. Blood sugar
alterations, gangrene, peritonitis, and acidosis are less likely complications.
A client with pancreatic cancer has been scheduled for a pancreaticoduodenectomy
(Whipple procedure). During health education, the client 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
Rationale: A pancreaticoduodenectomy (Whipple procedure or resection) is used for
potentially resectable cancer of the head of the pancreas. 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.
An adult client has been admitted to the medical unit for the treatment of acute
pancreatitis. What nursing action should be included in this client’s plan of care?
A. Measure the client’s abdominal girth daily.
B. Limit the use of opioid analgesics.
C. Monitor the client for signs of dysphagia.
D. Encourage activity as tolerated.
ANS: A
Rationale: Due to the risk of ascites, the nurse should monitor the client’s abdominal
girth. There is no specific need to avoid the use of opioids or to monitor for dysphagia,
and activity is usually limited.
A community health nurse is caring for a client whose multiple health problems
include chronic pancreatitis. During the most recent home visit, the nurse learns that the
client 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 prescribed.
B. Teach the client about the importance of abstaining from alcohol.
C. Arrange for the client to be transported to the hospital.
D. Insert an NG tube, if available, and stay with the client.
ANS: C
Rationale: 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. Client education is a later priority that may or may
not be relevant.
