Chapter 46: Management of Clients with Exocrine Pancreatic and Biliary Disorders Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 46: Management of Clients with Exocrine Pancreatic and Biliary Disorders

MULTIPLE CHOICE

1. Activities the nurse could suggest to a client interested in preventing gallstone formation include which of the following?

a.

Drink only bottled water.

b.

Increase the amount of protein eaten each day.

c.

Limit the amount of calcium in the diet.

d.

Maintain a low-fat diet.

ANS: D

Health promotion activities that can help limit or prevent gallstone formation include maintaining a low-fat diet, maintaining ideal body weight, and limiting the number of ones pregnancies. Low-carbohydrate diets and physical activity also seem to help.

DIF: Comprehension/Understanding REF: p. 1120 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

2. The nurse recognizes that the individual at highest risk for development of gallstones is

a.

a 20-year-old black man with sickle cell disease.

b.

a 35-year-old white woman being treated for breast cancer.

c.

a 49-year-old white man with a sedentary lifestyle.

d.

a 60-year-old white woman being treated for obesity.

ANS: D

The incidence of gallstones increases with age, as do the risks associated with cholelithiasis. Women account for almost 70% of clients treated for gallstones, although studies have suggested that the death rate is higher in men. Other disorders that are associated with an increased incidence of gallstones are diabetes mellitus, obesity, Crohns diseases, and cirrhosis.

DIF: Comprehension/Understanding REF: p. 1119 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

3. A client with a history of cholelithiasis presents at the hospital with nausea and vomiting, abdominal pain, and jaundice. The nurse would assess the client for

a.

common bile duct obstruction.

b.

infarct of the hepatic vein.

c.

perforation of the gallbladder.

d.

spasm of the biliary tree.

ANS: A

Jaundice appears only when common bile duct obstruction is present. Bilirubin, which is normally excreted through the colon, is now in the circulating volume because of the blocked common bile duct and is deposited in the skin and in the urine, causing dark urine, light-colored stools, jaundice, and itching.

DIF: Application/Applying REF: p. 1121 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

4. In evaluating a client for the presence of gallbladder disease, the nurse would recognize that the clients statement most suggestive of this problem is

a.

I am having difficulty swallowing.

b.

I get a sharp, stabbing pain every time I take a deep breath or cough.

c.

I have a terrible pain in my stomach; it is so bad I can feel it in my shoulder.

d.

I have a very strong craving for fatty foods like bacon and eggs fried in butter.

ANS: C

The most specific and characteristic manifestation of gallstone disease is pain, or biliary colic, which is caused by spasm of the biliary ducts as they try to dislodge stones. This pain usually follows the temporary obstruction of the gallbladder outlet. Characteristically, the pain starts in the upper midline area, and it may radiate around to the back and right shoulder blade, although some clients report that it passes straight through to the back and substernal areas.

DIF: Application/Applying REF: p. 1121 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

5. The nurse explains that for a client who is a poor surgical risk, one of the nonsurgical alternatives for gallstone disease is

a.

abdominal ultrasound.

b.

laser therapy.

c.

retrograde endoscopy.

d.

T-tube placement.

ANS: C

Retrograde endoscopy for stone removal is an important nonsurgical alternative. To remove a gallstone from the common bile duct, the physician passes an endoscope orally into the duodenum, and then passes a wire snare into the common bile duct through the ampulla of Vater, securing and removing the obstructing stone.

DIF: Application/Applying REF: p. 1122 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

6. A client returned to the nursing unit after cholecystectomy with common bile duct exploration has bile leaking from around the wound. The most appropriate nursing intervention at this time would be to

a.

assess the client further, asking about pain.

b.

reassure the client that this is normal and reinforce the dressing.

c.

monitor the client for elevations in blood pressure and pulse.

d.

encourage the client to change position in bed.

ANS: A

The risk of bile leakage into the abdominal cavity is more specific for surgeries that involve the gallbladder. With hemorrhage and bile leakage, the client feels severe pain and tenderness in the right upper quadrant; the abdominal girth increases; bile or blood may leak from the wound; blood pressure drops; and tachycardia develops.

DIF: Application/Applying REF: p. 1125 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

7. The morning after admission, a client being treated for gallstones begins to vomit about every 15 minutes and is complaining of abdominal pain. The most appropriate action by the nurse would be to

a.

encourage the client to ambulate.

b.

offer clear fluids.

c.

prepare to insert a nasogastric tube.

d.

turn the client to the right side.

ANS: C

If the client continues vomiting, the nurse should obtain an order for a nasogastric tube with a suction attachment to relieve the distention and vomiting. Suction also removes the gastric juices that stimulate cholecystokinin, which in turn causes painful contractions of the gallbladder.

DIF: Application/Applying REF: p. 1123 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Therapeutic Procedures

8. A client has returned from an open cholecystectomy. The nurse places the highest priority on which intervention?

a.

Coughing and deep breathing

b.

Early ambulation

c.

Wearing anti-embolic hose

d.

Use of a nasogastric tube

ANS: A

After cholecystectomy, clients find it difficult to take deep breaths and cough independently because of the location of the incision. Preventing pneumonia is a critical outcome of the diagnosis Risk for Injury.

DIF: Analysis/Analyzing REF: p. 1127 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

9. A nurse is providing discharge instructions for a post-cholecystectomy client. The nurse would view the goals for teaching had been effective when the client states he/she would

a.

call the physician if gas occurs.

b.

notify the physician of jaundice or itching.

c.

remain indoors until the dressings are removed.

d.

report dark-colored stools to the clinic.

ANS: B

The nurse should be sure that the client knows which manifestations to report to the physician and how to contact the physician. The client should be instructed to report fever, jaundice, dark-colored urine, pale-colored stools, and pruritus.

DIF: Evaluation/Evaluating REF: p. 1128 OBJ: Evaluation

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

10. A client has been diagnosed with cancer of the gallbladder. Which statement by the client would lead the nurse to feel concern for this clients coping?

a.

After my chemotherapy is over, I think I will retire and do a lot of traveling.

b.

Im going to see a lawyer and update my will and advance directives.

c.

Its hard deciding if I should have chemo or radiation because both have bad results.

d.

My doctors say there is no agreement on the best treatment.

ANS: A

The prognosis for gallbladder cancer is poor; only about 5% of clients with unresectable cancer are alive at the end of the first year after diagnosis. There is no agreement on the best treatment and neither chemotherapy nor radiation therapy offers good outcomes.

DIF: Application/Applying REF: p. 1133 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Coping Mechanisms

11. The nurse is providing discharge instructions to a client going home with a T tube after an open cholecystectomy. Goals for teaching have been met when the client says

a.

For drainage that is thick with mucus or blood, I can irrigate the T tube.

b.

I will need to milk the tube every 4 hours and record the drainage.

c.

The tube can be used to administer stone dissolving medications

d.

This tube will stay in for 1-2 weeks and I should watch for diminishing drainage.

ANS: D

The T tube will be removed in 1-2 weeks. Drainage should gradually diminish. Drainage that is thick with blood or mucus needs to be reported to the physician. Milking the tube is not recommended. Stone dissolving medications are given orally.

DIF: Evaluation/Evaluating REF: p. 1125 OBJ: Evaluation

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

12. When a client is admitted to the hospital for treatment of acute cholecystitis, the nurse would anticipate that the immediate medical management will be

a.

antibiotic therapy.

b.

provided by a medical nutritionist.

c.

systemic corticosteroid administration.

d.

total parenteral nutrition.

ANS: A

Clients suspected of having acute cholecystitis may need to be hospitalized, and initial management should include administration of antibiotics effective against organisms found in the bile in approximately 80% of cases.

DIF: Comprehension/Understanding REF: p. 1129 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

13. A client with acute pancreatitis has developed a Cullens sign. Which nursing diagnosis takes priority for this client?

a.

Acute Pain

b.

Altered Nutrition

c.

Imbalanced Fluid Volume

d.

Ineffective Breathing Patterns

ANS: A

Severe hemorrhagic pancreatitis may produce two distinctive manifestations: Turners sign (bluish discoloration of the left flank) and Cullens sign (bluish discoloration of the periumbilical area). Cullens sign indicates bleeding into the peritoneum, making the clients priority problem Imbalanced Fluid Volume.

DIF: Analysis/Analyzing REF: p. 1109 OBJ: Diagnosis

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

14. A nurse is teaching a client and spouse about insulin administration. The spouse becomes quite upset, saying Why are we having to use insulin at home? The diagnosis is pancreatitis! How did you make him a diabetic? The best response by the nurse is

a.

I see you are upset. Let me answer your questions before we talk about insulin.

b.

Im sorry youre upset. But you both need to understand how to use insulin.

c.

When so much endocrine tissue is damaged, the client becomes diabetic.

d.

Would you like the diabetic educator to come talk with you both?

ANS: A

The client who loses a great deal of endocrine pancreatic tissue, either through scarring from chronic pancreatitis or from surgical resection, will develop diabetes and will need insulin administration for the rest of the clients life. However, the spouse is too upset to be able to learn, and attending to the psychosocial needs takes precedence before teaching can be done.

DIF: Application/Applying REF: p. 1109 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Therapeutic Interactions

15. To attempt to alleviate the pain of a client with acute pancreatitis, the nurse would place the client in the

a.

prone position with a pillow under the abdomen.

b.

semi-Fowler position with a small pillow under the knees.

c.

side-lying position with a pillow splinting the abdomen.

d.

supine position with a cold pack to the abdomen.

ANS: C

Positioning (side-lying knee-chest position with a pillow pressed against the abdomen, or sitting position with the trunk flexed), back rubs, relaxation techniques, and a quiet environment all help promote comfort and rest.

DIF: Application/Applying REF: p. 1111 OBJ: Intervention

MSC: Physiological Integrity Basic Care and Comfort-Non-Pharmacological Comfort Interventions

16. In preparing the teaching plan on dietary changes after discharge for a client with chronic pancreatitis, the nurse would know that the statement most indicative of the clients understanding of the information is

a.

I wont be eating any more French fries or drinking hard liquor.

b.

A chicken breast and a glass of white wine sound like a good dinner.

c.

Im anxious to cooperate if it means I can get rid of this pain permanently.

d.

My diet doesnt sound too bad; lots of people have to watch what they eat.

ANS: A

For alcohol-related pancreatitis, total abstinence from alcohol is imperative and sometimes successful in itself for pain relief. A low-fat diet should be prescribed and may reduce painful stimulation of pancreatic enzyme secretion. Clients should understand the benefits of eating small, frequent meals high in protein, low in fat, and moderate to high in carbohydrates.

DIF: Evaluation/Evaluating REF: p. 1110 OBJ: Evaluation

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

17. The nurse would explain that Whipples operation involves

a.

excavation of a pancreatic abscess and implantation of an external drain.

b.

removal of the head of the pancreas and portions of the stomach and duodenum.

c.

surgical removal of a pancreatic pseudocyst and implantation of an external drain.

d.

surgical removal of the tail of the pancreas and portions of the colon.

ANS: B

Surgical management of pancreatic cancer includes Whipples operation, which involves a pancreatoduodenectomy with removal of the distal third of the stomach, the duodenum, common bile duct, gallbladder, and head of the pancreas.

DIF: Comprehension/Understanding REF: p. 1113 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

18. The nursing diagnosis that would serve as the primary guide when providing care to a client with cystic fibrosis (CF) is

a.

Constipation

b.

Fluid Volume Excess

c.

Ineffective Airway Clearance

d.

Swallowing, Impaired

ANS: C

Nursing management of the client with CF focuses on two major nursing diagnoses: Ineffective Airway Clearance and Imbalanced Nutrition: Less than Body Requirements.

DIF: Application/Applying REF: pp. 1118-1119

OBJ: Diagnosis

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

19. The nurse recognizes that the client with gallstones who would be the best candidate for treatment with extracorporeal shock wave lithotripsy (ECSL) is a client with

a.

common bile duct stones.

b.

liver disease.

c.

stones that are 6 cm in diameter.

d.

two gallstones.

ANS: D

The client should have symptomatic cholelithiasis with fewer than four stones, each smaller than 3 cm in diameter, and no history of liver or pancreatic disease. Contraindications to ECSL are the presence of common bile duct stones, recent acute cholecystitis, cholangitis, and pancreatitis.

DIF: Comprehension/Understanding REF: p. 1122 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Illness Management

20. A client had an endoscopic retrograde papillotomy for stone removal and has returned to the nursing unit. The client is asking for ice chips. What assessment takes priority? The nurse should assess the clients

a.

bowel sounds.

b.

gag reflex.

c.

sedation level.

d.

vital signs.

ANS: B

During this procedure, a local anesthetic is sprayed at the back of the clients throat to facilitate passing the endoscope. The nurse should carefully check for the return of the gag reflex before allowing oral intake. This is the priority assessment as the client is asking for ice chips. The client has probably received sedation for the procedure, making an assessment of sedation level important as well. Vital signs are monitored frequently post-procedure. Bowel sounds are the last priority as the client did not receive general anesthesia.

DIF: Analysis/Analyzing REF: pp. 1122, 1123

OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

21. A nurse assessing the first 24 hours of drainage from a T tube inserted during surgery for cholelithiasis would record as normal the T-tube output of

a.

less than 50 ml.

b.

100 to 200 ml.

c.

300 to 500 ml.

d.

500-1000 ml.

ANS: C

During the first 24 hours of an insertion of a T-tube, an output of 300 to 500 ml is normal.

DIF: Knowledge/Remembering REF: p. 1132 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

22. A client who underwent laparoscopic cholecystectomy asks the nurse how soon he/she can return to work. The nurse would respond that the final decision is up to the surgeon, but that clients can usually resume work after

a.

24 hours.

b.

3 to 4 days.

c.

5 to 7 days.

d.

2 weeks.

ANS: B

Most clients can resume normal activities and return to work in 3 to 4 days after laparoscopic cholecystectomy.

DIF: Comprehension/Understanding REF: p. 1125 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

23. A client with a T tube following choledochostomy asks the nurse why the tube is being clamped during mealtimes. The most accurate response by the nurse is

a.

It causes less pain during mealtime.

b.

It helps keep the common bile duct patent.

c.

It helps with digestion of fats in the meal.

d.

It will help the tube to come out more quickly.

ANS: C

After a few days, the T tube will probably be clamped during meals to aid in fat digestion.

DIF: Comprehension/Understanding REF: p. 1132 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

24. The nurse planning the care of a client admitted with severe pancreatitis would anticipate the diet order of

a.

clear liquids.

b.

enteral feedings.

c.

NPO with TPN.

d.

soft, low fat.

ANS: C

Clients with moderate to severe pancreatitis need to be supported nutritionally by total parenteral nutrition (TPN).

DIF: Comprehension/Understanding REF: p. 1110 OBJ: Intervention

MSC: Physiological Integrity Basic Care and Comfort-Nutrition and Oral Hydration

25. A client who had onset of acute pancreatitis 6 days ago has a respiratory rate of 26 with fine crackles throughout lung fields, and seems a little confused and agitated. The nurse would continue to assess this client for manifestations of

a.

adult respiratory distress syndrome.

b.

atelectasis and pneumonitis.

c.

pneumonia.

d.

tension pneumothorax.

ANS: A

Manifestations of adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen level below 50 mm Hg.

DIF: Analysis/Analyzing REF: p. 1113 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

26. A client who had pancreatic surgery has been started on medication therapy with pancrelipase (Pancrease). The manifestation that the nurse would report as an indication that the dosage may be insufficient is

a.

black, tarry stools.

b.

clay-colored stools.

c.

constipation.

d.

steatorrhea.

ANS: D

When the client begins to eat, the nurse should watch for the development of diarrhea and steatorrhea (fatty stools), which indicate that insufficient pancreatic enzymes are present.

DIF: Application/Applying REF: p. 1114 OBJ: Assessment

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Expected Effects/Outcomes

27. A client is being admitted for the eighth exacerbation of chronic pancreatitis in 2 years. The client is frail and emaciated and becomes agitated when the nurse asks about pain medication. Which referral can the nurse make to best meet this clients needs and address potential complications of the condition? The nurse should request a referral to a

a.

chaplain for spiritual distress related to the chronic nature of the disease.

b.

chemical dependency counselor to assess and treat substance abuse.

c.

medical nutritionist to assess and treat the clients malnutrition.

d.

surgeon to assess whether or not this client can be treated surgically.

ANS: B

In developed countries, the most common cause of chronic pancreatitis is chronic alcoholism. The major complication is addiction to narcotics. If the client continues to drink, the prognosis is poor. With the frequent exacerbations and agitation when asked about pain control, the nurse can suspect substance abuse in this client and a referral to a chemical dependency counselor would best address that problem.

DIF: Analysis/Analyzing REF: p. 1113 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Collaboration with Interdisciplinary Team

28. A client with acute pancreatitis has a drop in blood pressure from to mm Hg at 2 hours after admission. The client has not voided and has become short of breath. The nurse would anticipate that the abnormal laboratory value consistent with these manifestations is

a.

hypercalcemia.

b.

hyperglycemia.

c.

hypoalbuminemia.

d.

hypokalemia.

ANS: C

Fluid shifts to pleural and abdominal spaces have caused hypovolemia resulting from reduced blood proteins (albumin). The client will show hypoalbuminemia because of reduced blood proteins. This process is called third spacing.

DIF: Analysis/Analyzing REF: p. 1109 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Reduction of Risk Potential-Laboratory Values

29. A client being discharged after an episode of acute pancreatitis asks the nurse why items such as coffee/tea, spicy foods, and heavy meals should be avoided. The nurse should reply

a.

Eating these items may disrupt your sleep and you will need lots of rest.

b.

So that you wont get reflux disease, which is a common complication.

c.

Those things stimulate the pancreas too much and may give you another attack.

d.

Your sense of taste has been altered, and often people dont like these any more.

ANS: C

Items such as coffee, spicy foods, and heavy meals stimulate pancreatic secretions and may precipitate another attack of pancreatitis. Other dietary instructions include eating small, frequent meals, and eating high-protein, low-fat foods that are moderate to high in carbohydrates.

DIF: Application/Applying REF: p. 1115 OBJ: Intervention

MSC: Health Promotion Prevention and/or Early Detection of Health Problems-Self Care

MULTIPLE RESPONSE

1. Health promotion activities a nurse could recommend to a client in order to prevent pancreatitis include (Select all that apply)

a.

avoiding alcohol abuse.

b.

eating a high-protein diet.

c.

getting regular exercise.

d.

losing weight if needed.

ANS: A, D

Avoiding alcohol is the best way to promote health and to reduce the chances of developing pancreatitis. Obesity is another major risk factor. Other causes include hyperlipidemia, hypercalcemia, cholecystitis and cholelithiasis, pancreatic tumors or trauma, pancreatic ischemia, and certain drugs.

DIF: Application/Applying REF: pp. 1107-1108

OBJ: Assessment

MSC: Health Promotion Prevention and/or Early Detection of Health Problems-Disease Prevention

2. A client is admitted with acute pancreatitis. The orders are for pancreatic rest. The nurse would implement which of the following? (Select all that apply.)

a.

Administering pancreatic enzymes with meals

b.

Bed rest with appropriate positioning

c.

Immediate insertion of an NG tube

d.

Withholding foods and liquids

ANS: B, D

Pancreatic rest includes keeping the client NPO and, initially, bed rest. NG tube placement is considered only for clients with severe pain or ileus with distention or vomiting. When the client is allowed to eat, pancreatic enzyme replacement may be needed, but is not considered part of pancreatic rest.

DIF: Analysis/Analyzing REF: p. 1111 OBJ: Intervention

MSC: Pathophysiological Adaptation Physiological Adaptation-Illness Management

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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