Answers and Rationales: Practice Test on Hepatobiliary and Pancreatic Health Disorders by brewed
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Feel free to post comments or suggestions for any misleading statements, typographical or grammatical errors.
Thank you.
- brewed
Situation 1: Nurse Craig works as a probationary staff nurse at the Bicol Medical Center. During his shift, he was tasked by his head nurse to conduct a health education session about the functions of the hepatobiliary and pancreatic system.
1. Nurse Craig knows that the liver is located at the __________________ of the abdomen.
a. Right Upper Quadrant
b. Left Lower Quadrant
c. Right Lower Quadrant
d. Left Upper Quadrant
Answer: A. Right Upper Quadrant
Rationale: The liver is located in the right upper quadrant of the abdomen, beneath the diaphragm and weighing 1200 to 1600 grams; covered with a fibroelastic capsule called Glisson capsule that contains blood vessels, lymphatics and nerves.
2. Bile is synthesized in the liver and transported to the bile ducts via the bile canaliculi. What controls the flow of bile in the duodenum?
a. Cystic duct
b. Sphincter of Oddi
c. Common bile duct
d. Common hepatic duct
Answer: B. Sphincter of Oddi
Rationale: The sphincter of oddi is at the distal end of the common hepatic duct and controls the flow of bile into the duodenum. Cystic duct connects the gallbladder to the hepatic duct and they merge to form the common bile duct – where it opens into the duodenum allowing secretion of bile necessary for digestion. Bile canaliculi drain into the right or left hepatic ducts which come together to form the common hepatic duct.
3. Gallbladder is a sac like organ located on the inferior surface of the liver. Nurse Craig is aware that the gallbladder’s primary purpose is to:
a. metabolize bilirubin
b. store fat soluble vitamins
c. store and concentrate bile
d. produce bile
Answer: C. Store and concentrate bile
Rationale: To store and concentrate bile about 90 ml is the primary purpose of the gallbladder. The mucosa of the gallbladder wall absorbs water and electrolytes resulting in a high concentration of bile salts, bile pigments and cholesterol. Options A, B, and D are all functions of the liver.
4. What hormone promotes the storage and utilization of food primarily glucose and fats?
a. Glucagon
b. Thyroxine
c. Secretin
d. Insulin
Answer: D. Insulin
Rationale: The endocrine pancreas secretes insulin and glucagon from islets of Langerhans; where insulin is a protein hormone that promotes the storage of food primarily glucose and fats while glucagon stimulates glycogenolysis in the liver. Secretin is secreted from the small intestine that stimulates the acinar and duct cells to secrete the alkaline – rich fluid that neutralizes chyme. Thyroxine is a thyroid hormone that increases the rate of ATP production.
5. During the session, a client asks Nurse Craig if she can live without her gallbladder. In order to respond to this client, Nurse Craig must have which understanding of the hepatobiliary system?
a. The liver produces about 1000 ml of bile/day
b. The liver concentrates bile more than 10 times
c. The gallbladder makes about 90 ml bile/day
d. The gallbladder dilutes and releases bile
Answer: A. The liver produces about 1000 ml of bile/day
Rationale: The liver produces between 700 and 1000 ml of bile a day. The gallbladder stores and concentrates bile and then releases it when stimulated, but is not an essential structure.
Situation 2: Nurse Nelly is assessing Mr. Shick who is in the early stages of cirrhosis of the liver.
6. Which early sign would Nurse Nelly anticipates finding?
a. Peripheral edema
b. Ascites
c. Anorexia
d. Jaundice
Answer: C. Anorexia
Rationale: Early clinical manifestations of cirrhosis are subtle and usually include GI symptoms such as anorexia, nausea, vomiting and changes in bowel patterns. These changes are caused by the liver’s altered ability to metabolize carbohydrates, proteins and fats. Options A, B and D are later signs of liver failure and portal hypertension.
7. What diet should be implemented for Mr. Shick who is in the early stages of cirrhosis? a. High calorie, high carbohydrate
b. High protein, low fat
c. Low fat, low protein
d. High carbohydrate, low sodium
Answer: A. High calorie, high carbohydrate
Rationale: For clients who have cirrhosis without complications, a high calorie, high CHO diet is preferred to provide an adequate supply of nutrients. In the early stages of cirrhosis, there is no need to restrict fat, protein or sodium.
8. Mr. Shick complains that his skin always feel itchy and that he “scratches himself raw” while he sleeps. Nurse Nelly should recognize that the itching is the result of which abnormality associated with cirrhosis?
a. Folic acid deficiency
b. Prolonged prothrombin time
c. Increased bilirubin level
d. Hypokalemia
Answer: C. Increased bilirubin level
Rationale: Excess retained bilirubin produces an irritating effect on the peripheral nerves, causing intense itching. Folic acid deficiency causes varied symptoms, but not itching. Itching is not a symptom of a prolonged PT or hypokalemia.
9. Few days after, Mr. Shick is developing ascites. Nurse Nelly should recognize that the pathologic basis for the development of ascites in clients with cirrhosis is portal hypertension and:
a. an excess serum Na level
b. an increased metabolism of aldosterone
c. a decreased flow of hepatic lymph
d. a decreased serum albumin level
Answer: D. A decreased serum albumin level
Rationale: Acites results from increased pressure in the venous system caused by a low level of serum albumin (which contributes to decreased colloid osmotic pressure) and sodium retention. The serum sodium level is not increased. There is a decreased aldosterone clearance and an increased flow of hepatic lymph.
10. Which of the following health promotion activities would be appropriate for Nurse Nelly to suggest to his client add to the daily routine at home?
a. Supplement the diet with multivitamins
b. Limit daily alcohol intake
c. Take a sleeping pill at bedtime
d. Limit contacts with other people
Answer: A. Supplement the diet with multivitamins
Rationale: General health promotion measures include maintaining good nutrition, avoiding infection, and abstaining from alcohol. Rest and sleep are essential, but an impaired liver may not be able to detoxify sedatives and barbiturates. Such drugs must be used cautiously, if at all, by clients with cirrhosis. The client does not need to limit contact with others but should exercise caution to stay away from ill people.
Situation 3: Nurse Rihanna together with her colleagues at San Lazaro Hospital is conducting a community education on how to prevent the transmission of hepatitis.
11. Which of the following types of hepatitis is considered to be primarily a sexually transmitted disease?
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D
Answer: B. Hepatitis B
Rationale: Hepatitis B is considered to be a STD. It can also be transmitted by a percutaneous exposure to infected blood. Hepatitis A is transmitted vial the fecal-oral route. Hepatitis C is primarily transmitted percutaneoulsy and less frequently, sexually. Hepatitis D is transmitted percutaneously too.
12. Nurse Rihanna knows that during the icteric phase of viral hepatitis, the client will exhibit which of the following symptoms?
a. Tarry stools
b. Yellowed sclera
c. Shortness of breath
d. Light, frothy urine
Answer: B. Yellow sclera
Rationale: Icteric phase is marked by the onset of jaundice after the prodromal phase. Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy. Profound anorexia is also common. Tarry stools are indicative of GI bleeding and would not be expected in hepatitis. Light or clay colored stools may occur in hepatitis owing to bile duct obstruction. Shortness of breath is unexpected.
13. Which of the following precautions would Nurse Rihanna and her colleagues indicate as essential when caring for clients with Hepatitis A?
a. Gowning when entering a client’s room
b. Wearing a mask when providing care
c. Assigning the client in a private room
d. Wearing gloves when giving direct care
Answer: D. Wearing gloves when giving direct care
Rationale:
14. Nurse Rihanna is developing a teaching plan for a client with Hepatitis A. Which of the following instructions is appropriate?
a. Spray the house to eliminate infected insects
b. Tell family members to try to stay away from the client
c. Tell the family members to wash their hands frequently
d. Disinfect clothing and eating utensils
Answer: C. Tell the family members to wash their hands frequently
Rationale: Contact precautions are recommended for clients with Hepatitis A. This includes wearing gloves for direct care. A gown is not required unless substantial contact with the client is anticipated. It is not necessary to wear a mask. The client does not nned a private room unless incontinent of stool.
15. After the community education, a client approached Nurse Rihanna and expressed feelings of isolation as a result of having hepatitis. What would be Nurse Rihanna’s best response?
a. “Don’t Worry. It’s normal to feel that way.”
b. “Your friends are probably afraid of contracting hepatitis from you.”
c. “I’m sure you’re imagining that!”
d. “Tell me more about your feelings of isolation.”
Answer: D. “Tell me more about your feelings of isolation.”
Rationale: A nurse should encourage the client to further verbalize feelings of isolation. Instead of dismissing these feelings or making assumptions about the cause of isolation, the nurse should allow clients to verbalize their fears and provide education on how to prevent infection transmission. Option A is giving a false reassurance. Options B and C are non-therapeutic and employ threat.
Situation 4: Mrs. Smith, 44 years old is admitted to the hospital complaining of severe abdominal pain and extreme nausea and has vomited several times. A diagnosis of cholecystitis from cholelithiasis was made.
16. Based on the data, which nursing diagnosis would have the highest priority intervention at this time?
a. Anxiety r/t severe abdominal discomfort
b. Fluid Volume Deficit r/t vomiting
c. Pain r/t gallbladder inflammation
d. Imbalanced Nutrition: Less than body requirement r/t vomiting
Answer: C. Pain r/t gallbladder inflammation
Rationale: The priority for nursing care at this time is to decrease the client’s severe abdominal pain. The pain, which is frequently accompanied by nausea and vomiting, is caused by biliary spasm. Narcotic analgesics are given to relieve the severe pain and spasm of cholecystitis. Relief of pain may decrease nausea and vomiting and thereby decrease the likelihood of developing further complications, such as deficient fluid volume and imbalanced nutrition.
17. The group of characteristics that would alert Nurse Pharrel that his client has increased risk of developing gall bladder disease would be female:
a. over the age of 40, obese
b. over the age of 40, low cholesterol level
c. under the age of 40, history of high fat intake
d. under the age of 40, family history of gallstone
Answer: A. Over the age of 40, obese
Rationale: Factors that placed client a greater risk for developing gall bladder disease are female, forty years old and above, fat/obesity and fertile. Options B, C, and D are incorrect. (Just remember the 4 F’s)
18. When common bile duct is obstructed, Nurse Pharrel should evaluate her client for signs of which of the following complications?
a. Respiratory distress
b. Circulatory overload
c. Urinary tract infection
d. Prolonged bleeding time
Answer: D. Prolonged bleeding time
Rationale: A client with an obstructed common bile duct should be monitored for prolonged bleeding time. Such an obstruction prevents bile from entering the intestinal tract, thus decreasing the absorption of fat soluble vitamins (ADEK). Vit. K is necessary for prothrombin formation. Prothrombin deficiency causes delayed blood clotting, which results in prolonged bleeding time. An obstructed bile duct does not cause respiratory distress, circulatory overload or UTI.
19. Mrs. Smith complained of severe right upper quadrant pain. Which of the following medication would Nurse Pharrel anticipates administering to relieve the client’s pain?
a. Meperidine (Demerol)
b. Acetaminophen with codeine
c. Promethazine (Phernergan)
d. Morphine sulfate
Answer: A. Meperidine (Demerol)
Rarionale: This would be the narcotic analgesic of choice for a client with cholecystitis. Acetaminophen would not be appropriate to administer, because the codeine could cause biliary duct spasm and increase pain, as could opiates such as morphine sulfate. Promethazine (Phenergan) is an antiemetic.
20. A laparoscopic cholecystectomy is scheduled. Which of the following instructions should Nurse Pharrel include in his discharge plan?
a. Avoid showering for 48 hours after surgery
b. Return to work within one week
c. Change the dressing daily until the incision heals
d. Use acetaminophen (Tylenol) to control fever
Answer: B. Return to work within one week
Rationale: After a laparoscopic cholecystectomy, clients can return to work within 1 week. The client can remove dressings from the puncture site and shower the day after the surgery. The site does not need to be rebandaged but should be left open to air. The client should report any fever, which could be an indication of a complication.
Situation 5: Capt. Jack Sparrow was admitted in the Medical Floor of The Medical City. The admission history shows an alcohol abuse of excessive intake of liquor for more than 10 years. Laboratory findings result shows high trygyceride levels and hypercalcemia.
21. The initial diagnosis of pancreatitis is confirmed if Capt. Sparrow’s blood work shows a significant elevation in which of the following serum values?
a. Amylase
b. Glucose
c. Potassium
d. Trypsin
Answer: A. Amylase
Rationale: The primary diagnostic tests for pancreatitis are serum amylase, serum lipase, and urine amylase. All 3 lab results are typically elevated. Serum amylase is the most common tests; the result is usually higher than 200 units/dL. Serum glucose may be elevated in pancreatitis because of beta – cell damage, but this is not used to diagnose pancreatitis. Serum K and trypsin levels are not affected in pancreatitis.
22. Which of the following actions of pancreatic enzymes can cause pancreatic damage?
a. Utilization by the intestine
b. Autodigestion of the pancreas
c. Reflux into the pancreas
d. Clogging of the pancreatic duct
Answer: B. Autodigestion of the pancreas
Rationale: When the pancreas is injured and/or has an impaired or disrupted function, the pancreatic enzymes (phospolipase A, lipase, and elastase) leak into the pancreatic tissue and initiate autodigestion. Options C and D can be causes of pancreatitis. Option A is incorrect to this situation.
23. The initial treatment plan for Capt. Sparrow most likely would focus on which of the following as a priority?
a. Resting the GIT
b. Ensuring adequate nutrition
c. Maintaining fluid and electrolyte balance
d. Preventing the development of an infection
Answer: Resting the GIT
Rationale: There is a little definitive treatment for pancreatitis. It is crucial to decrease pancreatic enzymes to reduce stimulation of the pancreas. This is done by keeping the client NPO to rest the gastrointestinal tract and thereby suppress pancreatic enzymes secretion. Ensuring adequate nutrition, maintaining fluid and electrolyte balance, and preventing the development of an infection are issues for the client with pancreatitis but are not the primary focus of treatment.
24. Capt. Sparrow may exhibit Cullen’s sign on physical examination. Nurse Shakira knows that Cullen’s sign can be best described as:
a. Distended tortuous veins in the esophagus
b. Yellow-orange discoloration of the skin
c. Bluish discoloration of the left flank area
d. Bluish discoloration of the periumbilical area
Answer: D. Bluish discoloration of the periumbilical area
Rationale: Clinical manifestations vary with severity of attack. Cullen’s sign and Grey Turner’s sign may be present in clients with pancreatitis. Cullen’s sign is the bluish discoloration of the periumbilical area while Grey Turner’s sign is the bluish discoloration of the left flank area. Option A is a complication of cirrhosis which is esophageal varices. Option B is jaundice or icterus.
25. In alcohol related pancreatitis, which of the following interventions is the best way to reduce the exacerbation of pain?
a. Lying supine
b. Taking aspirin
c. Eating a low – fat diet
d. Abstaining from alcohol
Answer: D. Abstaining from alcohol
Rationale: Abstaining from alcohol is the best way to reduce the exacerbation of pain. Encourage position of comfort, which is elevation of the head at 45 degrees side lying with knees flexed rather lying supine. Taking aspirin may cause bleeding. An Opiod narcotic analgesic such as Demerol is given. Maintain NPO status (7 – 3 days) in order to reduce gastric secretions and aggravation of pancreatic pain and once feeding resumes provide several small meals.
Situation 6: Nurse Cassie is caring to clients who had undergone surgeries and diagnostic procedures.
26. Nurse Cassie understands that after a cholecystectomy and common bile duct exploration, the client will:
a. need to take oral bile salts
b. be incapable of producing bile
c. be unable to concentrate bile
d. not be able to digest fatty foods
Answer: C. Be unable to concentrate bile
Rationale: In cholecystectomy, the gallbladder is surgically removed. Gallbladder functions primarily to store and concentrate bile. The inability to concentrate bile results from the removal of gallbladder. Option A is a medical treatment for cholecystitis. Options B and D may result if there is liver failure.
27. Because of prolonged bile drainage from a T – tube, a client may develop symptoms related to a lack of fat soluble vitamins such as:
a. easy bruising
c. excessive jaundice
c. muscle twitching
d. tingling of the fingers
Answer: A. Easy bruising
Rationale: Easy bruising signifies a lack of fat soluble Vitamin K related to prolonged bile drainage from a T – tube. Excessive jaundice may result to clients with hepatitis or cirrhosis because of a disturbance of bilirubin metabolism. Options C and D are signs of hypocalcemia which in severe cases result in clients with acute pancreatitis.
28. Considering both the endocrine and exocrine functions of the pancreas, the client’s postoperative regimen would primarily include managing intake of:
a. alcohol and caffeine
b. fluids and electrolytes
c. vitamins and minerals
d. fats and carbohydrates
Answer: D. Fats and carbohydrates
Rationale: The pancreas produces enzymes (exocrine) and hormones (endocrine) that assist in the digestive process. The endocrine pancreas secretes insulin that stores and utilized fats. The pancreatic enzymes lipase and amylase aids in the digestion of fats and carbohydrates respectively. These should be managed to avoid exacerbation of pain postoperatively.
29. Nurse Cassie knows that several hours after liver biopsy, the client will remain in what position?
a. Left side lying with head of bed elevated
b. Right side lying with pillows placed under the costal margin
c. High fowler’s with both arms supported on pillows
d. Any comfortable recumbent position as long as the client remains immobile
Answer: B. Right side lying with pillows under the costal margin
Rationale: Positioning on the right side lying with pillows under the costal margin will provide compression over the biopsy site thus preventing bleeding. Options A, C and D are incorrect nursing care after a liver biopsy.
30. An obese client with a history of gallstone has an abdominal cholecystectomy. After surgery, Nurse Cassie plans to alleviate tension on the surgical wound by:
a. limiting deep breathing
b. maintaining T – tube patency
c. maintaining nasogastric tube patency
d. encouraging the right side lying position
Answer: C. Maintaining NGT patency
Rationale: Maintaining NGT patency will promote gastric decompression thus alleviates tension in the surgical wound. Encouraging deep breathing rather limiting is advised to decrease pain. Maintaining T- tube patency promotes gravity drainage of bile. Option D is incorrect for this situation for it is a nursing care done after a liver biopsy.
Situation 7: Mr. Gibson, 60 – year old, is admitted to the hospital with cirrhosis. He has history of alcoholism and hepatitis B.
31. What should Nurse Ashanti expect to find on his initial laboratory results?
a. hypernatremia
b. elevated ALT
c. elevated serum albumin
d. leukocytosis
Answer: B. Elevated ALT
Rationale: Elevation of Alanine aminotransferase (5 – 35 IU/L) indicates damage of liver cells and decreased liver function. Other lab values result a low serum albumin, hyponatremia, leucopenia, thrombocytopenia, prolonged PT, anemia and possible elevated serum ammonia.
32. Mr. Gibson is scheduled for a liver biopsy. What is your priority of care for this patient? a. monitor for bleeding
b. encouraging increased activity
c. controlling blood pressure
d. providing nutritional support
Answer: A. Monitor for bleeding
Rationale: Since the liver is a vascular organ, the priority of care is to monitor bleeding. The dressing should be monitored for oozing of blood and should be positioned on the right side, which helps apply pressure on the biopsy site. The client is usually maintained on bed rest for 24 hours to reduce the risk of bleeding so increased activity is contraindicated. Providing nutritional support is not the utmost priority at this time. Option C is to prevent the occurrence of portal hypertension as a complication from cirrhosis.
33. What life threatening complication will result when the liver is destroyed due to hepatitis B and up to the development of chronic hepatitis?
a. portal hypertension
b. esophageal varices .
c. liver failure
d. hepatic encephalopathy
Answer: C. Liver Failure
Rationale: All are complications of cirrhosis but option C is the most life threatening. Complications of hepatitis B include the development of chronic hepatitis, which destroys the liver and leads to cirrhosis and liver failure causing death. The complications of cirrhosis are portal hypertension leading to esophageal varices, right sided heart failure and varicose veins. Ascites, hepatic encephalopathy are also complications.
34. What instruction about diet modification should Nurse Ashanti give to Mr. Gibson?
a. increase fluid intake
b. avoid canned and processed food
c. eat food reach in protein
d. encourage to eat dairy products and poultry
Answer: B. Avoid canned and processed foods
Rationale: The client with late stage of cirrhosis is usually on a protein, sodium and fluid restricted diet. Foods to avoid would be canned and processed foods (high in sodium), chicken, meat, eggs and dairy products (high in CHON), and fluids are usually limited.
35. Mr. Gibson asks Nurse Ashanti why he has edema. Nurse Ashanti would use which of the following statements to explain how edema results from pathophysiologic changes in cirrhosis?
a. “The edema occurs because your liver produces fewer proteins that help draw fluid into the bloodstream”
b. “The high osmotic pressure of proteins in your blood pushes fluid into the body tissues”
c. “The kidneys are able to filter less fluid, so the body cannot excrete it as urine very easily”
d. “Your body is metabolizing sex hormones more quickly, leading to fluid retention.
Answer: A. The edema occurs because your liver produces fewer proteins that help draw fluid into the bloodstream”
Rationale: The liver is responsible for the production of albumin, which in turn is responsible for maintaining colloidal osmotic pressure. With less production of albumin, osmotic pressure decreases and edema develops. Options B, C and D are false statements that do not explain the relationship between cirrhosis and edema.
Situation 8: Mrs. Carey, 49-year-old female was rushed in the emergency department because of severe and steady right upper quadrant pain that radiates to the scapula lasting for 2 hours. She has vomited frequently and experiencing chills.
36. Based from the data presented, Mrs. Carey is experiencing which of the following problems?
a. acute pancreatitis
b. cholelithiasis
c. acute cholecystitis
d. hepatic encephalopathy
Answer: C. Acute cholecystitis
Rationale: In acute cholecystitis, the lodging of a gallstone in the duct causes inflammation of the cystic duct. The lodged gallstone in the cystic duct causes pressure against the wall of the gall bladder, decreasing blood flow. Cholelithiasis can cause cholecystitis because of the distention of the gallbladder thus, severe, steady RUQ pain that radiates to the scapula occurs. Other GI symptoms also occur but when patient experiences chill, an inflammation and infection are happening resulting to acute cholecystitis.
37. Physical exam findings revealed a severe pain in the RUQ with inspiratory arrest. Nurse Beyonce knows, that her client is positive for which of the following signs?
a. Grey Turner’s sign
b. McBurney’s sign
c. Cullen’s sign
d. Murphy’s sign
Answer: D. Murphy’s sign
Rationale: A positive Murphy's sign is seen in acute cholecystitis. It is elicited by firmly placing a hand at the costal margin in the right upper abdominal quadrant and asking the patient to breathe deeply. If the gallbladder is inflamed, the patient will experience pain and catch their breath as the gallbladder descends and contacts the palpating hand. Options A and C are signs of pancreatitis. Option D is a sign for appendicitis.
38. Which of the following tests is most commonly used to diagnose Mrs. Carey’s problem?
a. Abdominal computed tomography scan
b. Abdominal ultrasound
c. Barium swallow
d. Endoscopy
Answer: A. Abdominal computed tomography scan
Rationale: This is a definitive diagnostic test for acute cholecytitis. This provides a cross sectional images of the abdomen to differentiate subtle changes in the tissue in the selected structure particularly it will visualize where the gallstone has been lodged in the cystic duct.
39. Frequent vomiting puts Mrs. Carey at risk of which of the following acid-base imbalance?
a. metabolic acidosis and hyperkalemia
b. metabolic alkalosis and hyperkalemia
c. metabololic acidosis and hypokalemia
d. metabolic alkalosis and hypokalemia
Answer: D. Metabolic alkalosis and hypokalemia
Rationale: If frequent vomiting happens, the client is at risk for metabolic alkalosis and hypokalemia. Option C could happen in patient experiencing persistent diarrhea. Options A and B are incorrect.
40. When counseling Mrs. Carey in the ways to prevent the exacerbation of the problem, which of the following guidelines is most important?
a. Eat a low protein diet
b. Limit exercise to 10 minutes a day
c. Eat a low – fat diet, cholesterol diet
d. Keep weight proportional to height
Answer: D. Keep weight proportional to height
Rationale: Keeping weight proportional to height is the best indicator of being healthy. This is your Body Mass Index. Client should be taught to avoid high fat foods (cholesterol diet), whole milk products, fried foods, nuts, gravies, cooking oils, hot dogs, chocolate and cheese. Not all protein rich foods are restricted. Exercise should be encouraged to promote OLOF.
Situation 9: Nursing process is a systematic problem solving approach to the collaborative identification of client health needs and the application of nursing care to effectively meet those needs.
41. A client was admitted in the emergency department with exacerbation of cholelithiasis. When does discharge planning begins?
a. after physical examination c. upon admission
b. after initial assessment d. before discharge
Answer: C. Upon admission
Rationale: Discharge planning begins upon admission so to have a continuous/ongoing assessment to provide appropriate nursing intervention throughout the course of disease.
42. How will you assess a client with hepatic encephalopathy having asterixis?
a. On deep inspiration, pain is elicited and breathing stops
b. On deep palpation and released, pain is elicited
c. Ask client to hold his arms straight in front and flappy hand tremors occur
d. Place hand over the patient's right knee while the patient flexes their right hip against the resistance
Answer: C. Ask client to hold his arms straight in front and flappy hand tremors occur
Rationale: Asterixis/liver flap describes a motor disturbance characterized by intermittent lapses of an assumed posture. It is commonly associated with liver failure where it produces the flapping tremor of hepatic encephalopathy characterized by jerky, irregular flexion-extension movements at the wrist and metacarpophalangeal joints, often accompanied by lateral movements of the fingers. The motor disturbance may rarely involve the arms, neck, tongue, jaw and eyelids. It is usually bilateral, absent at rest, and asynchronous on each side. Option A is Murphy’s sign. Option B is rebound tenderness. Option D is Psoa’s sign.
43. The client who has acute pancreatitis tells Nurse Juris, “I Just want my gall bladder taken out now.” Nurse Juris best response should be which of the following?
a. “I don’t blame you but they want your pain under control first”
b. “Would you like to ask if your physician will schedule surgery today?”
c. “The symptoms are distressing, but the surgeon must wait until your gallbladder is less infected”
d. “They will try to dissolve the stones before they do the surgery”
Answer: C. “The symptoms are distressing, but the surgeon must wait until your gallbladder is less infected”
Rationale: With the advent of laparoscopic surgical technique, the only absolute contraindication for surgery is acute infection. The other options do not address this concern.
44. Mr. Prefix with cirrhosis was admitted to the hospital. Which of the following assessments made by Nurse Juris would indicate the development of portal hypertension?
a. Hematemesis
b. Elevated blood pressure
c. Asterixis
d. Confusion
Answer: A. Hematemesis
Rationale: In cirrhosis, the liver becomes fibrotic, which obstructs the venous blood flow through the liver. This increases the vascular pressure in the portal system, and causes congestion in the spleen and development of varicosities in the esophagus. Bleeding esophageal varices are a complication of portal hypertension and result in vomiting of blood (hematemesis) and possible hemorrhage and death.
45. Ms. Suffix with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. She tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
a. Impaired physical mobility r/t malaise
b. Ineffective individual coping r/t long term illness
c. Self care deficit r/t fatigue
d. Activity intolerance r/t fatigue
Answer: D. Activity intolerance r/t fatigue
Rationale: This is the most appropriate diagnosis for this client. The major goal of care for the client with hepatitis is to increase activity gradually as tolerated. Periods of alternating rest and activity should be included in the plan of care. There is no evidence that the client is physically immobile, unable to provide self care, or coping ineffectively.
Situation 10: Nurse Shaggy is the staff nurse on duty in the Medical Floor. He is caring to clients with hepatobiliary and pancreatic disorders. Health teaching is his primary role for the quick recovery of his clients.
46. Ms. Demeanor has jaundice. Nurse Shaggy’s most appropriate comfort measure to implement is:
a. Offer hot beverages frequently
b. Encourage taking a hot bath or shower
c. Keep the air temperature at approximately 68O to 70O F
d. Suggest the use of alcohol based skin lotion
Answer: C. Keep the air temperature at approximately 68O to 70O F
Rationale: Jaundice frequently causes pruritus. Comfort measures include keeping the air temperature cool (68O to 70O F) and the humidity at 30 to 40 percent. Tepid baths (not hot) with colloidal agents decrease itching. Use of an emollient lotion is also helpful, but anything drying should be avoided. Hot beverages are of no benefit as a comfort measure for pruritus due to jaundice.
47. When teaching Mr. Gabrielle with hepatitis A about infection control, Nurse Shaggy explains that he is most infectious to others at which of these times?
a. 7 days exposure
b. 2 months after exposure
c. 10 days before the onset of symptoms
d. 14 days after symptoms begin
Answer: B. 2 months after exposure
Rationale: The incubation period for hepatitis A is 4 – 6 weeks in length with viral shedding highest 10 – 14 days before the onset of symptoms and during the first week of symptoms. The other options do not fall within this time frame.
48. Which of the following dietary instructions would be appropriate for Nurse Shaggy to give a client who is recovering from acute pancreatitis?
a. Avoid crash dieting
b. Eat six small meals day
c. Restrict carbohydrate intake
d. Decrease sodium in diet
Answer: A. Avoid crash dieting
Rationale: Crash dieting or bingeing may cause an acute attack of pancreatitis and should be voided. CHO intake should be increased, because CHO are less stimulating to the pancreas. There is no need to maintain a dietary pattern of six small meals a day; the client can eat whenever desired. There is no need to place the client on a sodium – restricted diet, because pancreatitis does not promote fluid retention.
49. Mr. Foxx who has ascites and peripheral edema is at risk for impaired skin integrity. Which of the following intervention would be implemented to prevent skin breakdown?
a. ROM exercises every 4 hours
b. Use of alternating air pressure mattress
c. Massage of the abdomen once a shift
d. Elevation of the lower extremities
Answer: B. Use of alternating air pressure mattress
Rationale: Edematous tissue is easily traumatized and must receive meticulous care. An alternating air pressure mattress will help decrease pressure on the edematous tissue. Range-of-motion exercises are important to maintain joint function, but they do not necessarily prevent skin breakdown. When abdominal skin is stretched taut (tightly) due to ascites, it must be cleaned very carefully. The abdomen should not be massaged. Elevation of the lower extremities promotes venous return and decrease swelling.
50. A male client with liver dysfunction reports that his gums bleed spontaneously. In addition, Nurse Shaggy notes small hemorrhagic lesions on his face. Nurse Shaggy recognizes that the client needs nutritional vitamin:
a. D
b. E
c. A
d. K
Answer: D. Vitamin K
Rationale: All options are fat soluble vitamins stored in the liver. Vitamin K (Aquamephyton) is necessary for the proper clotting of blood and helps promote bone health. Without sufficient amounts of vitamin K, hemorrhaging can occur. Vitamin D (Calciferol) is required for growth, especially bone growth or "calcification". Vitamin D plays a critical role in the body’s use of calcium and phosphorous. It increases the amount of calcium absorbed from the small intestine and helps form and maintain bones. Vitamin E (Tocopherol) is the most effective, fat-soluble antioxidant known to occur in the human body. It makes the specialized membranes that enclose the body cells much more stable and helps to protect the structures inside the cells, such as DNA, from damage by free radicals and other harmful chemicals. Vitamin A (Retinol) is an antioxidant chemical that is essential for normal vision (particularly night vision), a healthy immune system, healthy reproductive organ function and normal fetal development.
Feel free to post comments or suggestions for any misleading statements, typographical or grammatical errors.
Thank you.
- brewed
Situation 1: Nurse Craig works as a probationary staff nurse at the Bicol Medical Center. During his shift, he was tasked by his head nurse to conduct a health education session about the functions of the hepatobiliary and pancreatic system.
1. Nurse Craig knows that the liver is located at the __________________ of the abdomen.
a. Right Upper Quadrant
b. Left Lower Quadrant
c. Right Lower Quadrant
d. Left Upper Quadrant
Answer: A. Right Upper Quadrant
Rationale: The liver is located in the right upper quadrant of the abdomen, beneath the diaphragm and weighing 1200 to 1600 grams; covered with a fibroelastic capsule called Glisson capsule that contains blood vessels, lymphatics and nerves.
2. Bile is synthesized in the liver and transported to the bile ducts via the bile canaliculi. What controls the flow of bile in the duodenum?
a. Cystic duct
b. Sphincter of Oddi
c. Common bile duct
d. Common hepatic duct
Answer: B. Sphincter of Oddi
Rationale: The sphincter of oddi is at the distal end of the common hepatic duct and controls the flow of bile into the duodenum. Cystic duct connects the gallbladder to the hepatic duct and they merge to form the common bile duct – where it opens into the duodenum allowing secretion of bile necessary for digestion. Bile canaliculi drain into the right or left hepatic ducts which come together to form the common hepatic duct.
3. Gallbladder is a sac like organ located on the inferior surface of the liver. Nurse Craig is aware that the gallbladder’s primary purpose is to:
a. metabolize bilirubin
b. store fat soluble vitamins
c. store and concentrate bile
d. produce bile
Answer: C. Store and concentrate bile
Rationale: To store and concentrate bile about 90 ml is the primary purpose of the gallbladder. The mucosa of the gallbladder wall absorbs water and electrolytes resulting in a high concentration of bile salts, bile pigments and cholesterol. Options A, B, and D are all functions of the liver.
4. What hormone promotes the storage and utilization of food primarily glucose and fats?
a. Glucagon
b. Thyroxine
c. Secretin
d. Insulin
Answer: D. Insulin
Rationale: The endocrine pancreas secretes insulin and glucagon from islets of Langerhans; where insulin is a protein hormone that promotes the storage of food primarily glucose and fats while glucagon stimulates glycogenolysis in the liver. Secretin is secreted from the small intestine that stimulates the acinar and duct cells to secrete the alkaline – rich fluid that neutralizes chyme. Thyroxine is a thyroid hormone that increases the rate of ATP production.
5. During the session, a client asks Nurse Craig if she can live without her gallbladder. In order to respond to this client, Nurse Craig must have which understanding of the hepatobiliary system?
a. The liver produces about 1000 ml of bile/day
b. The liver concentrates bile more than 10 times
c. The gallbladder makes about 90 ml bile/day
d. The gallbladder dilutes and releases bile
Answer: A. The liver produces about 1000 ml of bile/day
Rationale: The liver produces between 700 and 1000 ml of bile a day. The gallbladder stores and concentrates bile and then releases it when stimulated, but is not an essential structure.
Situation 2: Nurse Nelly is assessing Mr. Shick who is in the early stages of cirrhosis of the liver.
6. Which early sign would Nurse Nelly anticipates finding?
a. Peripheral edema
b. Ascites
c. Anorexia
d. Jaundice
Answer: C. Anorexia
Rationale: Early clinical manifestations of cirrhosis are subtle and usually include GI symptoms such as anorexia, nausea, vomiting and changes in bowel patterns. These changes are caused by the liver’s altered ability to metabolize carbohydrates, proteins and fats. Options A, B and D are later signs of liver failure and portal hypertension.
7. What diet should be implemented for Mr. Shick who is in the early stages of cirrhosis? a. High calorie, high carbohydrate
b. High protein, low fat
c. Low fat, low protein
d. High carbohydrate, low sodium
Answer: A. High calorie, high carbohydrate
Rationale: For clients who have cirrhosis without complications, a high calorie, high CHO diet is preferred to provide an adequate supply of nutrients. In the early stages of cirrhosis, there is no need to restrict fat, protein or sodium.
8. Mr. Shick complains that his skin always feel itchy and that he “scratches himself raw” while he sleeps. Nurse Nelly should recognize that the itching is the result of which abnormality associated with cirrhosis?
a. Folic acid deficiency
b. Prolonged prothrombin time
c. Increased bilirubin level
d. Hypokalemia
Answer: C. Increased bilirubin level
Rationale: Excess retained bilirubin produces an irritating effect on the peripheral nerves, causing intense itching. Folic acid deficiency causes varied symptoms, but not itching. Itching is not a symptom of a prolonged PT or hypokalemia.
9. Few days after, Mr. Shick is developing ascites. Nurse Nelly should recognize that the pathologic basis for the development of ascites in clients with cirrhosis is portal hypertension and:
a. an excess serum Na level
b. an increased metabolism of aldosterone
c. a decreased flow of hepatic lymph
d. a decreased serum albumin level
Answer: D. A decreased serum albumin level
Rationale: Acites results from increased pressure in the venous system caused by a low level of serum albumin (which contributes to decreased colloid osmotic pressure) and sodium retention. The serum sodium level is not increased. There is a decreased aldosterone clearance and an increased flow of hepatic lymph.
10. Which of the following health promotion activities would be appropriate for Nurse Nelly to suggest to his client add to the daily routine at home?
a. Supplement the diet with multivitamins
b. Limit daily alcohol intake
c. Take a sleeping pill at bedtime
d. Limit contacts with other people
Answer: A. Supplement the diet with multivitamins
Rationale: General health promotion measures include maintaining good nutrition, avoiding infection, and abstaining from alcohol. Rest and sleep are essential, but an impaired liver may not be able to detoxify sedatives and barbiturates. Such drugs must be used cautiously, if at all, by clients with cirrhosis. The client does not need to limit contact with others but should exercise caution to stay away from ill people.
Situation 3: Nurse Rihanna together with her colleagues at San Lazaro Hospital is conducting a community education on how to prevent the transmission of hepatitis.
11. Which of the following types of hepatitis is considered to be primarily a sexually transmitted disease?
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D
Answer: B. Hepatitis B
Rationale: Hepatitis B is considered to be a STD. It can also be transmitted by a percutaneous exposure to infected blood. Hepatitis A is transmitted vial the fecal-oral route. Hepatitis C is primarily transmitted percutaneoulsy and less frequently, sexually. Hepatitis D is transmitted percutaneously too.
12. Nurse Rihanna knows that during the icteric phase of viral hepatitis, the client will exhibit which of the following symptoms?
a. Tarry stools
b. Yellowed sclera
c. Shortness of breath
d. Light, frothy urine
Answer: B. Yellow sclera
Rationale: Icteric phase is marked by the onset of jaundice after the prodromal phase. Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy. Profound anorexia is also common. Tarry stools are indicative of GI bleeding and would not be expected in hepatitis. Light or clay colored stools may occur in hepatitis owing to bile duct obstruction. Shortness of breath is unexpected.
13. Which of the following precautions would Nurse Rihanna and her colleagues indicate as essential when caring for clients with Hepatitis A?
a. Gowning when entering a client’s room
b. Wearing a mask when providing care
c. Assigning the client in a private room
d. Wearing gloves when giving direct care
Answer: D. Wearing gloves when giving direct care
Rationale:
14. Nurse Rihanna is developing a teaching plan for a client with Hepatitis A. Which of the following instructions is appropriate?
a. Spray the house to eliminate infected insects
b. Tell family members to try to stay away from the client
c. Tell the family members to wash their hands frequently
d. Disinfect clothing and eating utensils
Answer: C. Tell the family members to wash their hands frequently
Rationale: Contact precautions are recommended for clients with Hepatitis A. This includes wearing gloves for direct care. A gown is not required unless substantial contact with the client is anticipated. It is not necessary to wear a mask. The client does not nned a private room unless incontinent of stool.
15. After the community education, a client approached Nurse Rihanna and expressed feelings of isolation as a result of having hepatitis. What would be Nurse Rihanna’s best response?
a. “Don’t Worry. It’s normal to feel that way.”
b. “Your friends are probably afraid of contracting hepatitis from you.”
c. “I’m sure you’re imagining that!”
d. “Tell me more about your feelings of isolation.”
Answer: D. “Tell me more about your feelings of isolation.”
Rationale: A nurse should encourage the client to further verbalize feelings of isolation. Instead of dismissing these feelings or making assumptions about the cause of isolation, the nurse should allow clients to verbalize their fears and provide education on how to prevent infection transmission. Option A is giving a false reassurance. Options B and C are non-therapeutic and employ threat.
Situation 4: Mrs. Smith, 44 years old is admitted to the hospital complaining of severe abdominal pain and extreme nausea and has vomited several times. A diagnosis of cholecystitis from cholelithiasis was made.
16. Based on the data, which nursing diagnosis would have the highest priority intervention at this time?
a. Anxiety r/t severe abdominal discomfort
b. Fluid Volume Deficit r/t vomiting
c. Pain r/t gallbladder inflammation
d. Imbalanced Nutrition: Less than body requirement r/t vomiting
Answer: C. Pain r/t gallbladder inflammation
Rationale: The priority for nursing care at this time is to decrease the client’s severe abdominal pain. The pain, which is frequently accompanied by nausea and vomiting, is caused by biliary spasm. Narcotic analgesics are given to relieve the severe pain and spasm of cholecystitis. Relief of pain may decrease nausea and vomiting and thereby decrease the likelihood of developing further complications, such as deficient fluid volume and imbalanced nutrition.
17. The group of characteristics that would alert Nurse Pharrel that his client has increased risk of developing gall bladder disease would be female:
a. over the age of 40, obese
b. over the age of 40, low cholesterol level
c. under the age of 40, history of high fat intake
d. under the age of 40, family history of gallstone
Answer: A. Over the age of 40, obese
Rationale: Factors that placed client a greater risk for developing gall bladder disease are female, forty years old and above, fat/obesity and fertile. Options B, C, and D are incorrect. (Just remember the 4 F’s)
18. When common bile duct is obstructed, Nurse Pharrel should evaluate her client for signs of which of the following complications?
a. Respiratory distress
b. Circulatory overload
c. Urinary tract infection
d. Prolonged bleeding time
Answer: D. Prolonged bleeding time
Rationale: A client with an obstructed common bile duct should be monitored for prolonged bleeding time. Such an obstruction prevents bile from entering the intestinal tract, thus decreasing the absorption of fat soluble vitamins (ADEK). Vit. K is necessary for prothrombin formation. Prothrombin deficiency causes delayed blood clotting, which results in prolonged bleeding time. An obstructed bile duct does not cause respiratory distress, circulatory overload or UTI.
19. Mrs. Smith complained of severe right upper quadrant pain. Which of the following medication would Nurse Pharrel anticipates administering to relieve the client’s pain?
a. Meperidine (Demerol)
b. Acetaminophen with codeine
c. Promethazine (Phernergan)
d. Morphine sulfate
Answer: A. Meperidine (Demerol)
Rarionale: This would be the narcotic analgesic of choice for a client with cholecystitis. Acetaminophen would not be appropriate to administer, because the codeine could cause biliary duct spasm and increase pain, as could opiates such as morphine sulfate. Promethazine (Phenergan) is an antiemetic.
20. A laparoscopic cholecystectomy is scheduled. Which of the following instructions should Nurse Pharrel include in his discharge plan?
a. Avoid showering for 48 hours after surgery
b. Return to work within one week
c. Change the dressing daily until the incision heals
d. Use acetaminophen (Tylenol) to control fever
Answer: B. Return to work within one week
Rationale: After a laparoscopic cholecystectomy, clients can return to work within 1 week. The client can remove dressings from the puncture site and shower the day after the surgery. The site does not need to be rebandaged but should be left open to air. The client should report any fever, which could be an indication of a complication.
Situation 5: Capt. Jack Sparrow was admitted in the Medical Floor of The Medical City. The admission history shows an alcohol abuse of excessive intake of liquor for more than 10 years. Laboratory findings result shows high trygyceride levels and hypercalcemia.
21. The initial diagnosis of pancreatitis is confirmed if Capt. Sparrow’s blood work shows a significant elevation in which of the following serum values?
a. Amylase
b. Glucose
c. Potassium
d. Trypsin
Answer: A. Amylase
Rationale: The primary diagnostic tests for pancreatitis are serum amylase, serum lipase, and urine amylase. All 3 lab results are typically elevated. Serum amylase is the most common tests; the result is usually higher than 200 units/dL. Serum glucose may be elevated in pancreatitis because of beta – cell damage, but this is not used to diagnose pancreatitis. Serum K and trypsin levels are not affected in pancreatitis.
22. Which of the following actions of pancreatic enzymes can cause pancreatic damage?
a. Utilization by the intestine
b. Autodigestion of the pancreas
c. Reflux into the pancreas
d. Clogging of the pancreatic duct
Answer: B. Autodigestion of the pancreas
Rationale: When the pancreas is injured and/or has an impaired or disrupted function, the pancreatic enzymes (phospolipase A, lipase, and elastase) leak into the pancreatic tissue and initiate autodigestion. Options C and D can be causes of pancreatitis. Option A is incorrect to this situation.
23. The initial treatment plan for Capt. Sparrow most likely would focus on which of the following as a priority?
a. Resting the GIT
b. Ensuring adequate nutrition
c. Maintaining fluid and electrolyte balance
d. Preventing the development of an infection
Answer: Resting the GIT
Rationale: There is a little definitive treatment for pancreatitis. It is crucial to decrease pancreatic enzymes to reduce stimulation of the pancreas. This is done by keeping the client NPO to rest the gastrointestinal tract and thereby suppress pancreatic enzymes secretion. Ensuring adequate nutrition, maintaining fluid and electrolyte balance, and preventing the development of an infection are issues for the client with pancreatitis but are not the primary focus of treatment.
24. Capt. Sparrow may exhibit Cullen’s sign on physical examination. Nurse Shakira knows that Cullen’s sign can be best described as:
a. Distended tortuous veins in the esophagus
b. Yellow-orange discoloration of the skin
c. Bluish discoloration of the left flank area
d. Bluish discoloration of the periumbilical area
Answer: D. Bluish discoloration of the periumbilical area
Rationale: Clinical manifestations vary with severity of attack. Cullen’s sign and Grey Turner’s sign may be present in clients with pancreatitis. Cullen’s sign is the bluish discoloration of the periumbilical area while Grey Turner’s sign is the bluish discoloration of the left flank area. Option A is a complication of cirrhosis which is esophageal varices. Option B is jaundice or icterus.
25. In alcohol related pancreatitis, which of the following interventions is the best way to reduce the exacerbation of pain?
a. Lying supine
b. Taking aspirin
c. Eating a low – fat diet
d. Abstaining from alcohol
Answer: D. Abstaining from alcohol
Rationale: Abstaining from alcohol is the best way to reduce the exacerbation of pain. Encourage position of comfort, which is elevation of the head at 45 degrees side lying with knees flexed rather lying supine. Taking aspirin may cause bleeding. An Opiod narcotic analgesic such as Demerol is given. Maintain NPO status (7 – 3 days) in order to reduce gastric secretions and aggravation of pancreatic pain and once feeding resumes provide several small meals.
Situation 6: Nurse Cassie is caring to clients who had undergone surgeries and diagnostic procedures.
26. Nurse Cassie understands that after a cholecystectomy and common bile duct exploration, the client will:
a. need to take oral bile salts
b. be incapable of producing bile
c. be unable to concentrate bile
d. not be able to digest fatty foods
Answer: C. Be unable to concentrate bile
Rationale: In cholecystectomy, the gallbladder is surgically removed. Gallbladder functions primarily to store and concentrate bile. The inability to concentrate bile results from the removal of gallbladder. Option A is a medical treatment for cholecystitis. Options B and D may result if there is liver failure.
27. Because of prolonged bile drainage from a T – tube, a client may develop symptoms related to a lack of fat soluble vitamins such as:
a. easy bruising
c. excessive jaundice
c. muscle twitching
d. tingling of the fingers
Answer: A. Easy bruising
Rationale: Easy bruising signifies a lack of fat soluble Vitamin K related to prolonged bile drainage from a T – tube. Excessive jaundice may result to clients with hepatitis or cirrhosis because of a disturbance of bilirubin metabolism. Options C and D are signs of hypocalcemia which in severe cases result in clients with acute pancreatitis.
28. Considering both the endocrine and exocrine functions of the pancreas, the client’s postoperative regimen would primarily include managing intake of:
a. alcohol and caffeine
b. fluids and electrolytes
c. vitamins and minerals
d. fats and carbohydrates
Answer: D. Fats and carbohydrates
Rationale: The pancreas produces enzymes (exocrine) and hormones (endocrine) that assist in the digestive process. The endocrine pancreas secretes insulin that stores and utilized fats. The pancreatic enzymes lipase and amylase aids in the digestion of fats and carbohydrates respectively. These should be managed to avoid exacerbation of pain postoperatively.
29. Nurse Cassie knows that several hours after liver biopsy, the client will remain in what position?
a. Left side lying with head of bed elevated
b. Right side lying with pillows placed under the costal margin
c. High fowler’s with both arms supported on pillows
d. Any comfortable recumbent position as long as the client remains immobile
Answer: B. Right side lying with pillows under the costal margin
Rationale: Positioning on the right side lying with pillows under the costal margin will provide compression over the biopsy site thus preventing bleeding. Options A, C and D are incorrect nursing care after a liver biopsy.
30. An obese client with a history of gallstone has an abdominal cholecystectomy. After surgery, Nurse Cassie plans to alleviate tension on the surgical wound by:
a. limiting deep breathing
b. maintaining T – tube patency
c. maintaining nasogastric tube patency
d. encouraging the right side lying position
Answer: C. Maintaining NGT patency
Rationale: Maintaining NGT patency will promote gastric decompression thus alleviates tension in the surgical wound. Encouraging deep breathing rather limiting is advised to decrease pain. Maintaining T- tube patency promotes gravity drainage of bile. Option D is incorrect for this situation for it is a nursing care done after a liver biopsy.
Situation 7: Mr. Gibson, 60 – year old, is admitted to the hospital with cirrhosis. He has history of alcoholism and hepatitis B.
31. What should Nurse Ashanti expect to find on his initial laboratory results?
a. hypernatremia
b. elevated ALT
c. elevated serum albumin
d. leukocytosis
Answer: B. Elevated ALT
Rationale: Elevation of Alanine aminotransferase (5 – 35 IU/L) indicates damage of liver cells and decreased liver function. Other lab values result a low serum albumin, hyponatremia, leucopenia, thrombocytopenia, prolonged PT, anemia and possible elevated serum ammonia.
32. Mr. Gibson is scheduled for a liver biopsy. What is your priority of care for this patient? a. monitor for bleeding
b. encouraging increased activity
c. controlling blood pressure
d. providing nutritional support
Answer: A. Monitor for bleeding
Rationale: Since the liver is a vascular organ, the priority of care is to monitor bleeding. The dressing should be monitored for oozing of blood and should be positioned on the right side, which helps apply pressure on the biopsy site. The client is usually maintained on bed rest for 24 hours to reduce the risk of bleeding so increased activity is contraindicated. Providing nutritional support is not the utmost priority at this time. Option C is to prevent the occurrence of portal hypertension as a complication from cirrhosis.
33. What life threatening complication will result when the liver is destroyed due to hepatitis B and up to the development of chronic hepatitis?
a. portal hypertension
b. esophageal varices .
c. liver failure
d. hepatic encephalopathy
Answer: C. Liver Failure
Rationale: All are complications of cirrhosis but option C is the most life threatening. Complications of hepatitis B include the development of chronic hepatitis, which destroys the liver and leads to cirrhosis and liver failure causing death. The complications of cirrhosis are portal hypertension leading to esophageal varices, right sided heart failure and varicose veins. Ascites, hepatic encephalopathy are also complications.
34. What instruction about diet modification should Nurse Ashanti give to Mr. Gibson?
a. increase fluid intake
b. avoid canned and processed food
c. eat food reach in protein
d. encourage to eat dairy products and poultry
Answer: B. Avoid canned and processed foods
Rationale: The client with late stage of cirrhosis is usually on a protein, sodium and fluid restricted diet. Foods to avoid would be canned and processed foods (high in sodium), chicken, meat, eggs and dairy products (high in CHON), and fluids are usually limited.
35. Mr. Gibson asks Nurse Ashanti why he has edema. Nurse Ashanti would use which of the following statements to explain how edema results from pathophysiologic changes in cirrhosis?
a. “The edema occurs because your liver produces fewer proteins that help draw fluid into the bloodstream”
b. “The high osmotic pressure of proteins in your blood pushes fluid into the body tissues”
c. “The kidneys are able to filter less fluid, so the body cannot excrete it as urine very easily”
d. “Your body is metabolizing sex hormones more quickly, leading to fluid retention.
Answer: A. The edema occurs because your liver produces fewer proteins that help draw fluid into the bloodstream”
Rationale: The liver is responsible for the production of albumin, which in turn is responsible for maintaining colloidal osmotic pressure. With less production of albumin, osmotic pressure decreases and edema develops. Options B, C and D are false statements that do not explain the relationship between cirrhosis and edema.
Situation 8: Mrs. Carey, 49-year-old female was rushed in the emergency department because of severe and steady right upper quadrant pain that radiates to the scapula lasting for 2 hours. She has vomited frequently and experiencing chills.
36. Based from the data presented, Mrs. Carey is experiencing which of the following problems?
a. acute pancreatitis
b. cholelithiasis
c. acute cholecystitis
d. hepatic encephalopathy
Answer: C. Acute cholecystitis
Rationale: In acute cholecystitis, the lodging of a gallstone in the duct causes inflammation of the cystic duct. The lodged gallstone in the cystic duct causes pressure against the wall of the gall bladder, decreasing blood flow. Cholelithiasis can cause cholecystitis because of the distention of the gallbladder thus, severe, steady RUQ pain that radiates to the scapula occurs. Other GI symptoms also occur but when patient experiences chill, an inflammation and infection are happening resulting to acute cholecystitis.
37. Physical exam findings revealed a severe pain in the RUQ with inspiratory arrest. Nurse Beyonce knows, that her client is positive for which of the following signs?
a. Grey Turner’s sign
b. McBurney’s sign
c. Cullen’s sign
d. Murphy’s sign
Answer: D. Murphy’s sign
Rationale: A positive Murphy's sign is seen in acute cholecystitis. It is elicited by firmly placing a hand at the costal margin in the right upper abdominal quadrant and asking the patient to breathe deeply. If the gallbladder is inflamed, the patient will experience pain and catch their breath as the gallbladder descends and contacts the palpating hand. Options A and C are signs of pancreatitis. Option D is a sign for appendicitis.
38. Which of the following tests is most commonly used to diagnose Mrs. Carey’s problem?
a. Abdominal computed tomography scan
b. Abdominal ultrasound
c. Barium swallow
d. Endoscopy
Answer: A. Abdominal computed tomography scan
Rationale: This is a definitive diagnostic test for acute cholecytitis. This provides a cross sectional images of the abdomen to differentiate subtle changes in the tissue in the selected structure particularly it will visualize where the gallstone has been lodged in the cystic duct.
39. Frequent vomiting puts Mrs. Carey at risk of which of the following acid-base imbalance?
a. metabolic acidosis and hyperkalemia
b. metabolic alkalosis and hyperkalemia
c. metabololic acidosis and hypokalemia
d. metabolic alkalosis and hypokalemia
Answer: D. Metabolic alkalosis and hypokalemia
Rationale: If frequent vomiting happens, the client is at risk for metabolic alkalosis and hypokalemia. Option C could happen in patient experiencing persistent diarrhea. Options A and B are incorrect.
40. When counseling Mrs. Carey in the ways to prevent the exacerbation of the problem, which of the following guidelines is most important?
a. Eat a low protein diet
b. Limit exercise to 10 minutes a day
c. Eat a low – fat diet, cholesterol diet
d. Keep weight proportional to height
Answer: D. Keep weight proportional to height
Rationale: Keeping weight proportional to height is the best indicator of being healthy. This is your Body Mass Index. Client should be taught to avoid high fat foods (cholesterol diet), whole milk products, fried foods, nuts, gravies, cooking oils, hot dogs, chocolate and cheese. Not all protein rich foods are restricted. Exercise should be encouraged to promote OLOF.
Situation 9: Nursing process is a systematic problem solving approach to the collaborative identification of client health needs and the application of nursing care to effectively meet those needs.
41. A client was admitted in the emergency department with exacerbation of cholelithiasis. When does discharge planning begins?
a. after physical examination c. upon admission
b. after initial assessment d. before discharge
Answer: C. Upon admission
Rationale: Discharge planning begins upon admission so to have a continuous/ongoing assessment to provide appropriate nursing intervention throughout the course of disease.
42. How will you assess a client with hepatic encephalopathy having asterixis?
a. On deep inspiration, pain is elicited and breathing stops
b. On deep palpation and released, pain is elicited
c. Ask client to hold his arms straight in front and flappy hand tremors occur
d. Place hand over the patient's right knee while the patient flexes their right hip against the resistance
Answer: C. Ask client to hold his arms straight in front and flappy hand tremors occur
Rationale: Asterixis/liver flap describes a motor disturbance characterized by intermittent lapses of an assumed posture. It is commonly associated with liver failure where it produces the flapping tremor of hepatic encephalopathy characterized by jerky, irregular flexion-extension movements at the wrist and metacarpophalangeal joints, often accompanied by lateral movements of the fingers. The motor disturbance may rarely involve the arms, neck, tongue, jaw and eyelids. It is usually bilateral, absent at rest, and asynchronous on each side. Option A is Murphy’s sign. Option B is rebound tenderness. Option D is Psoa’s sign.
43. The client who has acute pancreatitis tells Nurse Juris, “I Just want my gall bladder taken out now.” Nurse Juris best response should be which of the following?
a. “I don’t blame you but they want your pain under control first”
b. “Would you like to ask if your physician will schedule surgery today?”
c. “The symptoms are distressing, but the surgeon must wait until your gallbladder is less infected”
d. “They will try to dissolve the stones before they do the surgery”
Answer: C. “The symptoms are distressing, but the surgeon must wait until your gallbladder is less infected”
Rationale: With the advent of laparoscopic surgical technique, the only absolute contraindication for surgery is acute infection. The other options do not address this concern.
44. Mr. Prefix with cirrhosis was admitted to the hospital. Which of the following assessments made by Nurse Juris would indicate the development of portal hypertension?
a. Hematemesis
b. Elevated blood pressure
c. Asterixis
d. Confusion
Answer: A. Hematemesis
Rationale: In cirrhosis, the liver becomes fibrotic, which obstructs the venous blood flow through the liver. This increases the vascular pressure in the portal system, and causes congestion in the spleen and development of varicosities in the esophagus. Bleeding esophageal varices are a complication of portal hypertension and result in vomiting of blood (hematemesis) and possible hemorrhage and death.
45. Ms. Suffix with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. She tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
a. Impaired physical mobility r/t malaise
b. Ineffective individual coping r/t long term illness
c. Self care deficit r/t fatigue
d. Activity intolerance r/t fatigue
Answer: D. Activity intolerance r/t fatigue
Rationale: This is the most appropriate diagnosis for this client. The major goal of care for the client with hepatitis is to increase activity gradually as tolerated. Periods of alternating rest and activity should be included in the plan of care. There is no evidence that the client is physically immobile, unable to provide self care, or coping ineffectively.
Situation 10: Nurse Shaggy is the staff nurse on duty in the Medical Floor. He is caring to clients with hepatobiliary and pancreatic disorders. Health teaching is his primary role for the quick recovery of his clients.
46. Ms. Demeanor has jaundice. Nurse Shaggy’s most appropriate comfort measure to implement is:
a. Offer hot beverages frequently
b. Encourage taking a hot bath or shower
c. Keep the air temperature at approximately 68O to 70O F
d. Suggest the use of alcohol based skin lotion
Answer: C. Keep the air temperature at approximately 68O to 70O F
Rationale: Jaundice frequently causes pruritus. Comfort measures include keeping the air temperature cool (68O to 70O F) and the humidity at 30 to 40 percent. Tepid baths (not hot) with colloidal agents decrease itching. Use of an emollient lotion is also helpful, but anything drying should be avoided. Hot beverages are of no benefit as a comfort measure for pruritus due to jaundice.
47. When teaching Mr. Gabrielle with hepatitis A about infection control, Nurse Shaggy explains that he is most infectious to others at which of these times?
a. 7 days exposure
b. 2 months after exposure
c. 10 days before the onset of symptoms
d. 14 days after symptoms begin
Answer: B. 2 months after exposure
Rationale: The incubation period for hepatitis A is 4 – 6 weeks in length with viral shedding highest 10 – 14 days before the onset of symptoms and during the first week of symptoms. The other options do not fall within this time frame.
48. Which of the following dietary instructions would be appropriate for Nurse Shaggy to give a client who is recovering from acute pancreatitis?
a. Avoid crash dieting
b. Eat six small meals day
c. Restrict carbohydrate intake
d. Decrease sodium in diet
Answer: A. Avoid crash dieting
Rationale: Crash dieting or bingeing may cause an acute attack of pancreatitis and should be voided. CHO intake should be increased, because CHO are less stimulating to the pancreas. There is no need to maintain a dietary pattern of six small meals a day; the client can eat whenever desired. There is no need to place the client on a sodium – restricted diet, because pancreatitis does not promote fluid retention.
49. Mr. Foxx who has ascites and peripheral edema is at risk for impaired skin integrity. Which of the following intervention would be implemented to prevent skin breakdown?
a. ROM exercises every 4 hours
b. Use of alternating air pressure mattress
c. Massage of the abdomen once a shift
d. Elevation of the lower extremities
Answer: B. Use of alternating air pressure mattress
Rationale: Edematous tissue is easily traumatized and must receive meticulous care. An alternating air pressure mattress will help decrease pressure on the edematous tissue. Range-of-motion exercises are important to maintain joint function, but they do not necessarily prevent skin breakdown. When abdominal skin is stretched taut (tightly) due to ascites, it must be cleaned very carefully. The abdomen should not be massaged. Elevation of the lower extremities promotes venous return and decrease swelling.
50. A male client with liver dysfunction reports that his gums bleed spontaneously. In addition, Nurse Shaggy notes small hemorrhagic lesions on his face. Nurse Shaggy recognizes that the client needs nutritional vitamin:
a. D
b. E
c. A
d. K
Answer: D. Vitamin K
Rationale: All options are fat soluble vitamins stored in the liver. Vitamin K (Aquamephyton) is necessary for the proper clotting of blood and helps promote bone health. Without sufficient amounts of vitamin K, hemorrhaging can occur. Vitamin D (Calciferol) is required for growth, especially bone growth or "calcification". Vitamin D plays a critical role in the body’s use of calcium and phosphorous. It increases the amount of calcium absorbed from the small intestine and helps form and maintain bones. Vitamin E (Tocopherol) is the most effective, fat-soluble antioxidant known to occur in the human body. It makes the specialized membranes that enclose the body cells much more stable and helps to protect the structures inside the cells, such as DNA, from damage by free radicals and other harmful chemicals. Vitamin A (Retinol) is an antioxidant chemical that is essential for normal vision (particularly night vision), a healthy immune system, healthy reproductive organ function and normal fetal development.
