The nurse performs an assessment on a client who reports abdominal pain. Based on the assessment findings, what problem does the nurse suspect?
Awake,
... [Show More] alert, and oriented reporting diffuse abdominal pain rated 9/10. Skin warm and dry. Cullen's sign noted. Abdomen rigid with guarding. Temperature 101 degrees F (38.3 degrees C), BP 96/64, HR 102, RR 26.
Choose One
1. Cirrhosis
2. Pancreatitis
3. Peptic ulcer
4. Ulcerative colitis
2
Rationale
2. Correct: These s/s point to pancreatitis. Look at the big clues: Cullen's sign, rigid abdomen with guarding, and fever.
1. Incorrect: What are the classic s/s of cirrhosis that are different from pancreatitis? Firm, nodular liver, dyspepsia, change in bowel habits, splenomegaly, acites.
3. Incorrect: Peptic ulcers typically do not present with severe pain, but with a burning pain in the mid-epigastric area and back. Dyspepsia is common as well, but no bruising around the flank area or umbilicus.
4. Incorrect: Ulcerative colitis presents with diarrhea, rectal bleeding, vomiting, weight loss, cramping, rebound tenderness and fever.
The nurse is educating a client diagnosed with cirrhosis about the functions of the liver. What functions should the nurse include?
Select All That Apply
1. Removes old RBCs from the body.
2. Produces clotting factors.
3. Detoxifies the body.
4. Releases digestive enzymes.
5. Breaks down medications.
2, 3, 5
Rationale
2., 3., & 5. Correct: Three of the four functions are listed: the liver produces clotting factors, detoxifies the body, and breaks down medications. It also synthesizes albumin.
1. Incorrect: The spleen, not the liver, removes old RBCs from the body.
4. Incorrect: The exocrine function of the pancreas releases digestive enzymes into the small intestine.
What is the most important action for the nurse to take prior to a client having a liver biopsy?
Choose One
1. Make certain the consent has been signed.
2. Obtain vital signs.
3. Check clotting study results.
4. Position client supine with right arm above head.
3
Rationale
3. Correct: This is a priority question. All actions should be done by the nurse, however, the nurse better check the clotting study results. The client could hemorrhage if the clotting factors are too messed up.
1. Incorrect: Yes, the consent must be signed, but what is more life saving? Checking the clotting factor results.
2. Incorrect: Yes, the nurse will need to obtain pre-procedure vital signs. However, the procedure may not be done if the clotting study results are bad.
4. Incorrect: Yes, the client will need to be positioned so that the primary healthcare provider has access to the liver. But again, this is not the priority.
What signs/symptoms would lead the nurse to suspect that a client diagnosed with cirrhosis may be developing hepatic coma?
Select All That Apply
1. Asterixis
2. Fetor
3. Grey Turner's sign
4. Hyperactive reflexes
5. Squiggly handwriting
1, 2, 5
Rationale
1., 2., & 5. Correct: Signs and symptoms that a client diagnosed with cirrhosis is getting worse and headed for hepatic coma include asterixis, fetor, and handwriting changes.
3. Incorrect: Grey Turner's sign is seen with pancreatitis.
4. Incorrect: With hepatic coma, the client is full of toxins, so reflexes will be decreased.
The family of a client being treated for bleeding esophageal varices asks the nurse why the client is receiving octreotide. How should the nurse respond?
Choose One
1. "Octreotide is an antibiotic given to decrease the risk of developing an infection."
2. "Taking this medication forms a protective barrier over the varices to prevent bleeding recurrence."
3. "Octreotide helps eliminate ammonia from the body."
4. "This medication lowers the pressure in the liver, so bleeding stops."
4
Rationale
4. Correct: Octreotide is a synthetic hormone that selectively inhibits the release of vasodilating hormones in the internal organs. By doing this it decreases blood flow to the liver. When you decrease blood flow to the liver, the pressure in the liver lowers. Less volume, less pressure. So, bleeding should stop.
1. Incorrect:Octreotide is not an antibiotic.
2. Incorrect: You might be thinking of sucralfate, which forms a barrier over an ulcer so acid can't get on the ulcer.
3. Incorrect: No, lactulose decreases ammonia.
A client is diagnosed with a duodenal ulcer due to Helicobacter pylori (H Pylori). In addition to antibiotic therapy, the nurse anticipates that the client will also receive what class of pharmacologic agents?
Select All That Apply
1. Miotic inhibitor
2. Serotonin antagonist
3. H2 antagonist
4. Acetylsalicyclic acid
5. Proton pump inhibitor
3, 5
Rationale
3., & 5. Correct: H2 antagonist or receptor blockers are used to decrease excess stomach acid seen with ulcers. Antisecretory agents like proton pump inhibitors are indicated for the treatment of peptic ulcer disease. Antisecretory agents decrease the secretion of gastric acids. Protein pump inhibitors, a combination of antibiotics and bismuth salts are most commonly used for treatment of H Pylori.
1. Incorrect: Mitotic inhibitors are chemotherapeutic agents that are indicated for the treatment of malignancies and cancerous cells. They are most often used in combination chemotherapy regimens to enhance the overall cytotoxic effect.
2. Incorrect: Serotonin antagonists are antiemetic agents that are indicated for the treatment of nausea and vomiting. Serotonin antagonists block the serotonin receptor sites located throughout the body responsible for the mediation of nausea and vomiting.
4. Incorrect: Acetylsalicylic acid is a non narcotic analgesic that inhibits the cox-2 protective mechanisms to the gastric mucosa. This could make the ulcer worse. Clients are advised to avoid the use of NSAIDs and acetylsalicylic acid due to increased bleeding potential.
The nurse is caring for a client following a cholecystectomy. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms?
Select All That Apply
1. Drink between meals.
2. Reduce intake of carbohydrates.
3. Eat small, frequent meals daily.
4. Sit semi-recumbent for meals.
5. Remain upright for one hour after eating.
6. Lie down on left side after eating.
1, 2, 3, 4, 6
Rationale
1., 2, 3, 4., & 6. Correct: Clients are instructed to eliminate all fluids during meals. In some cases, clients may also need to eliminate fluids for one hour before and immediately after meals in order to control symptoms and slow the progress of food through the digestive tract. The symptoms described indicate the client is experiencing dumping syndrome, an adverse response following gastric or bariatric surgery. Clients may also experience tachycardia, nausea or cramping with the intake of food due to surgical restructuring of the gastrointestinal tract. Because this will be a lifetime issue, the nurse must teach the client to adjust eating habits and patterns. Reduction of carbohydrates will help decrease the problem since carbohydrates speed through the digestive track too quickly. Eating smaller, more frequent meals in a semi-recumbent position will further slow food through the digestive tract and eliminate most of the uncomfortable symptoms. After eating, the client should lie down on the left side to keep food in the stomach longer.
5. Incorrect: Sitting up after a meal is counterproductive, since this will increase the speed of food through the digestive tract. Therefore, clients are encouraged to lie down on the left side following meals to slow the processing of food.
What signs/symptoms does the nurse expect to see in a client who has ulcerative colitis?
Select All That Apply
1. Abdominal cramping
2. Hematemesis
3. Diarrhea
4. Fever
5. Rebound tenderness
6. Rectal bleeding
1, 3, 4, 5, 6
Rationale
1., 3., 4., 5., & 6. Correct: Ulcerative colitis is an ulcerative inflammatory bowel disease in the large intestines. Common s/s include abdominal cramping, diarrhea, fever, rebound tenderness, and rectal bleeding.
2. Incorrect: Hematemesis is seen with upper GI bleeding.
A client returns to the room post appendectomy. In what position should the nurse place the client?
Choose One
1. Sims'
2. Prone
3. Semi-fowler's
4. Right lateral
3
Rationale
3. Correct: After any major abdominal surgery, the position of choice is to elevate the head of the bed 35-45 degrees. This will decrease pressure on the abdomen and suture line.
1. Incorrect: Sims' is a semi-prone position where the client assumes a posture halfway between lateral and prone. This is used for clients who need their airway protected.
2. Incorrect: Prone is not recommended. This will put more pressure on the suture line and abdomen.
4. Incorrect: Slightly side lying would be okay if the head of the bed was elevated to decrease abdominal and suture line pressure. The best position is semi-fowler's immediately post op.
What interventions should the nurse include when caring for a client who is receiving total parenteral nutrition (TPN)?
Select All That Apply
1. Change tubing and filter every 48 hours.
2. Monitor IV drip rate hourly.
3. Compare new bag with prescription prior to infusing.
4. Weigh weekly.
5. Cover TPN with dark bag.
6. Check urine for protein.
3, 5
Rationale
3., & 5. Correct: Remember safety and that TPN is a medication. You must make sure that what is in the bag is what was prescribed, so double check the bag against the prescription. Cover the IV bag with a dark bag to prevent chemical breakdown.
1. Incorrect: The IV tubing and filter must be changed with each new bag. Remember: A bag cannot hang more than 24 hours.
2. Incorrect: TPN must be placed on an IV pump. Relying on calculating to maintain a drip rate is dangerous. The client could get too much TPN too fast without having it on a pump at the prescribed rate per hour. This is a safety issue.
4. Incorrect: The client should be weighed daily. We want to make sure the client is not losing weight while on TPN. They should be maintaining or gaining weight.
6. Incorrect: Monitor urine for glucose and ketones. The only way protein will be in the urine is if the kidneys are damaged. [Show Less]