Chapter 38 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 38

Question 1

Type: MCSA

The nurse should instruct the patient with a diagnosis of cholelithiasis to make which lifestyle modification to alleviate symptoms?

1. Reduce sodium intake.

2. Increase fluids.

3. Reduce smoking.

4. Reduce fat consumption.

Correct Answer: 4

Rationale 1: While all patients should be instructed to reduce sodium intake, this practice will not assist in reducing cholelithiasis or its pain.

Rationale 2: Increasing fluids will not assist in reducing cholelithiasis or its pain.

Rationale 3: While all patients should cease smoking, there is no relationship between smoking and cholelithiasis.

Rationale 4: The patient who has cholelithiasis should be instructed on the relationship between increased fat consumption and the severity of pain associated with cholelithiasis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-1

Question 2

Type: MCSA

When assessing a patient who has cirrhosis, which finding would best indicate the patient is developing ascites?

1. Accumulation of fluid in the abdomen

2. Yellow skin

3. Ecchymosis

4. Upper-right-quadrant pain

Correct Answer: 1

Rationale 1: Ascites is the accumulation of the fluid in the abdomen and is a result of portal hypertension.

Rationale 2: Yellow skin is a manifestation of jaundice and is associated with hepatic disorders.

Rationale 3: The patient experiencing hepatic problems might have bleeding and bruising issues due to inadequate vitamin K.

Rationale 4: Obstructed biliary flow could be the cause of upper-right-quadrant pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-2

Question 3

Type: MCSA

A patient with hepatitis has a prescription for alpha interferon. Which manifestation would indicate that the patient is experiencing an untoward effect of this medication?

1. Jaundice

2. Flulike syndrome

3. Gallbladder pain

4. Clay-colored stools

Correct Answer: 2

Rationale 1: Jaundice is yellow-tinged skin associated with hepatitis.

Rationale 2: The patient who is receiving alpha interferon may experience a flulike syndrome.

Rationale 3: Gallbladder pain is the result of stones in the gallbladder.

Rationale 4: Clay-colored stool are associated with liver or biliary disease.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 38-1

Question 4

Type: MCMA

The nurse is teaching a patient about strategies for reducing the risk of hepatitis B transmission. Which statements by the patient indicate understanding of the nurses instruction?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. I will wash my hands frequently to prevent fecal-oral transmission.

2. I will avoid alcohol.

3. I will avoid contact with blood and body fluids.

4. I will avoid contaminated food and water.

5. I will use safe sex techniques.

Correct Answer: 3,5

Rationale 1: The hepatitis A virus, not hepatitis B virus, is spread by fecal-oral transmission.

Rationale 2: Alcohol use does not cause hepatitis B transmission.

Rationale 3: Hepatitis B is contracted through contaminated blood and body fluids. Strategies that reduce exposure to blood and body fluids of others reduce the risk of hepatitis B transmission.

Rationale 4: The hepatitis A virus, not hepatitis B virus, is spread through contaminated food and water.

Rationale 5: Hepatitis B is contracted through contaminated blood and body fluids. Strategies that reduce exposure to blood and body fluids of others, including safe sex techniques, will reduce the risk of hepatitis B transmission.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 38-1

Question 5

Type: MCSA

A patient who has portal system encephalopathy is receiving Neomycin (neomycin sulfate). Which manifestation would indicate to the nurse that the patients condition is improving?

1. An increase in the potassium level

2. Asterixis

3. Relief of jaundice

4. Increased level of consciousness

Correct Answer: 4

Rationale 1: Neomycin (neomycin sulfate) causes diarrhea, which reduces potassium and does not lead to hyperkalemia.

Rationale 2: Asterixis is a hand flap and is a sign of portal encephalopathy, which should abate with administration of Neomycin (neomycin sulfate).

Rationale 3: Neomycin does not improve jaundice.

Rationale 4: The patient experiencing portal encephalopathy will have decreased judgment, confusion, disorientation, and incoherence related to a high level of ammonia in the blood.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 38-3

Question 6

Type: MCSA

Which outcome should receive priority in the care plan for a patient who has had a paracentesis to treat ascites?

1. The patient will have normal bilateral breath sounds.

2. The patients spleen will not rupture.

3. The patients respiratory effort will be lessened.

4. The patient will not manifest symptoms of hepatomegaly.

Correct Answer: 3

Rationale 1: Paracentesis will not help clear abnormal breath sounds.

Rationale 2: A ruptured spleen is not a complication of a paracentesis.

Rationale 3: The purpose of paracentesis is to remove enough fluid to reduce pressure on the diaphragm and abdominal organs. A manifestation of successful paracentesis is a reduction in respiratory effort.

Rationale 4: Damage to the liver can cause the ascites that necessitates paracentesis. Paracentesis will not reduce liver size.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 38-2

Question 7

Type: MCSA

Which teaching point is appropriate for a nurse to include when teaching a patient who has undergone a liver transplant?

1. Your immunosuppressive medications may cause weight loss.

2. Reduce scheduled tacrolimus to every other day if nausea occurs.

3. Take acetaminophen (Tylenol) if fever develops.

4. Report sore throats to your health care provider.

Correct Answer: 4

Rationale 1: These medications generally cause weight gain.

Rationale 2: Anti-rejection drugs are taken every day and may not be omitted.

Rationale 3: Acetaminophen (Tylenol) should not be taken, as it is liver-toxic.

Rationale 4: The patient who has undergone a liver transplant should be instructed to report any signs of infection, such as a sore throat, as the medications prescribed to prevent organ rejection increase the risk of contracting infectious diseases.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-3

Question 8

Type: MCSA

A patient with pancreatitis asks the nurse, Why are my stools so frothy and smell so bad? What is the nurses best response?

1. This is a sign of malnutrition.

2. This indicates your stools have more fat in them.

3. This is a sign of peptic ulcer disease.

4. You may be developing diabetes mellitus.

Correct Answer: 2

Rationale 1: Pancreatitis can lead to malnutrition, but steatorrhea is not a sign of malnutrition. This statement is inaccurate.

Rationale 2: Steatorrhea is fatty, frothy, smelly stools associated with pancreatitis caused by a lack of pancreatic enzymes in the gastric lumen. Because of the lack of enzymes, fat in the GI tract is not absorbed properly and a greater than normal amount of fat is excreted in the stool, causing the symptoms of steatorrhea.

Rationale 3: Peptic ulcer disease can be related to pancreatitis, but it is not related to steatorrhea, or fatty stools.

Rationale 4: Diabetes mellitus causes increased urine production and could be the result of pancreatitis, but it does not affect stool characteristics.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-7

Question 9

Type: MCSA

A patient has chronic pancreatitis and a serum amylase level of 180 units/L. The nurse should instruct the patient to follow which dietary plan?

1. Low residue, no alcohol

2. Low fat, no alcohol

3. Low fat, no fiber

4. Mechanical soft

Correct Answer: 2

Rationale 1: A low-residue diet is prescribed for patients experiencing bowel disorders.

Rationale 2: The patient experiencing pancreatitis after the serum amylase level returns to normal levels should be instructed to consume a diet low in fat with no alcohol.

Rationale 3: Almost all patients should consume a low-fat diet, but most patients need increased fiber.

Rationale 4: A mechanical soft diet is reserved for the patient who needs to conserve energy or has a mouth or dentition disorder.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-7

Question 10

Type: MCSA

The nurse assesses a patient who is reporting epigastric pain. The patients serum amylase level is 369 units/L. What is the nurses best

action?

1. Continue to monitor the patient.

2. Refer the patient to a dietician.

3. Contact the primary health care provider.

4. Question the patient regarding alcohol use patterns.

Correct Answer: 3

Rationale 1: Continued monitoring is essential but is not the primary action indicated.

Rationale 2: Referral to a dietician is not indicated at this time.

Rationale 3: The primary health care provider should be notified of the patients symptoms and the laboratory findings.

Rationale 4: The nurse should assess alcohol use patterns, but this is not the primary action indicated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-7

Question 11

Type: MCSA

Which finding in a patient who has a Sengstaken-Blakemore tube for esophageal varices is the priority for follow-up?

1. Left lower leg swollen and reddened

2. Absent bowel sounds to lower-left quadrant

3. Decreased level of consciousness

4. 3 cm darkened area on left heel

Correct Answer: 3

Rationale 1: A swollen and reddened lower leg may indicate a venous thrombus, which is a serious disorder. It is not the highest-priority finding.

Rationale 2: Absent bowel sounds may indicate ileus, which is a serious disorder. It is not the highest-priority finding.

Rationale 3: The patient with a Sengstaken-Blakemore tube is at risk for hypoxia, as the tube has two balloons that are used to tamponade the esophageal bleeding. One balloon is in the stomach and the other is in the esophagus, and if the tube migrates, the airway can be obstructed. Decreased level of consciousness may indicate hypoxia and is the priority for follow-up.

Rationale 4: A darkened area on the heel may indicate a pressure ulcer. This is not the highest-priority finding.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 38-1

Question 12

Type: MCMA

The nurse is caring for a patient with severe liver disease. The nurse notes new ecchymotic areas on the patients arms and legs. Which laboratory results will the nurse analyze regarding this finding?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Complete blood count

2. Coagulation studies

3. Serum albumin

4. Serum ammonia levels

5. Serum hepatitis antibodies

Correct Answer: 1,2

Rationale 1: Ecchymosis indicates a bleeding tendency. The nurse would review the CBC for hemoglobin and hematocrit level changes.

Rationale 2: The liver plays a major role in the normal clotting cascade. Ecchymosis indicates a bleeding tendency. The nurse should review coagulation studies for changes.

Rationale 3: Albumin levels reflect liver impairment and nutritional status and are not related to a risk for bleeding.

Rationale 4: Serum ammonia levels elevate during liver failure due to the livers inability to convert ammonia to urea for renal excretion. This test does not relate to bleeding tendency.

Rationale 5: Testing for the presence of hepatitis antibodies in the blood does not provide information regarding coagulation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-3

Question 13

Type: MCSA

The nurse assesses a patient who has cirrhosis secondary to liver failure. Which finding would require immediate follow-up by the nurse?

1. Asterixis

2. Jaundice

3. Increased abdominal girth

4. Dyspnea

Correct Answer: 4

Rationale 1: Asterixis, or liver flap, is an early sign of portal systemic encephalopathy. Asterixis should be reported and evaluated but is not the priority.

Rationale 2: Jaundice is a chronic problem with liver failure and does not present an immediate threat to the patient.

Rationale 3: Increased abdominal girth is an expected finding with cirrhosis.

Rationale 4: Dyspnea is the priority for this patient. The nurse should use ABCs to prioritize. Dyspnea can occur from pressure on the diaphragm.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 38-3

Question 14

Type: MCSA

The nurse assesses a patient with cirrhosis who is experiencing hypertension, edema, and shortness of breath. Which nursing diagnosis will the nurse establish?

1. Fluid Volume Deficit

2. Ineffective Tissue Perfusion

3. Fluid Volume Excess

4. Impaired Skin Integrity

Correct Answer: 3

Rationale 1: Hypotension and dry mucous membranes are associated with Fluid Volume Deficit.

Rationale 2: Ineffective Tissue Perfusion is an appropriate diagnosis for a patient experiencing cyanosis or tissue necrosis.

Rationale 3: Hypertension, shortness of breath, and edema are manifestations of fluid excess.

Rationale 4: Edema can cause an alteration in skin integrity, but there is no evidence of such problems with this patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 38-2

Question 15

Type: MCSA

A patient who reports a severe, steady pain in the epigastric area along with nausea and vomiting states, This happens every time I eat barbecued ribs. It will go away in a little while, especially if I lie on my back. The nurse would consider which disorder as the likely cause of these symptoms?

1. Porcine allergy

2. Obesity

3. Cholelithiasis

4. Pancreatitis

Correct Answer: 3

Rationale 1: There is no evidence that the patient is allergic to pork or pork products.

Rationale 2: The patient may be obese, but these symptoms are not related to that condition.

Rationale 3: Symptoms of cholelithiasis (gallstone) include severe, steady pain in the epigastric region or upper-right quadrant of the abdomen. The pain may radiate to the back, right scapula, or shoulder. The pain often begins suddenly following a meal and may last as long as 5 hours. It is often accompanied by nausea and vomiting.

Rationale 4: The symptoms of pancreatitis are not generally associated with eating a specific food but rather with heavy alcohol consumption. The pain becomes worse when the patient lies supine.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-5

Question 16

Type: MCSA

The nurse is caring for a patient with cholelithiasis who has a new laboratory finding of serum amylase of 300 units/L. The patient states, My primary health care provider said I dont have pancreatitis. What is the most likely explanation for the laboratory finding?

1. The gallstone is causing acute cholecystitis.

2. The gallstone has migrated to the neck of the pancreas.

3. The gallstone has caused bile to back into the pancreas.

4. The gallstone is blocking the common bile duct.

Correct Answer: 4

Rationale 1: Acute cholecystitis is not reflected in elevated amylase levels.

Rationale 2: It would be highly unlikely for the gallstone to migrate to the neck of the pancreas.

Rationale 3: The gallstone does not cause bile to back into the pancreas, although it can cause pancreatic enzymes to back up into the pancreas.

Rationale 4: When a gallstone blocks the common bile duct, pancreatic enzymes cannot exit the common bile duct and back up into the pancreas, causing pancreatitis, with elevated pancreatic enzymes. A normal serum amylase level is 0130 units/L.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-5

Question 17

Type: MCMA

The clinic nurse has been providing care for a patient with a long history of cholelithiasis. Which statement by the patient would make the nurse suspicious that the condition has progressed to cholecystitis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. I was in terrible pain for 2 hours, but then it went away.

2. Im hot and sweating, and then cold and shivering.

3. The pains in the same location as when I had appendicitis.

4. I need an emesis basin; Ive vomited four times.

5. My abdomen and my back both hurt.

Correct Answer: 2,4,5

Rationale 1: The pain of cholecystitis usually lasts longer than that of biliary colic, continuing for 12 to 18 hours.

Rationale 2: Fever often is present with cholecystitis and may be accompanied by chills.

Rationale 3: The pain related to cholecystitis is not located in the lower-right quadrant.

Rationale 4: Anorexia, nausea, and vomiting are common symptoms of cholecystitis.

Rationale 5: Acute cholecystitis features pain that involves the entire upper-right quadrant (RUQ) and may radiate to the back, right scapula, or shoulder. Movement or deep breathing may aggravate the pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-5

Question 18

Type: MCMA

The nurse has given a patient instruction about the possible complications of unresolved cholecystitis. Which statements by the patient would indicate correct understanding of the instruction?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. I could have infected pus stored in my gallbladder.

2. My gallbladder could rot and cause a big infection in my abdomen.

3. My gallbladder trouble could become chronic.

4. My cholesterol could get very high.

5. My gallbladder could turn inside out into the bile duct.

Correct Answer: 1,2,3

Rationale 1: Complications of cholecystitis include empyema, a collection of infected fluid within the gallbladder.

Rationale 2: Gangrene and perforation with resulting peritonitis may occur. An abscess may form.

Rationale 3: Chronic cholecystitis can develop.

Rationale 4: Cholesterol is implicated in the development of gallstones, but increased cholesterol levels are not caused by gallbladder disease.

Rationale 5: The gallbladder will not turn inside out into the bile duct.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 38-5

Question 19

Type: MCMA

The nurse should include which teaching points when planning discharge for a patient who has a T-tube following a cholecystectomy?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Keep the skin around the site clean and free from bile drainage.

2. Report drainage of more than 500 mL per day to the health care provider.

3. Primarily maintain a side-lying position to facilitate drainage.

4. Report skin redness or irritation in the drain site area.

5. Pin the drainage tube to clothing to maintain slight traction on the site.

Correct Answer: 1,2,4

Rationale 1: Bile is irritating to the skin. The area around the tube site should be protected from bile drainage and cleaned frequently.

Rationale 2: Drainage of more than 500 mL in a discharged patient should be reported to the primary health care provider.

Rationale 3: A Fowlers position facilitates drainage best.

Rationale 4: Redness or irritation at the drain site should be reported to the primary health care provider.

Rationale 5: The drainage device and tubing should be positioned to avoid pulling on the tubing.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-6

Question 20

Type: MCMA

A patient asks the nurse about ways to reduce the risk of developing gallstones and cholecystitis. The nurse should discuss which health promotion activities?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Walk for 30 minutes five times a week.

2. Eat a low-fiber, high-calorie diet.

3. Eat a low-cholesterol diet.

4. Eat large amounts of citrus fruits.

5. Lose weight as rapidly as possible.

Correct Answer: 1,3

Rationale 1: Physical activity can help reduce the incidence of cholelithiasis and cholecystitis.

Rationale 2: A high-fiber, low-calorie diet appears to have a protective effect, reducing the incidence of cholelithiasis and cholecystitis.

Rationale 3: Eating a low-cholesterol diet appears to be protective against cholelithiasis and cholecystitis.

Rationale 4: Eating large amounts of citrus fruits is not associated with protection from gallbladder disorders.

Rationale 5: Rapid weight loss can contribute to gallstone formation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-5

Question 21

Type: MCMA

The nurse is teaching a patient about modifiable risk factors for cholelithiasis. Which specific factors would the nurse discuss?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Age

2. Obesity

3. Alternating rapid weight loss with rapid regaining of the weight

4. Family history

5. Elevated serum cholesterol

Correct Answer: 2,3,5

Rationale 1: Age is not a modifiable risk factor.

Rationale 2: Obesity is a modifiable risk factor for cholelithiasis.

Rationale 3: The patient should not lose and gain weight frequently. This is a modifiable risk factor.

Rationale 4: Family history is not a modifiable risk factor.

Rationale 5: Elevated serum cholesterol levels increase the patients risk for developing cholelithiasis. This is a modifiable risk factor.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-5

Question 22

Type: MCSA

A patient in the icteric phase of hepatitis asks the nurse, Why are my stools no longer brown? How should the nurse respond?

1. Your liver isnt making any of the substance that makes stools brown.

2. The bilirubin that causes the coloration is going into your blood and turning your skin yellow.

3. It is being released into your bloodstream and turning your blood darker red.

4. The answer is not known. More research is needed regarding this question.

Correct Answer: 2

Rationale 1: The stools are light brown or clay colored because bile pigment is not excreted through the normal fecal pathway. Instead, the pigment is excreted by the kidneys.

Rationale 2: The icteric (jaundiced) phase usually begins 5 to 10 days after the onset of symptoms. Inflammation of the liver and bile ducts prevents bilirubin from being excreted into the small intestine. Serum bilirubin levels are elevated, causing yellowing of the skin and mucous membranes.

Rationale 3: The blood is not turned darker when bilirubin levels are elevated.

Rationale 4: The cause of this phenomenon is known.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-1

Question 23

Type: MCSA

The nurse is caring for a patient who has just returned from a humanitarian trip to Central America. The patient is jaundiced and is diagnosed with hepatitis A. The patient is the parent of three school-age children. Which statement by the patient is a priority for follow-up?

1. I need to get home to take care of my children.

2. We cared for several very ill people on our trip.

3. I plan to get a lot of rest in the next few days.

4. I am likely to recover fully eventually.

Correct Answer: 1

Rationale 1: The virus is typically found in the feces up to 2 weeks before symptoms occur and the week following the onset of symptoms, but it may remain as long as 3 months. The disease is most contagious at this time. The nurse must teach the patient about prevention of transmission.

Rationale 2: This disease is spread through the fecal-oral route. It is likely the patient contracted the illness on the trip.

Rationale 3: Rest is recommended for the patient with hepatitis A.

Rationale 4: Full recovery is the typical scenario with this illness.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 38-1

Question 24

Type: MCSA

The nurse is caring for a patient with hepatitis C who is treating the illness with licorice root. Which statement by the patient requires follow-up regarding this medication?

1. I feel so tired all the time.

2. My fingers are swollen.

3. I have a dull ache in my abdomen.

4. I have antibodies for hepatitis C in my blood.

Correct Answer: 2

Rationale 1: Feeling tired is expected in a patient with hepatitis C.

Rationale 2: Herbalists may use licorice root to treat hepatitis. It has both antiviral and anti-inflammatory effects. Long-term use of licorice root, however, can lead to hypertension and affect fluid and electrolyte balance. Swollen fingers may be a sign of electrolyte imbalance.

Rationale 3: A dull ache in the abdomen is often seen in patients with hepatitis.

Rationale 4: It is expected that this patient would have antibodies to hepatitis C in the blood.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-1

Question 25

Type: MCSA

The nurse is presenting a community education session on the prevention of liver cancer. Which information should the nurse include?

1. The best way to prevent liver cancer is to catch it early. Liver cancer is easily detected by a physical exam.

2. The best way to prevent liver cancer is by not drinking alcohol and avoiding high-risk behaviors that increase the chances of contracting hepatitis B and C.

3. The best way to prevent liver cancer is to avoid public restaurants, as the cleanliness of the restaurant or the care that is taken in the food preparation cannot be predicted.

4. The best way to prevent liver cancer is to exercise regularly.

Correct Answer: 2

Rationale 1: Catching liver cancer early may help increase the odds of survival, but it is not a prevention method. Liver cancer is also not easily detected by a physical exam at an early stage.

Rationale 2: Avoiding smoking, alcohol, hepatitis B and C, and other known toxins that can cause liver cancer is the most effective way to prevent the disease.

Rationale 3: Avoiding public restaurants would not eliminate exposure to liver cancer-causing agents.

Rationale 4: Regular exercise is not associated with prevention of liver cancer.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-4

Question 26

Type: MCSA

A patient with liver cancer has been admitted to hospice. The patient asks why he developed this disease. The nurse knows there is a high likelihood this patient has which medical history?

1. Alcohol consumption

2. Frequent nausea and vomiting

3. H. pylori

4. Sexually transmitted infections

Correct Answer: 1

Rationale 1: This patient most likely has a past history of alcohol consumption, heavy smoking, hepatitis B or C, or anabolic steroid use.

Rationale 2: There is no correlation between frequent nausea and vomiting and the development of liver cancer.

Rationale 3: There is no correlation between the presence of H. pylori and the development of liver cancer. However, H. pylori can cause more problems with hepatic encephalopathy.

Rationale 4: There is no correlation between sexually transmitted infections and the development of liver cancer.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-4

Question 27

Type: MCSA

A patient is scheduled for a laparoscopic cholecystectomy. The health care provider has indicated that there is a chance that the procedure may need to be done as an open cholecystectomy. The nurse knows that if the patient has an open procedure, what is more likely?

1. The patient may have an increase in bowel movements.

2. The patient may notice more fatty food intolerance.

3. The patient may experience faster recovery.

4. The patient may have a T-tube that will allow drainage of bile.

Correct Answer: 4

Rationale 1: There should be no increase in bowel movements.

Rationale 2: There is no more fatty food intolerance with one type of procedure over another.

Rationale 3: The recovery time is actually longer with an open procedure.

Rationale 4: An open cholecystectomy may require insertion of a T-tube if the common bile duct is explored.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-6

Question 28

Type: MCSA

A patient admitted with acute pancreatitis has a nasogastric tube, is in pain, and is on bed rest. The patient says, I dont understand why I cant eat. How should the nurse respond?

1. Start the patient on a small amount of clear liquids.

2. Explain the purpose of the nasogastric tube and the reasons for keeping the patient NPO.

3. Tell the patient that pain medication is limited to prevent addiction.

4. Tell the patient that IV fluids are sufficient for now.

Correct Answer: 2

Rationale 1: As long as the pain continues, the pancreas should be rested by restricting food.

Rationale 2: The patient must understand the purpose of the treatment plan. Explaining the need for being NPO is important.

Rationale 3: Addiction should not be a factor in treating patients in acute pain.

Rationale 4: Saying that IV fluids are sufficient is dismissive of the patients concern. If the patient is receiving TPN, that should be explained. If the patient is only receiving fluids, they are not sufficient to sustain life over the long term.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-9

Question 29

Type: MCSA

A patient with chronic pancreatitis is taking pancreatic enzymes. Which statement would indicate to the nurse that the patient correctly understands instruction about this medication?

1. I should take this medication right before bedtime.

2. This medication is monitored by the lab work.

3. I take this medication only when my stomach is hurting.

4. I will take this medication with food.

Correct Answer: 4

Rationale 1: Pancreatic enzymes should be taken with meals.

Rationale 2: There are no particular lab tests that monitor pancreatic enzymes.

Rationale 3: Pancreatic enzymes need to be taken on a regular schedule, not just when the patient is experiencing symptoms.

Rationale 4: Pancreatic enzymes must be taken with food.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 38-9

Question 30

Type: MCSA

A patient is admitted with acute pancreatitis. The nurse recognizes that nutritional outcomes have been met after assessing which finding regarding the patients weight?

1. Has increased 0.5 pounds over 1 week

2. Has increased 1 pound over the past day

3. Has decreased 2 pounds over 1 week

4. Has decreased 2 pounds over the past day

Correct Answer: 1

Rationale 1: The overall nutritional outcome for this patient is to not lose weight. Thus, a weight gain of 0.5 pounds over 1 week meets this goal.

Rationale 2: Nutritional status is reflected over 1 week, whereas fluid status is reflected from day to day. A 1-pound weight gain over the past day is likely fluid.

Rationale 3: The overall nutritional outcome for this patient is to not lose weight. The 2-pound loss over 1 week reflects a net nutritional loss.

Rationale 4: Nutritional status is reflected over 1 week, whereas fluid status is reflected from day to day. A decrease of 2 pounds over the past day indicates fluid loss.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 38-7

Question 31

Type: MCMA

The nurse is caring for a patient with pancreatic cancer. The nurse closely monitors for jaundice, knowing that which assessments closely correlate with jaundice?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pruritus

2. Pain

3. Vision disturbances

4. Nausea

5. Skin lesions

Correct Answer: 1,5

Rationale 1: Pruritus usually accompanies jaundice. Therefore, the patient may also require care for itching to avoid damaging the skin.

Rationale 2: Pain does not accompany jaundice.

Rationale 3: Vision disturbances do not accompany jaundice.

Rationale 4: Nausea may accompany pancreatic cancer but is not necessarily associated with jaundice.

Rationale 5: Skin lesions may result from scratching.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-7

Question 32

Type: MCSA

Often a patient with pancreatic cancer tends to lose weight due to the inability of the body to absorb nutrients. The nurse instructs the patient to be alert to which finding that may indicate malabsorption?

1. Vomiting

2. Jaundice

3. Steatorrhea

4. Pain

Correct Answer: 3

Rationale 1: Vomiting does not necessarily indicate malabsorption.

Rationale 2: Jaundice does not necessarily correlate to malabsorption.

Rationale 3: Steatorrhea is loose, fatty, foul-smelling stools caused by a lack of the enzyme lipase. Lipase is needed to digest fats.

Rationale 4: Pain is neither a result nor the cause of malabsorption.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-8

Question 33

Type: MCSA

A patient with end-stage pancreatic cancer is admitted to the nursing unit. The patient is lethargic and jaundiced. What is the priority nursing care for this patient?

1. Manage nutrition.

2. Increase activity.

3. Manage comfort.

4. Understand the effects of high bilirubin levels.

Correct Answer: 3

Rationale 1: Managing nutrition is no longer the primary intervention in caring for patients with end-stage pancreatic cancer.

Rationale 2: This patient should not be asked to increase activity.

Rationale 3: A patient with end-stage pancreatic cancer who is lethargic and jaundiced will need comfort management and palliative care.

Rationale 4: Understanding the effects of high bilirubin levels is not a primary care objective for this patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 38-8

Question 34

Type: MCSA

The nurse is preparing a patient with pancreatitis for discharge to home. The nurse is instructing the patient about decreasing pancreatic stimulation to reduce pain. What method should the nurse suggest?

1. Minimize exposure to light.

2. Stay in an upright position.

3. Avoid the smell of food.

4. Increase household noise and stimulation.

Correct Answer: 3

Rationale 1: Exposure to light has no effect on pancreatic stimulation.

Rationale 2: Staying in an upright position will not affect pancreatic stimulation.

Rationale 3: The smell of food helps to stimulate pancreatic secretions. Limiting the opportunity to smell food will help reduce pancreatic secretions.

Rationale 4: Minimizing rather than increasing stimulations such as household noise and activity will reduce pancreatic secretions.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-9

Question 35

Type: MCSA

A patient arrives at the clinic for follow-up care for pancreatitis. The patient lives alone, has high cholesterol levels, and admits to alcoholism. What is the priority intervention for this patient?

1. Provide information on alcohol cessation programs.

2. Provide teaching about dietary needs.

3. Remind the patient of the implications of recurring jaundice.

4. Provide initial instruction on medication.

Correct Answer: 1

Rationale 1: This patient will need continuing support for the alcohol problem. Providing information regarding alcohol cessation programs will be a priority intervention.

Rationale 2: Discussing dietary needs is important but is not the biggest priority.

Rationale 3: Teaching the patient about symptoms that indicate the need to seek medical assistance is very important but is not the biggest priority.

Rationale 4: Medication instruction would have been provided prior to discharge. At this point reinforcement may be necessary, but this is not the highest priority.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 38-9

 

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