Chaps 46: Liver, Pancreas and Biliary Tract Problems

Question 1

A physician who has never been immunized for hepatitis B is exposed to the hepatitis B virus (HBV) through a needle stick from an infected patient. What should the infection control nurse inform both the physician and patient that treatment for the exposure should include?

a. Evaluation of liver function tests in 60 days
b. Active immunization with hepatitis B vaccine
c. Hepatitis B immunoglobulin (HBIG) injection
d. Both the hepatitis B vaccine and HBIG

Answer 1

ANS: D
The recommended treatment for exposure to hepatitis B in unvaccinated individuals is to receive both HBIG and the hepatitis B vaccine, which would provide temporary passive immunity and promote active immunity

Question 2

A patient contracts hepatitis from food contaminated by a worker with hepatitis in a fast-food restaurant. During the icteric phase of the patient’s illness, what should the nurse expect serological testing to reveal?

a. HBsAg (hepatitis B surface antigen)
b. Anti-HBc IgM (antibody to HBV core antigen)
c. Anti-HAV IgG (antibody to hepatitis A virus, immunoglobulin G)
d. Anti-HAV IgM (antibody to hepatitis A virus, immunoglobulin M)

Answer 2

ANS: D
Hepatitis A virus (HAV) is transmitted through the oral–fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A.

Question 3

While the nurse is obtaining a nursing history from a patient diagnosed with hepatitis C, what information reported by the patient indicates the highest risk factor for hepatitis C?

a. Sexual exposure
b. Injection drug use
c. Eating contaminated shellfish
d. Recent travel to an underdeveloped country

Answer 3

ANS: B

One of the highest risk factors for contracting hepatitis C is injection drug use.

Question 4

During evaluation of a patient at an outpatient clinic, the nurse determines that administration of hepatitis B vaccine has been effective when a specimen of the patient’s blood reveals which of the following results?

a. HBsAg
b. Anti-HBs (antibody to hepatitis B surface antigen)
c. Anti-HBcAg (antibody to hepatitis B core antigen)
d. Anti-HBc IgM (antibody to hepatitis B core antigen, immunoglobulin M)

Answer 4

ANS: B

The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine.

Question 5

Serological testing of a patient reveals the presence of antibodies to the hepatitis C virus (anti-HCV). Which following nursing action is appropriate?

a. Schedule the patient for HCV genotype testing.
b. Teach the patient that the HCV infection will resolve in 2 to 4 months.
c. Administer immunoglobulin and the HCV vaccine.
d. Instruct the patient on self-administration of -interferon.

Answer 5

ANS: A
Genotyping of HCV has an important role in managing treatment and is done before drug therapy with -interferon or other medications is started.

Question 6

A person who is homeless is hospitalized with severe anorexia and fatigue. She has mild jaundice and hepatomegaly, and her liver function tests are abnormal. The physician suspects viral hepatitis. In planning care for the patient, to which patient outcome should the nurse assign the highest priority?

a. Maintains adequate nutrition
b. Adapts to changes in appearance
c. Gradually increases tolerance for activity
d. Identifies source of exposure to hepatitis virus

Answer 6

ANS: A
The highest priority outcome is to maintain nutrition and collaborate with health care providers and family to provide an appropriate diet so that proper nutritional requirements can be provided.

Question 7

A patient with acute hepatitis B asks the nurse if treatment is available for the condition. What should the nurse explain to the patient?

a. Patients with acute hepatitis B can be given HBIG to help reduce the symptoms.
b. A variety of antiviral medications are available to treat acute hepatitis B, but serious side effects limit their use.
c. No medication is available for treatment of HBV infection.
d. Chronic HBV infection can be treated with interferon and lamivudine (Heptovir) and adefovir (Hepsera).

Answer 7

ANS: C
No drug therapies are available to treat acute hepatitis, although -interferon and nucleoside analogues (i.e., lamivudine) may be used to treat chronic hepatitis B.

Question 8

Combination therapy of -interferon and ribavirin (Rebetol) is being used to treat hepatitis C in a patient infected with human immunodeficiency virus (HIV). What will the nurse monitor for in the patient?

a. Blood glucose
b. Lymphocyte count
c. Potassium level
d. Serum creatinine

Answer 8

ANS: B
HCV treatment with a combination of interferon and ribavirin may reduce CD4+ counts, worsen leukopenia, and increase the patient’s risk for anemia. HIV medications may have to be altered because of the potential for drug interactions between some HIV medications and ribavirin.

Question 9

During the acute phase of hepatitis, what would the nurse expect the patient’s laboratory results to include?

a. Increased stool urobilinogen
b. Decreased urinary urobilinogen
c. Decreased prothrombin time
d. Increased total serum bilirubin

Answer 9

ANS: D

During the acute phase of hepatitis, the nurse would expect the patient to have an increase in total serum bilirubin.

Question 10

A 68-year-old patient has an abrupt onset of anorexia, nausea and vomiting, hepatomegaly, and abnormal liver function studies. Serological testing is negative for viral causes of hepatitis. During assessment of the patient, what is it most important for the nurse to ask the patient about?

a. Any prior exposure to people with jaundice
b. The use of all prescription and over-the-counter medications
c. Treatment of chronic diseases with corticosteroids
d. Exposure to children recently immunized for hepatitis B

Answer 10

ANS: B
The patient’s symptoms, the lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol).

Question 11

When teaching a patient recovering from hepatitis B about management of the illness, the nurse determines that additional teaching is needed when the patient makes which of the following statements?

a. “I should not drink alcohol for at least a year.”
b. “When I have recovered from this infection, I should have lifelong immunity to the virus.”
c. “When the jaundice is gone, I have recovered from my illness and the infection is cured.”
d. “I should use a condom during sexual intercourse until my tests for the virus are negative.”

Answer 11

ANS: C

After the acute (icteric) phase, there is a convalescent phase lasting several months

Question 12

The nurse assesses a patient with cirrhosis and finds 4+ pitting edema of the feet and legs and massive ascites. The data indicate that the nurse should monitor which of the following?

a. Temperature
b. Albumin level
c. Hemoglobin
d. Activity level

Answer 12

ANS: B
The low oncotic pressure caused by hypoalbuminemia is a major pathophysiological factor in the development of ascites and edema.

Question 13

A 32-year-old patient has early alcoholic cirrhosis diagnosed by a liver biopsy. In teaching the patient about the disease, it important for the nurse to inform her that the disease may be reversed at this point with which of the following interventions?

a. Vitamin B supplements
b. Abstinence from alcohol
c. Maintenance of a nutritious diet
d. Long-term, low-dose corticosteroids

Answer 13

ANS: B

The disease progression can be stopped or reversed by alcohol abstinence.

Question 14

Which hepatitis virus has DNA as its characteristic virus type?

a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis E

Answer 14

ANS: B

Hepatitis B virus has DNA as the virus type; all of the others have RNA as the virus type.

Question 15

When assessing a patient for signs of impending coma resulting from hepatic encephalopathy, what should the nurse ask the patient to do?

a. Stand on one foot.
b. Extend both arms.
c. Ambulate with the eyes closed.
d. Perform the Valsalva manoeuvre.

Answer 15

ANS: B

Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy.

Question 16

When lactulose (Cephulac) 30 mL four times per day is ordered for a patient with advanced cirrhosis, he complains that it causes diarrhea. The nurse explains to the patient that it is still important for him to take the drug because the drug will create which of the following actions?

a. Promote fluid loss
b. Prevent constipation
c. Prevent gastrointestinal (GI) bleeding
d. Improve nervous system function

Answer 16

ANS: D
The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although the medication may promote fluid loss through the stool, prevent constipation, and prevent bearing down during bowel movements (which could lead to esophageal bleeding), the medication is not ordered for these purposes for this patient

Question 17

A patient with advanced liver disease has marked ascites and signs of hepatic encephalopathy. Following instruction about his diet, the nurse determines that teaching has been effective when the patient’s choice of foods from the menu includes which of the following?

a. Cheese omelette with mushrooms and milk
b. Pancakes with butter and honey and orange juice
c. Baked beans with ham, cornbread, sweet potatoes, and coffee
d. Baked chicken with French-fried potatoes, low-protein bread, and tea

Answer 17

ANS: B
The patient with acute hepatic encephalopathy is placed on a low-protein diet to decrease ammonia levels; therefore, the best choice is pancakes with butter and honey and orange juice

Question 18

A patient with cirrhosis has a massive hemorrhage from esophageal varices. In planning care for the patient, to what goal does the nurse give the highest priority?

a. Control of the bleeding
b. Maintenance of the airway
c. Maintenance of fluid volume
d. Relief of the patient’s anxiety

Answer 18

ANS: B
Maintaining gas exchange has the highest priority because oxygenation is essential for life. The airway is compromised by the bleeding in the esophagus, and aspiration easily occurs.

Question 19

During treatment of a patient with a Minnesota balloon tamponade for bleeding esophageal varices, what nursing responsibilities should be included?

a. Encourage the patient to cough and breathe deeply.
b. Insert the tube and verify its position every 4 hours.
c. Monitor the patient for shortness of breath.
d. Deflate the gastric balloon every 8 to 12 hours.

Answer 19

ANS: C
If the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway; therefore, it is important for the nurse to monitor the patient for shortness of breath.

Question 20

A patient with cirrhosis has an episode of bleeding esophageal varices that is controlled with administration of vasopressin and endoscopic sclerotherapy. To detect possible complications of the bleeding episode, what is it most important for the nurse to monitor?

a. Prothrombin time
b. Serum bilirubin levels
c. Serum ammonia levels
d. Serum potassium levels

Answer 20

ANS: C
The blood in the GI tract will be absorbed as protein and may result in an increase in ammonia level because the liver cannot metabolize protein well.

Question 21

The nurse identifies a nursing diagnosis of risk for impaired skin integrity for a patient with cirrhosis who has ascites and 4+ pitting edema of the feet and legs. What is an appropriate nursing intervention for this problem?

a. Restrict dietary protein intake.
b. Turn the patient every 4 hours.
c. Perform passive range of motion four times per day.
d. Arrange for a special pressure-relieving mattress.

Answer 21

ANS: D

The pressure-relieving mattress will decrease the risk for skin breakdown for this patient

Question 22

A shunting procedure is considered for a patient with cirrhosis following an episode of bleeding esophageal varices. The nurse understands which of the following about these procedures?

a. They improve patient survival rates.
b. They increase the risk of hepatic encephalopathy.
c. They require surgery to redirect blood flow around the liver.
d. They are first-line therapies for portal hypertension and esophageal varices.

Answer 22

ANS: B
The risk for hepatic encephalopathy increases after shunt procedures because blood bypasses the portal system and ammonia is diverted past the liver and into the systemic circulation.

Question 23

A patient with cancer of the liver has severe ascites that is causing shortness of breath and difficulty breathing. The physician plans a paracentesis to relieve the fluid pressure on the diaphragm. To prepare the patient for the procedure, what should the nurse do?

a. Ask the patient to empty the bladder.
b. Position the patient flat on the right side.
c. Obtain informed consent for the procedure.
d. Have the patient lie flat with a small pillow under the small of the back.

Answer 23

ANS: A

The patient should empty the bladder to decrease the risk of bladder perforation during the procedure.

Question 24

When interpreting HBV serological profile results, the nurse would anticipate the hepatitis B surface antigen (HBsAg) to be positive in which one of the following circumstances?

a. Chronic infection
b. Immunity from vaccination
c. Past exposure
d. Occult HBV infection

Answer 24

ANS: A
When interpreting HBV serological profile results, the nurse would anticipate the HBsAg to be positive in both acute and chronic infection.

Question 25

A patient hospitalized with possible acute pancreatitis has severe abdominal pain and nausea and vomiting. Which of the following elevated serum levels would the nurse expect the diagnosis to be confirmed by?

a. Calcium
b. Bilirubin
c. Potassium
d. Amylase

Answer 25

ANS: D

Amylase is elevated early in acute pancreatitis

Question 26

In planning care for a patient with acute pancreatitis, to which of the following patient outcomes would the nurse assign the highest priority?

a. Develops no complications
b. Maintains normal respiratory function
c. Expresses satisfaction with pain control
d. Maintains adequate fluid and electrolyte balance

Answer 26

ANS: B
Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal.

Question 27

The nurse knows that levels of which one of the following should be monitored when the patient is receiving adefovir?

a. Potassium
b. Sodium
c. Creatinine
d. Urea

Answer 27

ANS: C
Serum creatinine levels should be monitored, especially in patients at risk, including those with pre-existing renal disease and those taking nephrotoxic drugs.

Question 28

The nurse identifies the collaborative problem of “potential complication: electrolyte imbalance” for a patient with severe acute pancreatitis. What assessment findings would alert the nurse to electrolyte imbalances associated with acute pancreatitis?

a. Hypotension
b. Hyperglycemia
c. Muscle cramps and tetany
d. Paralytic ileus and abdominal distension

Answer 28

ANS: C

Muscle cramps and tetany indicate hypocalcemia, a potential complication of acute pancreatitis.

Question 29

When obtaining a health history from a patient with acute pancreatitis, what history should the nurse specifically ask the patient about?

a. Smoking
b. Alcohol use
c. Diabetes mellitus
d. High-fat dietary intake

Answer 29

ANS: B

Alcohol use is one of the most common risk factors for pancreatitis

Question 30

The physician prescribes pancreatin (Viokase) for a patient with chronic pancreatitis. The nurse teaches the patient that the drug is considered effective if the patient experiences which of the following findings?

a. Normal stools
b. Decreased jaundice
c. An improved appetite
d. Decreased abdominal pain

Answer 30

ANS: A
The patient’s steatorrhea should improve if the treatment with pancreatic enzymes is effective, and the patient would experience normal stools

Question 31

Which nursing diagnosis is a priority when the nurse is caring for the patient with pancreatic cancer?

a. Chronic pain related to tumour pressure on abdominal structures
b. Imbalanced nutrition: less than required related to anorexia
c. Impaired skin integrity related to itching secondary to jaundice
d. Grieving related to potentially terminal diagnosis

Answer 31

ANS: A
All of these nursing diagnoses are appropriate for a patient with pancreatic cancer, but treating the patient’s pain is the priority because the patient will be unable to meet outcomes for the other nursing diagnoses unless the pain is controlled.

Question 32

32. A patient is admitted to the hospital with a sudden onset of severe right upper quadrant pain that radiates to the right shoulder. She has a history of fat intolerance and heartburn. The nurse recognizes that the patient most likely has a biliary tract obstruction when the patient reports experiencing which of the following?
    a. Spider angiomas
    b. Clay-coloured stools
    c. Dilute, bright-yellow urine
    d. Epigastric pain relieved by vomiting

Answer 32

ANS: B

The clay-coloured stools indicate biliary obstruction, which requires rapid intervention to resolve.

Question 33

When caring for a patient following an incisional cholecystectomy for cholelithiasis, on what patient outcome should the nurse place the highest priority?

a. Turning, coughing, and deep-breathing every 2 hours to prevent respiratory complications
b. Choosing low-fat foods from the menu to prevent weight gain
c. Performing leg exercises every hour while awake to prevent foot drop
d. Ambulating the evening of the operative day to prevent constipation

Answer 33

ANS: A
Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing.

Question 34

Although acetaminophen is a common analgesic that patients consume, it does have toxic effects. When teaching a patient about acetaminophen use, the nurse tells the patient that doses in excess of how many grams a day lead to acute liver failure?

a. 2 g
b. 5 g
c. 7.5 g
d. 10 g

Answer 34

ANS: D

Ingestion of more than 10 grams per day of acetaminophen leads to acute liver failure.

Question 35

When providing discharge instructions to a patient following a laparoscopic cholecystectomy at an outpatient surgical centre, the nurse recognizes that teaching has been effective when the patient makes which of the following comments?

a. “I should plan to limit my activities and not return to work for 4 to 6 weeks.”
b. “I can expect some reddish yellow drainage from the incisions for a few days.”
c. “I should remove the bandages on my incisions tomorrow and take a shower.”
d. “I will always need to maintain a low-fat diet because I no longer have a gallbladder.”

Answer 35

ANS: C
After a laparoscopic cholecystectomy, the patient will have bandages in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living.

Question 36

Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of most concern?

a. The patient’s skin has multiple spider-shaped blood vessels on the abdomen.
b. The patient has ascites and a 2-kg weight gain from the previous day.
c. The patient complains of right upper quadrant pain with abdominal palpation.
d. The patient’s hands flap back and forth when the arms are extended.

Answer 36

ANS: D

The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur.

Question 37

A patient with severe cirrhosis has a new prescription for propranolol (Inderal). The nurse will teach the patient that the medication is ordered to do which one of the following?

a. Decrease systemic blood pressure (BP)
b. Prevent the development of ischemia
c. Lower the risk for bleeding varices
d. Reduce fluid retention and edema

Answer 37

ANS: C
-Adrenergic blockers have been shown to decrease the risk for bleeding in esophageal varices. Although propranolol will reduce BP and prevent cardiac ischemia, these are not the purposes for this patient

Question 38

Management of ascites is focused on which one of the following actions?

a. Limiting intake
b. Sodium restriction
c. Administering antibiotics
d. Ensuring adequate rest

Answer 38

ANS: B

Management of ascites is focused on sodium restriction, diuretics, and fluid removal

Question 39

When taking the BP of a patient with severe acute pancreatitis, the nurse notices carpal spasm of the patient’s hand. Which action should the nurse take next?

a. Notify the physician immediately.
b. Retake the patient’s BP.
c. Check the calcium level on the chart.
d. Ask the patient about any arm pain.

Answer 39

ANS: C
The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau sign.

Question 40

A patient is admitted with a diagnosis of hepatic encephalopathy with the following symptoms: lethargy, drowsiness, disorientation, asterixic with abnormal reflexes. Which grade on the scale for hepatic encephalopathy would the nurse document for this patient?

a. Grade 1
b. Grade 2
c. Grade 3
d. Grade 4

Answer 40

ANS: B

The nurse would document this patient’s hepatic encephalopathy as being grade 2.

Question 41

When the nurse is caring for a patient with acute pancreatitis, which of these assessment data should be of most concern?

a. Absent bowel sounds
b. Abdominal tenderness
c. Left upper quadrant pain
d. Palpable abdominal mass

Answer 41

ANS: D
A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis.