Chapter 6 challenge

1. Chapter 6 challenge Patti Hamilton

2. 1. Nurses, as well as other health care providers, are at risk for hepatitis B. For prophylaxis to be most effective in these workers: • 1. prophylaxis must be instituted before exposure. • 2. prophylaxis can be instituted either before or after exposure. • 3. prophylaxis must be instituted after exposure. • 4. prophylaxis instituted before or after is effective forever. • Answer – 1. prophylaxis must be instituted before exposure. • Rationale – The hepatitis vaccine has been shown to provide protection in approximately 90% of people vaccinated before exposure.

3. 2. Liver needle biopsy is a safe, simple and valuable method of diagnosing pathologic liver conditions. However, the nurse must anticipate possible complications, including which of the following diagnoses? • 1. Pain, related to leakage of blood and bile into the peritoneal cavity. • 2. Noncompliance, of medications, related to testing procedure. • 3. Social isolation, related to tissue sample being removed for biopsy. • 4. Disturbed sleep pattern, related to lack of information on hospital protocol. • Answer – 1. pain, related to leakage of blood and bile into the peritoneal cavity. • Rationale – when leakage involves a large quantity of blood or bile, the peritoneal reaction is great and the resulting pain is severe. The nurse should report these signs immediately to the physician.

4. 3. Mr. B., a 78 year old patient, is admitted with common bile duct obstruction related to cancer of the pancreas. Choose all of the clinical manifestations the nurse would expect to assess. • 1. Brown feces. • 2. Scleral icterus • 3. Dark tea colored urine • 4. Jaundice • Answer – 2. Scleral icterus, 3. Dark tea colored urine, 4. Jaundice. rationale – With common bile duct obstruction the patient will become jaundice resulting in scleral icterus. The urine may be dark amber or tea colored and contain urobilinogen as the kidneys try to remove excess billirubin from the blood stream.

5. 4. It is especially important for the patient to cough and deep breathe postoperatively following an open cholecystectomy because: • 1. the patients are often obese. • 2. the patients usually smoke. • 3. the patient is on bed rest for a more prolonged period. • 4. the patient tends to take shallow breaths due to placement of the incision. • Answer – 4. the patient tends to take shallow breaths due to placement of the incision. • Rationale – to prevent pneumonia and atelectasis

6. 5. In hepatic encephalopathy, when the nurse requests that the patient stretch out the arm and hyperextend the wrist with the fingers separated, relaxed, and extended to whether rapid, irregular flexion and extension(flapping) of the wrist occur, the nurse is assessing for the presence of: • 1. varices • 2. asterixis • 3. pruritus • 4. bacterial toxins • Answer – 2. asterixis • Rationale – these are signs and symptoms of asterixis, patients who present with these symptoms are acutely ill with Hepatic encephalopathy, a type of brain damage caused by liver disease.

7. 6. Mr. E. has advanced cirrhosis of the liver. What type of food might you expect to find limited in his diet? • 1. fruits • 2. vegetables • 3. meats • 4. carbohydrates • Answer – 3. meats • Rationale – With impending liver failure, protein will be restricted because of the livers inability to synthesize plasma proteins. The liver will become clogged.

8. 7. Patients with liver abscess present with vague signs and symptoms, which are often: • 1. asterixis, ascites, esophageal varices. • 2. fever accompanied by chills, abdominal pain, and tenderness in right upper quadrant. • 3. enlarged spleen, spider telangiectases. • 4. constipation, left quadrant abdominal cramping and loud, high-pitched abdominal sounds upon auscultation. • Answer – 2. fever accompanied by chills, abdominal pain and tenderness in right upper quadrant. • Rationale – Patients with liver abscess present with signs and symptoms similar to the flu. Tenderness in the right upper quadrant of the abdomen would be a sign that the liver may be involved.

9. 8. A small number of patients who have had a laparoscopic cholecystectomy report mild pain resulting from: • 1. paralytic ileus with mesenteric irritation. • 2. incision along the rectus abdominis muscle. • 3. diaphragmatic irritation secondary to residue carbon dioxide. • 4. spasm of the duct of Wirsung. • Answer – 3. diaphragmatic irritation secondary to residue carbon dioxide. • Rationale – During a laparoscopic cholecystectomy the abdominal cavity is inflated with 3 to 4 L of carbon dioxide to improve visibility.

10. 9. Ms. F. has been admitted with right upper quadrant pain and has been placed on a low-fat diet. Which of the following trays would be acceptable for her? • 1. whole milk, veal, rice and pastry. • 2. liver, fried potatoes, gelatin and avocado. • 3. skim milk, lean fish, tapioca pudding, and fruit. • 4. ham, mashed potatoes, creamed peas, and gelatin. • Answer – 3. skim milk, lean fish, tapioca pudding and fruit. • Rationale – low fat diets include skim milk, seafood, lean meats (chicken), fruits and veggies. Pudding may be served if made with skim milk.

11. 10. Hepatitis types B, C, D, and G are spread mainly through all of the following except: • 1. blood transfusions. • 2. contaminated needles and instruments. • 3. direct contact with body fluids, from infected people, such as through breast milk and sexual contact. • 4. oral-fecal route • Answer – 4. oral-fecal route • Rationale – Hepatitis A and E are spread through the oral-fecal route. Hepatitis B, C, D, G are spread from all of the above.

12. 11. In patients with acute pancreatitis, the administration of the analgesic morphine may cause: • 1. paralytic ileus • 2. addiction • 3. urinary retention • 4. spasms of the sphincter of Oddi • Answer – 4. spasm of the sphincter of Oddi • Rationale – Morphine increases the intralumenal pressure in the sphincter of Oddi causing it to spasm.

13. 12. A patient is scheduled for surgery for a common bile exploration. The nurse would expect the patient to return from surgery with: • 1. an underwater-seal drainage. • 2. a T-tube connected to gravity drainage. • 3. a penrose drain • 4. a nephrostomy tube. • Answer – 2. A T-tube connected to gravity drainage. • Rationale – Common bile exploration is performed through the use of a T-shaped rubber tube that the surgeon placed in the bile duct during the operation. Through the end of the T-tube that exits through the abdominal wall, dye can be injected and radiographic film taken. After the test the T-tube may be left in place to a sterile closed-drainage system.

14. 13. Which types of hepatitis now have vaccines for prevention? • 1. B only • 2. B and D • 3. A and B • 4. A,B,C,D,E, and G • Answer – 3. A and B • Rationale – Hepatitis A vaccine consists of 2 doses. 1 dose initially and then a booster 6-12 mos. later. Hepatitis B vaccine consists of 3 doses. 1 dose initially, then 1 dose 1 month later and a 3rd dose 6 mos. Later. No vaccines are available for Hepatitis C,D,E,and G.

15. 14. The nursing intervention of the patient with cholecystitis associated with cholelithiasis is based on the knowledge that: • 1. the disorder can be successfully treated with oral bile salts that dissolve gallstones. • 2 morphine is the drug of choice to relieve the pain of bile duct spasms during an acute attack. • 3. a heavy meal with a high fat content may precipitate the signs and symptoms of the disease. • 4. a low cholesterol diet is indicated to reduce the availability of cholesterol for gallstone formation. • Answer – 3. a heavy meal with a high fat content may precipitate the signs and symptoms of the disease. • Rationale – Subjective data includes complaints of indigestion after eating food high in fat. The pain is abrupt in onset, reaches a peak intensity quickly, and remains at that level for 2 – 4 hours.

16. 15. Teaching in relation to home management following laparoscopic cholecystectomy should include: • 1. keeping the bandages on the puncture sites for 48 hours. • 2. reporting any bile-colored drainage or pus from any incision. • 3. using over-the-counter antiemetics if nausea and vomiting occur. • 4. emptying and measuring the contents of the bile bag from the T-tube every day. • Answer – 2. reporting any bile-colored drainage or pus from any incision. • Rationale – Bile colored drainage indicates incomplete clipping of the cystic duct. Pus indicates infection. Drainage into the abdomen increases the risk of peritonitis.

17. 16. A patient with advanced cirrhosis asks the nurse why his abdomen is so swollen. The nurse’s response to the patient is based on the knowledge that: • 1. a lack of clotting factors promotes the collection of blood in the abdominal cavity. • 2. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. • 3. decreased peristalsis in the GI tract contributes to gas formation and bowel distention. • 4. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid. • Answer – 2. Portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. • Rationale – The livers inability to synthesize albumin as a result of liver damage causes hypoalbuminemia. The Obstruction of the portal vein from inflammation results in portal hypertension.

18. 17. When caring for a patient with hepatic encephalopathy the nurse may give enemas, provide a low-protein diet, and limit physical activity. These measures are done to: • 1. promote fluid loss • 2. eliminate potassium loss. • 3. decrease portal pressure. • 4. decrease the production of ammonia • Answer – 4. decrease the production of ammonia • Rationale – Hepatic encephalopathy is a type of brain damage caused by liver disease and consequent ammonia intoxication. A very low protein diet inhibits the production of ammonia.

19. 18. In planning care for a patient with metastatic cancer of the liver, the nurse includes interventions that: • 1. focus primarily on symptomatic and comfort measures. • 2. reassure the patient that chemotherapy offers a good prognosis for recovery. • 3. promote the patient’s confidence that surgical excision of the tumor will be successful. • 4. provide information necessary for the patient to make decisions regarding liver transplantation. • Answer – 1. focus primarily on symptomatic and comfort measures. • Rationale – The prognosis for cancer of the liver is poor. Death may occur within 4 -7 mos. Focus is on keeping the patient as comfortable as possible.

20. 19. Patients who receive a liver transplant secondary to viral B or C hepatitis often experience _________ or __________ of the transplanted liver. • Answer – reinfection and cirrhosis • rationale – Statistics show that patients who have liver disease secondary to viral hepatitis experience reinfection of the transplanted liver. With Hepatitis B or C approximately 20% to 30% of patients will develop cirrhosis of the transplanted liver by the 5th year post-transplant.