Preview Extract
Chapter 46
1. A nurse gives a client with hepatitis A discharge instructions. This client works at a local
pizza restaurant and has been ill for a few days. There have been six more cases of hepatitis A
admitted in the last 2 days. The nurse carefully explains hand-washing techniques to this
client. The nurse recognizes that the most likely way this client could have infected others is:
1. Through the fecal−oral route at the restaurant.
2. Through blood contact.
3. Through sexual contact.
4. Unable to be determined; the spread of hepatitis A is unknown
Answer: Through the fecal−oral route at the restaurant
Rationale:
Hepatitis A is most commonly transmitted via the fecal−oral route; it can be transmitted via
oral sex and via blood contact, but this is less likely given the client’s job at the restaurant.
2. A client is admitted to an acute care facility with acute onset of hepatitis B. In an effort to
best determine the route of transmission, the nurse asks which of the following questions?
1. “Do you use IV drugs?”
2. “Do you wash your hands frequently?”
3. “Are you married?”
4. “Have you been vaccinated against hepatitis B?”
Answer: “Do you use IV drugs?”
Rationale:
The nurse needs to determine if the client is an IV drug user. Hepatitis B is most commonly
transmitted via blood and body fluids, but can also be transmitted via inanimate objects
because the virus can live for up to a week on surfaces. Washing hands is a method of
prevention for hepatitis A. Marital status doesn’t preclude someone from being exposed to the
virus. There is a vaccine for hepatitis B.
3. A client is seen in the public health clinic for symptoms of hepatitis. The nurse is
questioning the client regarding exposure. The client provides the following information: a
recent missionary trip to Africa; involved in a monogamous heterosexual relationship for 25
years; no history of IV drug use; blood transfusions 5 years ago. What is the most likely type
of hepatitis for this client?
1. Hepatitis A
2. Hepatitis B
3. Hepatitis C
4. Hepatitis G
Answer: Hepatitis A
Rationale:
Hepatitis A is found in contaminated water, which may be found in various locations in
Africa the client visited. While the client could be hiding the truth about other high-risk
behaviors, the client does have the one risk factor that is a possibility for hepatitis A. While
the client received blood 5 years ago, this should not be a risk factor for hepatitis, though it
still might be for HIV. There are no risk factors indicated for hepatitis B, C, or G.
4. A young client is seen in the public health department for flulike symptoms. The nurse
suspects hepatitis. The nurse knows that the client may likely develop jaundice:
5. 5 to 10 days after the initial flulike symptoms.
6. 2 weeks after exposure.
7. 2 to 3 weeks after getting ill.
8. Up to 16 weeks after the initial exposure.
Answer: 5 to 10 days after the initial flulike symptoms.
Rationale:
The prodromal stage begins 2 weeks after exposure. The icteric stage begins 5 to 10 days
after the initial flulike symptoms. This is when the client might develop jaundice. The
convalescent phase begins 2 to 3 weeks after the symptoms begin, and recovery may take up
to 16 weeks.
5. A client presents to the emergency department (ED) complaining of poor appetite,
jaundice, low-grade fever, and pain in the right upper quadrant. The nurse is performing an
admission assessment. The nurse recognizes these symptoms as:
1. Similar for all of the hepatitis viruses.
2. Hepatitis A.
3. Hepatitis B.
4. Hepatitis C.
Answer: Similar for all of the hepatitis viruses.
Rationale:
The symptoms for the varying types of hepatitis are all very similar and cannot be
distinguished without lab work.
6. A client is seen in the clinic complaining of fatigue, joint pain, and lack of appetite. The
health care provider (HCP) suspects hepatitis in the prodromal phase based upon the client’s
signs and symptoms and history. What other symptoms might the HCP find?
1. Fever
2. Jaundice
3. Severe abdominal pain
4. Dark urine
Answer: Fever
Rationale:
Fever is another symptom the HCP may find in the prodromal phase of hepatitis. Jaundice
and dark urine that results from jaundice occur in the icteric phase. In the prodromal phase,
mild constant abdominal pain is sometimes present, but not severe abdominal pain.
7. A client presents to the emergency department with bleeding esophageal varices. The nurse
also initially assesses the client for which of the following?
1. Ascites
2. Hypertension
3. Cardiac disease
4. Activity intolerance
Answer: Ascites
Rationale:
The client’s esophageal varices indicate that the client has portal hypertension, which is
different than typical hypertension. Portal hypertension also causes ascites. The client may or
may not be at risk for cardiac disease. Activity intolerance is likely, but is not an initial
assessment.
8. The nurse notes that the client admitted with cirrhosis is more anxious than usual. The
client has ascites and has had a poor appetite. The client states, “I can’t breathe.” The nurse’s
most appropriate initial response is to:
5. Evaluate the respiratory status.
6. Contact the health care provider.
7. Assess the abdomen.
8. Give the client his medication.
Answer: Evaluate the respiratory status.
Rationale:
Clients with ascites may have difficulty with breathing due to the size of the abdomen.
Therefore, the initial response is for the nurse to evaluate the respiratory status of the client. If
there is medication ordered that may assist in decreasing the ascites, the nurse may, after
evaluating the respiratory status, choose to give the medication or to contact the health care
provider. Assessing the abdomen will reveal ascites.
9. A client diagnosed with cirrhosis and ascites is receiving discharge instructions. The nurse
is discussing dietary restrictions. The nurse instructs the client to avoid:
1. Cheese.
2. Raw apple.
3. Broccoli.
4. Pasta.
Answer: Cheese.
Rationale:
The client with cirrhosis should avoid processed foods, such as cheese, canned soups,
packaged meats, and so forth. This client can eat raw fruit, vegetables, and pasta because the
dietary restrictions will involve sodium and fluids, as well-high protein foods, particularly as
client becomes more advanced.
10. The priority medication for a client who has developed hepatic encephalopathy is:
5. Lactulose (Chronulac).
6. Vitamin K (Mephyton).
7. Diazepam (Valium).
8. Norfloxacin (Noroxin).
Answer: Lactulose (Chronulac).
Rationale:
The client who has developed hepatic encephalopathy will be given lactulose to help the
client excrete excess ammonia levels from the blood into the colon. Vitamin K and
norfloxacin may be given to clients with esophageal varices. The diazepam is not indicated
for a client with hepatic encephalopathy, but rather oxazepam will likely be given to control
agitation because it is not metabolized in the liver.
11. Reflecting upon the client’s other symptoms, the nurse determines the client likely has
developed hepatic encephalopathy when the client:
5. Becomes increasingly agitated, with changes in mentation.
6. Begins to have bleeding esophageal varices.
7. Has ascites.
8. Begins to complain of a significant headache.
Answer: Becomes increasingly agitated with changes in mentation.
Rationale:
Clients will exhibit symptoms of changing mentation with possible agitation as they develop
hepatic encephalopathy. Bleeding esophageal varices and ascites only indicate the client has
hepatic portal hypertension. Developing a headache is not indicative of hepatic
encephalopathy.
12. An agitated, confused client with hepatic encephalopathy has just received a dose of
lactulose (Chronulac). The nurse determines this medication has been effective if the client:
1. Becomes more alert and cooperative.
2. Has one formed stool per day.
3. Is able to breathe better.
4. Asks for less pain medication.
Answer: Becomes more alert and cooperative.
Rationale:
Lactulose decreases the ammonia content in the blood. Lactulose is given until the client has
two to three loose stools per day. The hepatic encephalopathy client may have problems with
breathing due to ascites, but lactulose will not impact this. Lactulose will not impact the
amount of pain medication the client requests.
13. A client is asking the nurse about how individuals get liver cancer. The nurse responds
correctly by stating:
1. “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.”
2. “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.”
3. “The best way to prevent liver cancer is to catch it early. Liver cancer is easily detected by
physical exam.”
4. “The best way to prevent liver cancer is to avoid IV drug use. Using IV drugs has the
highest correlation with contracting hepatitis B and C.”
Answer: “The best way to prevent liver cancer is by not drinking alcohol, not smoking, and
avoiding high-risk behaviors that increase the chances of contracting hepatitis B and C.”
Rationale:
Avoiding smoking, alcohol, hepatitis B and C, and other known toxins that can cause liver
cancer best prevents liver cancer. Avoiding public restaurants will not eliminate exposure to
liver-cancer-causing agents, since hepatitis A is more commonly transmitted at restaurants.
Liver cancer, caught early, may help increase the odds of survival, but is not a prevention
method. It is also not easily detected by physical exam at an early stage. Avoiding IV drug
use is only one method of diminishing the risk factors for liver cancer, and is not inclusive.
14. A client with liver cancer has been admitted to hospice. The client asks why he developed
this disease. The nurse knows there is a high likelihood this client has which of the following
past medical histories?
1. Alcohol consumption
2. Sexually transmitted diseases
3. H. pylori
4. Frequent nausea and vomiting
Answer: Alcohol consumption
Rationale:
This client has most likely had a past history of alcohol consumption, heavy smoking,
hepatitis B or C, or anabolic steroids. There is no correlation between sexually transmitted
disease, frequent nausea and vomiting, or the presence of H. pylori. However, H. pylori can
cause more problems with hepatic encephalopathy.
15. The nurse is preparing a client with liver cancer for end of life. The nurse knows the goal
of treatment in this case is to:
1. Make the client as comfortable as possible.
2. Provide as much medication as possible.
3. Teach the client how to manage the illness.
4. Understand the family’s wishes.
Answer: Make the client as comfortable as possible.
Rationale:
The goal for the end of life is to make the client with end-stage liver disease as comfortable
as possible. Providing medication, teaching the client how to manage the illness, and
understanding the family’s wishes are not applicable.
16. A 32-year-old female with a BMI of 40 is pregnant and has been having abdominal pain
with nausea and vomiting. The nurse is educating the client on the risk factors for gallbladder
disease. The client has which of the following risk factors for gallbladder disease?
1. Female, obesity, high estrogen state
2. Female, obesity
3. Obesity, age, symptoms
4. Age, high estrogen state
Answer: Female, obesity, high estrogen state
Rationale:
Females have gallbladder disease more commonly than men. Obesity and high estrogen states
(pregnancy is an example) increase the risk factor for gallbladder disease. Other risk factors
include certain ethnic groups, certain medications, diabetes, Crohn’s disease, cirrhosis, and
recent weight loss.
17. A client is female with gallbladder disease symptoms. The nurse knows this client is at
higher risk for the disease because:
1. The female hormones increase the secretion of cholesterol and biliary stasis.
2. The male hormones interfere with the production of bile.
3. The female hormones increase the client’s body weight, which decreases the production of
bile.
4. Females tend to take more medications than males, and medications increase cholesterol
production that causes biliary stasis.
Answer: The female hormones increase the secretion of cholesterol and biliary stasis.
Rationale:
The current belief is that estrogen increases the secretion of cholesterol and progesterone
causes an increase in biliary stasis.
18. A nurse is teaching a client about the modifiable risk factors for gallbladder disease. The
nurse determines that the client understands the teaching when the client states which of the
following?
1. “I will lose no more than 2 pounds per week and will exercise more.”
2. “I will quit taking my birth control pills.”
3. “My estrogen replacement pills should help prevent gallbladder disease.”
4. “Thankfully, my diabetes is not related to gallbladder disease.”
Answer: “I will lose no more than 2 pounds per week and will exercise more.”
Rationale:
Rapid weight loss is associated with gallbladder disease, so the client should be advised to
lose weight at a pace of 2 pounds per week. Exercise helps to diminish the risk factors, such
as obesity and high lipid levels. Persons taking birth control pills and estrogen replacement
(hormone replacement) have a higher risk factor associated with gallbladder disease.
Diabetes, Crohn’s disease, and cirrhosis are associated with a higher incidence of gallbladder
disease.
19. A client with a laparoscopic cholecystectomy is complaining postoperatively of shoulder
pain and is asking if the surgical team incorrectly positioned the client when in surgery. The
nursing diagnosis for this client is Comfort: Readiness for Enhanced. A nursing intervention
that is appropriate for this client is:
1. Provide a warm pack to the shoulder and ambulate the client, progressing to the client’s
prior activity level.
2. Provide pain medication for breakthrough pain unrelieved by the PCA morphine.
3. Provide an antiemetic as ordered.
4. Examine the abdomen for sign of peritonitis.
Answer: Provide a warm pack to the shoulder and ambulate the client, progressing to the
client’s prior activity level.
Rationale:
Shoulder pain postoperatively following a laparoscopic procedure is often a result of the
gases instilled into the abdomen. Utilizing a warm moist pack and ambulating the client will
assist in reducing this complaint. Most clients do not require breakthrough pain medication
on top of the PCA, as the client can regulate the pain medicine. Providing an antiemetic will
not be beneficial because the client is not complaining of nausea. There is no indication of
peritonitis.
20. The client who is scheduled for an open cholecystectomy is questioning why she must
have an open surgery. The health care provider has already obtained informed consent from
this client. The nurse responds with:
1. “There are cases where an open surgery is more beneficial to the client, such as an infected
gallbladder or the need to explore the common bile duct. I can have your health care provider
talk with you again if you have more specific questions.”
2. “Not everyone will qualify for a laparoscopic procedure due to their size. I will call your
health care provider and tell her you want a laparoscopic procedure.”
3. “Some clients are not good candidates for laparoscopic procedures because they are afraid
of anesthesia.”
4. “The health care provider needs to discuss this with you. I don’t know why one surgery is
chosen over another.”
Answer: “There are cases where an open surgery is more beneficial to the client, such as an
infected gallbladder or the need to explore the common bile duct. I can have your health care
provider talk with you again if you have more specific questions.”
Rationale:
The surgeon determines whether a laparoscopic procedure is workable for each client. This
decision is based upon many factors, including prior surgeries, infection of the gallbladder,
the need to explore the common bile duct, and so on. Laparoscopic clients generally heal
quicker, with fewer postoperative complications.
21. A client 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 client has an open procedure, which of the
following is more likely?
1. The client may have a T Tube that will allow drainage of bile.
2. The client may have an increase in bowel movements.
3. The client may experience faster recovery.
4. The client may notice more fatty food intolerance.
Answer: The client may have a T Tube that will allow drainage of bile.
Rationale:
An open cholecystectomy may require a T Tube inserted if the common bile duct is explored.
There should be no increase in bowel movements. The recovery time is actually longer with
an open procedure. There is no more fatty food intolerance with one type of procedure over
another.
22. A client has been admitted with acute pancreatitis and has a nasogastric tube. The client is
NPO and has not eaten in several days. The client has been in pain and on bed rest. The client
tells the nurse, “I don’t understand why I can’t eat.” The nurse responds by:
1. Explaining the purpose of the nasogastric tube and the reasons for keeping the client NPO.
2. Asking the client if pain medication is needed.
3. Telling the client that pain medication is limited to prevent addiction.
4. Providing the client food.
Answer: Explaining the purpose of the nasogastric tube and the reasons for keeping the client
NPO.
Rationale:
The client must understand the purpose of the treatment plan. Providing an understanding of
the need for being NPO is important. Pain medication addiction is more likely in chronic
pancreatitis than in acute. The client will need to remain NPO to allow the pancreas to rest.
23. A client with chronic pancreatitis is taking pancreatic enzymes. The client understands the
client teaching when the client states:
1. “I will take this medication with food.”
2. “I should take this medication on an empty stomach.”
3. “I take this medication only when my stomach is hurting.”
4. “This medication is monitored by the lab work.”
Answer: “I will take this medication with food.”
Rationale:
Pancreatic enzymes need to be taken with food and on a regular schedule, not just when the
client is experiencing symptoms. There are no particular labs that are done to monitor
pancreatic enzymes.
24. A client is admitted with acute pancreatitis. The nurse recognizes the client’s nutritional
outcomes have been met when the client exhibits which of the following?
1. Client’s weight has increased 0.5 pounds over 1 week.
2. Client’s weight has decreased 2 pounds over 1 week.
3. Client’s weight has decreased 2 pounds over the past day.
4. Client’s weight has increased 1 pound over the past day.
Answer: Client’s weight has increased 0.5 pounds over 1 week.
Rationale:
The overall nutritional outcome for this client is to not lose weight. Nutritional status is
reflected over 1 week, whereas fluid status is reflected from day to day. Thus, the client’s
weight gain of 0.5 pound over 1 week meets the outcomes for this goal, whereas the 2-pound
loss over 1 week reflects a net nutritional loss. The weight decreasing 2 pounds and
increasing 1 pound over the past day indicates fluid loss and gain, respectively.
25. A nurse is caring for a client with pancreatic cancer. The nurse closely monitors the client
for jaundice, knowing that which of the following assessments closely correlates with
jaundice?
1. Pruritus
2. Nausea
3. Pain
4. Vision disturbances
Answer: Pruritus
Rationale:
Pruritus usually accompanies jaundice. Therefore, the client may also require care for itching
so the client does not damage the skin. Nausea may accompany pancreatic cancer, but is not
necessarily associated with jaundice. Pain and vision disturbances do not accompany
jaundice.
26. Often a client with pancreatic cancer tends to lose weight due to the inability of the body
to absorb nutrients. The nurse instructs the client to be alert to which of the following that
may indicate malabsorption?
1. Steatorrhea
2. Vomiting
3. Pain
4. Jaundice
Answer: Steatorrhea
Rationale:
Steatorrhea is loose, fatty, foul-smelling stools caused from the lack of the enzyme lipase.
Lipase is needed to digest fats. Vomiting, pain, and jaundice do not necessarily indicate
malabsorption.
27. A client with end-stage pancreatic cancer is admitted to the nursing unit. The client is
lethargic and jaundiced. A priority goal for this client will be to:
1. Manage comfort.
2. Understand effects of high bilirubin levels.
3. Manage nutrition.
4. Increase activity.
Answer: Manage comfort.
Rationale:
A client with end-stage pancreatic cancer who is lethargic and jaundiced will need comfort
managed and will receive palliative care. Managing nutrition and understanding the effects of
high bilirubin levels may be important for this client, but it depends upon the extent of the
lethargy and the client’s wishes for aggressive treatment options. Increased activity would not
be practical for this client.
28. A nurse is assigned to care for a client with pancreatitis. The nurse teaches the client to
assess which of the following parameters on a daily basis?
1. Weight
2. Blood pressure
3. Pulse
4. Sclera
Answer: Weight
Rationale:
The client checks daily weights. Changes from day to day reflect fluid status, but changes
over a week’s time indicate nutritional status. The pancreatic client is at risk for
malabsorption, and nutritional status should be monitored.
29. A nurse is preparing a client with pancreatitis to be discharged to home. The nurse is
instructing the client on decreasing pancreatic stimulation. One method to decrease pancreatic
secretion is to:
1. Avoid the smell of food.
2. Increase household noise and stimulation.
3. Minimize exposure to light.
4. Stay in an upright position.
Answer: Avoid the smell of food.
Rationale:
The smell of food helps to stimulate pancreatic secretions. Limiting the opportunity to smell
food will help the client reduce pancreatic secretions. Minimizing other stimulations, such as
household noise and activity, will also reduce pancreatic secretions. Staying in an upright
position will not affect pancreatic stimulation.
30. A client arrives at the clinic for follow-up care for pancreatitis. This client was discharged
from an acute care facility 4 days ago. The client has been an alcoholic, which contributed to
the pancreatitis. What is the priority intervention for this client?
1. Provide information for Alcoholics Anonymous.
2. Provide teaching about dietary needs.
3. Provide initial instruction on medication.
4. Remind the client of the potential for jaundice.
Answer: Provide information for Alcoholics Anonymous.
Rationale:
This client will need continuing support for the alcohol problem. Providing information
regarding Alcoholics Anonymous will be a priority intervention 4 days after discharge. The
other answer choices will have occurred upon discharge from the hospital, and though
reinforcement instructions may be needed, they will not be the highest priority.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
