Nokea
A home health nurse is caring for a patient discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the patient who has had pancreatic surgery?
- A. Proteinuria and hyperkalemia
- B. Hemorrhage and hypercalcemia
- C. Weight loss and hypoglycemia
- D. Malabsorption and hyperglycemia
Correct Answer: D
Rationale: The nurse arrives at this diagnosis based on the complications of malabsorption and hyperglycemia. These complications often lead to the need for dietary modifications. Pancreatic enzyme replacement, a low-fat diet, and vitamin supplementation often are also required to meet the patients nutritional needs and restrictions. Electrolyte imbalances often accompany pancreatic disorders and surgery, but the electrolyte levels are more often deficient than excessive. Hemorrhage is a complication related to surgery, but not specific to the nutritionally based nursing diagnosis. Weight loss is a common complication, but hypoglycemia is less likely.
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A nurse is preparing a plan of care for a patient with pancreatic cysts that have necessitated drainage through the abdominal wall. What nursing diagnosis should the nurse prioritize?
- A. Disturbed Body Image
- B. Impaired Skin Integrity
- C. Nausea
- D. Risk for Deficient Fluid Volume
Correct Answer: B
Rationale: While each of the diagnoses may be applicable to a patient with pancreatic drainage, the priority nursing diagnosis is Impaired Skin Integrity. The drainage is often perfuse and destructive to tissue because of the enzyme contents. Nursing measures must focus on steps to protect the skin near the drainage site from excoriation. The application of ointments or the use of a suction apparatus protects the skin from excoriation.
A patient has been diagnosed with pancreatic cancer and has been admitted for care. Following initial treatment, the nurse should be aware that the patient is most likely to require which of the following?
- A. Inpatient rehabilitation
- B. Rehabilitation in the home setting
- C. Intensive physical therapy
- D. Hospice care
Correct Answer: D
Rationale: Pancreatic carcinoma has only a 5% survival rate at 5 years regardless of the stage of disease at diagnosis or treatment. As a result, there is a higher likelihood that the patient will require hospice care than physical therapy and rehabilitation.
A patient is admitted to the unit with acute cholecystitis. The physician has noted that surgery will be scheduled in 4 days. The patient asks why the surgery is being put off for a week when he has a sick gallbladder. What rationale would underlie the nurses response?
- A. Surgery is delayed until the patient can eat a regular diet without vomiting.
- B. Surgery is delayed until the acute symptoms subside.
- C. The patient requires aggressive nutritional support prior to surgery.
- D. Time is needed to determine whether a laparoscopic procedure can be used.
Correct Answer: B
Rationale: Unless the patients condition deteriorates, surgical intervention is delayed just until the acute symptoms subside (usually within a few days). There is no need to delay surgery pending an improvement in nutritional status, and deciding on a laparoscopic approach is not a lengthy process.
A patient has a recent diagnosis of chronic pancreatitis and is undergoing diagnostic testing to determine pancreatic islet cell function. The nurse should anticipate what diagnostic test?
- A. Glucose tolerance test
- B. ERCP
- C. Pancreatic biopsy
- D. Abdominal ultrasonography
Correct Answer: A
Rationale: A glucose tolerance test evaluates pancreatic islet cell function and provides necessary information for making decisions about surgical resection of the pancreas. This specific clinical information is not provided by ERCP, biopsy, or ultrasound.
A 55-year-old man has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this patients health problem?
- A. Toxins have accumulated and inflamed your pancreas.
- B. Bacteria likely migrated from your intestines and became lodged in your pancreas.
- C. A virus that was likely already present in your body has begun to attack your pancreatic cells.
- D. The enzymes that your pancreas produces have damaged the pancreas itself.
Correct Answer: D
Rationale: Although the mechanisms causing pancreatitis are unknown, pancreatitis is commonly described as the autodigestion of the pancreas. Less commonly, toxic substances and microorganisms are implicated as the cause of pancreatitis.