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The nurse is caring for a client with severe acute pancreatitis with a glucose level of 750 mg/dL. What does the nurse understand is the cause of this level of hyperglycemia?
- A. Severe acute pancreatitis causes an increase in circulating calcium.
- B. The client has not been taking the insulin and eating simple carbohydrates.
- C. The client has diabetes as well as pancreatitis.
- D. Severe acute pancreatitis causes an imbalance of glucagon, insulin, and somatostatin.
Correct Answer: D
Rationale: Complications from severe acute pancreatitis are serious and sometimes fatal. Hyperglycemia results from an imbalance of glucagon, insulin, and somatostatin. Increase in circulating calcium does not result in an increase in glucose levels. The nurse cannot assume that the client has diabetes and is noncompliant.
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The nurse is caring for a client who has undergone surgery for a liver disorder and has started shivering. Which intervention would be appropriate?
- A. Provide the client with warm fluids.
- B. Cover the client with a light blanket.
- C. Ensure that the room temperature is below 70?°F.
- D. Place the client on a hypothermia blanket.
Correct Answer: B
Rationale: The nurse should cover the client with a light blanket to prevent shivering. This is because the client who has undergone surgery for liver disorder also faces the risk of hyperthermia related to infection, rejection, or both. Providing the client with warm fluids will not control shivering. The client is covered with a hypothermia blanket if the temperature rises to 105?°F. The room temperature need not be below 70?°F.
A client with esophageal varices is scheduled to undergo injection sclerotherapy. Which client statement indicates that the nurse's teaching was successful?
- A. The physician will use a balloon to compress the vessels.
- B. I might need to have this procedure done again.
- C. I seems odd that a rubber band can block off the vessels.
- D. A catheter will be inserted through my belly to fix the vessels.
Correct Answer: B
Rationale: Persistent portal hypertension allows varices to form again, making it necessary to repeat injection sclerotherapy or variceal banding regularly. Injection sclerotherapy involves passing an endoscope orally to locate the varix. Balloon tamponade is used to compress actively bleeding esophageal varices as a temporary measure. Variceal banding involves using a rubber band over the varix to restrict blood flow that eventually leads to sloughing.
A client has developed drug-induced hepatitis from a drug reaction to antidepressants. What treatment does the nurse anticipate the client will receive to treat the reaction?
- A. Paracentesis
- B. Liver transplantation
- C. High-dose corticosteroids
- D. Azathioprine
Correct Answer: C
Rationale: Drug-induced hepatitis occurs when a drug reaction damages the liver. This form of hepatitis can be severe and fatal. High-dose corticosteroids usually administered first to treat the reaction. Liver transplantation may be necessary. Paracentesis should be used to withdraw fluid for the treatment of ascites. Azathioprine (Imuran) may be used for autoimmune hepatitis.
When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which intervention should the nurse consider?
- A. Report the condition to the physician immediately.
- B. Measure abdominal girth according to a set routine.
- C. Provide the client with nonprescription laxatives.
- D. Ask the client about food intake.
Correct Answer: B
Rationale: If the abdomen appears enlarged, the nurse measures it according to a set routine. Measuring the abdominal girth is the most accurate method of determining an increase or decrease in abdominal distention. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis. The nurse would report to the physician about abdominal enlargement along with other parameters of the assessment.
A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?
- A. Cure the cirrhosis.
- B. Treat the esophageal varices.
- C. Reduce fluid accumulation and venous pressure.
- D. Promote optimal neurologic function.
Correct Answer: C
Rationale: Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.