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Which of the following nursing actions is a priority when the nurse is caring for a patient with pancreatic cancer?
- A. Offer high-calorie, high-protein dietary choices.
- B. Offer psychological support for anxiety or depression.
- C. Educate about the need to avoid scratching pruritic areas.
- D. Administer prescribed opioids to relieve pain as needed.
Correct Answer: D
Rationale: Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to education, or manage anxiety or depression.
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A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, which of the following serological findings should the nurse expect?
- A. Antibody to hepatitis D virus (anti-HDV)
- B. Hepatitis B surface antigen (HBsAg)
- C. Anti-hepatitis A virus immunoglobulin G (anti-HAV IgG)
- D. Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)
Correct Answer: D
Rationale: Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.
The nurse is caring for a patient who has advanced cirrhosis and is receiving lactulose. Which of the following findings by the nurse indicates that the medication is effective?
- A. The patient is alert and oriented.
- B. The patient denies nausea or anorexia.
- C. The patient's bilirubin level decreases.
- D. The patient has at least one stool daily.
Correct Answer: A
Rationale: The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.
Which of the following data obtained by the nurse during the assessment of a patient with cirrhosis is of most concern?
- A. The patient's hands flap back and forth when the arms are extended.
- B. The patient has ascites and a 2-kg weight gain from the previous day.
- C. The patient's skin has multiple spider-shaped blood vessels on the abdomen.
- D. The patient complains of right upper-quadrant pain with abdominal palpation.
Correct Answer: A
Rationale: The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain do indicate the need for treatment but not as urgently as the changes in neurological status.
Which of the following nursing actions should be included in the plan of care for a patient with cirrhosis who has ascites and 4+ edema of the feet and legs?
- A. Weekly weight of patient.
- B. Reposition the patient every 4 hours.
- C. Restrict sodium intake.
- D. Perform passive range-of-motion QID.
Correct Answer: C
Rationale: To maintain skin integrity, restrict sodium intake as ordered to prevent additional fluid retention. The patient should be weighed daily, not weekly. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity, patients should be repositioned at least every two hours. Passive range of motion will not take pressure off areas like the sacrum that are vulnerable to breakdown.
The nurse is admitting a patient who is homeless and has viral hepatitis with symptoms of severe anorexia and fatigue. Which of the following patient goals should have the highest priority when the nurse is developing the plan of care?
- A. Increase activity level.
- B. Maintain adequate nutrition.
- C. Establish a stable home environment.
- D. Identify the source of exposure to hepatitis.
Correct Answer: B
Rationale: The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.