Question

The nurse is admitting a client diagnosed with ascites. Which assessment finding would the nurse anticipate?

Answer 1

Correct Answers:

Pedal edema

Rationale :

🦶Pedal edema is a common finding in clients with ascites due to fluid overload and portal hypertension associated with liver dysfunction.

💧As fluid accumulates in the peritoneal cavity, vascular hydrostatic pressure increases, causing fluid to shift into the interstitial spaces, particularly in dependent areas like the feet.

👩🏻‍🤝‍🧑🏿Clients with ascites often exhibit signs of circulatory compromise, including edema, due to impaired albumin synthesis and fluid retention.

📉Unlike weight loss, flushed skin, or hematemesis, which may occur in other conditions, pedal edema is a specific and expected symptom of ascites related to liver disease.

📌Core Message

Ascites causes pedal edema due to fluid overload and portal hypertension.

Answer 2

Correct Answers:

Check stools for diarrhea

Rationale :

💩Clients receiving jejunal feedings are at risk for diarrhea due to the rapid infusion of nutrients into the small intestine.

🧪This feeding bypasses the stomach’s regulatory role, leading to dumping-like effects that can result in loose stools.

📋Monitoring stools helps detect malabsorption or intolerance to the formula, ensuring timely intervention to prevent dehydration and nutritional deficiencies.

🧠Routine blood glucose checks or residual volume measurements are more relevant for gastric feedings, not jejunostomy tubes.

📌Core Message

Jejunostomy feeding may cause diarrhea due to rapid intestinal infusion of formula.

Answer 3

Correct Answers:

"This medication will decrease gastric acid secretion."

Rationale :

🧪Omeprazole is a proton pump inhibitor (PPI) used to decrease gastric acid secretion, which helps reduce stimulation of the pancreas.

🔥In acute pancreatitis, decreasing acid reduces pancreatic enzyme release, preventing further inflammation.

🧴This protects the gastrointestinal lining and aids in reducing gastric irritation and pain.

🧠PPIs are not primarily used for nutrient absorption, infection reduction, or carbohydrate digestion, making the other choices incorrect.

📌Core Message

Omeprazole reduces gastric acid to limit pancreatic stimulation during acute pancreatitis.

Answer 4

Correct Answers:

Administer prior to antacids

Rationale :

🕒Pancrelipase should be given before meals and snacks, and prior to antacids to ensure optimal enzyme function in the acidic environment.

🧫Antacids can alter gastric pH, potentially reducing the effectiveness of pancrelipase.

🦷Rinsing the mouth is not necessary, and the enzyme is meant to be taken with meals, not avoided with food.

💩The medication helps reduce fatty stools, not cause them, by promoting fat digestion in clients with pancreatic insufficiency.

📌Core Message

Pancrelipase must be given before antacids to ensure enzyme effectiveness in fat digestion.

Answer 5

Correct Answers:

Pantoprazole 80 mg IV bolus twice daily

Rationale :

🔥Pantoprazole, a proton pump inhibitor, helps reduce gastric acid secretion, minimizing pancreatic stimulation and preventing exacerbation.

💊Clients with acute pancreatitis are kept NPO to rest the pancreas, and acid suppression is key to reducing enzyme activity.

📋Pancrelipase is typically used in chronic, not acute, pancreatitis.

🥗Dietary intake (e.g., low-residue) and ambulation are contraindicated during the acute phase.

📌Core Message

Pantoprazole is used in acute pancreatitis to suppress acid and minimize pancreatic activity.

Answer 6

Correct Answers:

Weight loss

Rationale :

🍽️Clients with chronic pancreatitis often experience weight loss due to malabsorption and inadequate digestion of nutrients.

🧫Damage to pancreatic tissue leads to reduced enzyme production, impairing digestion of fats, proteins, and carbohydrates.

💩This malnutrition contributes to steatorrhea, vitamin deficiencies, and overall poor nutritional status.

🌡️Cool skin and bruising (Cullen or Grey Turner signs) are more acute findings and not characteristic of the chronic stage.

📌Core Message

Chronic pancreatitis leads to malabsorption and weight loss due to enzyme deficiency.

Answer 7

Correct Answers:

"Have you ever had a blood transfusion?"

Rationale :

🩸Hepatitis C is most commonly transmitted via blood and blood products, especially prior to the implementation of screening in the early 1990s.

💊Risk factors include IV drug use, transfusions, and occupational exposures, not necessarily travel or bowel habits.

📋This question helps identify potential sources of viral exposure and guide testing and counseling.

🧬Unlike hepatitis A, hepatitis C is not commonly spread through the fecal-oral route, making other questions less relevant.

📌Core Message

A history of blood transfusion is a major risk factor for hepatitis C transmission.

Answer 8

Correct Answers:

Lipase 900 u/L (20-180 u/L)

Rationale :

📈An elevated lipase level, especially >3x normal, is a hallmark of acute pancreatitis and requires prompt reporting.

🩺Although other lab values are within acceptable ranges, the lipase level indicates severe pancreatic inflammation.

📋Recognizing this elevation early enables interventions to prevent complications such as necrosis or shock.

🧠WBC, potassium, and albumin levels are not critically abnormal in this case.

📌Core Message

Lipase elevation is the most specific lab marker for acute pancreatitis severity.

Answer 9

Correct Answers:

Maintain nasogastric tube to intermittent suction

Rationale :

🌡️In acute pancreatitis, the pancreas is inflamed and should be rested to avoid further stimulation.

🧪An NG tube with suction removes gastric contents, preventing the release of pancreatic enzymes triggered by food or acid.

🍴This helps control pain, reduce nausea, and prevent pancreatic autodigestion.

🏃Ambulation and feeding increase pancreatic activity, which is contraindicated during acute flares.

📌Core Message

NG suction helps rest the pancreas and reduce pain during acute pancreatitis.

Answer 10

Correct Answers:

Risk for bleeding

Rationale :

🧪A prolonged PT indicates coagulation abnormalities, which increases the client’s risk for bleeding, especially in the presence of liver dysfunction.

🟡Jaundice and decreased appetite are expected with cirrhosis, but the coagulopathy is more urgent.

📋The liver produces clotting factors, and damage can lead to bleeding tendencies, even if hemoglobin appears normal.

🚨This risk takes priority over other potential but non-life-threatening issues like nutrition or skin integrity.

📌Core Message

Prolonged PT in cirrhosis signals a high risk for bleeding due to impaired clotting factor production.

1 :
The nurse is admitting a client diagnosed with ascites. Which assessment finding would the nurse anticipate?

2 :
When planning care for a client receiving an enteral feeding via jejunostomy tube, which intervention would the nurse include?

3 :
The client with acute pancreatitis asks why she is taking omeprazole. What is the nurse's best response?

4 :
The nurse is preparing a client presentation regarding pancrelipase (Viokase) therapy. Which information would the nurse include in the teaching session?

5 :
A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?

6 :
The nurse is making a home visit to a client with chronic pancreatitis. Which data is consistent with this diagnosis?

7 :
A female client is visiting the Medical Clinic with suspected hepatitis C. Which assessment question should the nurse ask this client?

9 :
When planning care for a client with acute pancreatitis, which order would the nurse anticipate that will contribute to pain control?

10 :
A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?

1 : The nurse is admitting a client diagnosed with ascites. Which assessment finding would the nurse anticipate?

2 : When planning care for a client receiving an enteral feeding via jejunostomy tube, which intervention would the nurse include?

3 : The client with acute pancreatitis asks why she is taking omeprazole. What is the nurse's best response?

4 : The nurse is preparing a client presentation regarding pancrelipase (Viokase) therapy. Which information would the nurse include in the teaching session?

5 : A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?

6 : The nurse is making a home visit to a client with chronic pancreatitis. Which data is consistent with this diagnosis?

7 : A female client is visiting the Medical Clinic with suspected hepatitis C. Which assessment question should the nurse ask this client?

9 : When planning care for a client with acute pancreatitis, which order would the nurse anticipate that will contribute to pain control?

10 : A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?

1 :
The nurse is admitting a client diagnosed with ascites. Which assessment finding would the nurse anticipate?

2 :
When planning care for a client receiving an enteral feeding via jejunostomy tube, which intervention would the nurse include?

3 :
The client with acute pancreatitis asks why she is taking omeprazole. What is the nurse's best response?

4 :
The nurse is preparing a client presentation regarding pancrelipase (Viokase) therapy. Which information would the nurse include in the teaching session?

5 :
A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?

6 :
The nurse is making a home visit to a client with chronic pancreatitis. Which data is consistent with this diagnosis?

7 :
A female client is visiting the Medical Clinic with suspected hepatitis C. Which assessment question should the nurse ask this client?

9 :
When planning care for a client with acute pancreatitis, which order would the nurse anticipate that will contribute to pain control?

10 :
A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?