NR 464 Med/Surg II - Exam 1 [Gallbladder, Pancreas,
Liver] Questions With Complete Solutions
acute pancreatitis Correct Answers - acute inflammatory
process of the pancreas
- degree varies from mild edema to severe necrosis
acute pancreatitis complication: abscess Correct Answers -
large fluid filled cavity within pancreas
- secondary to necrosis
- may perforate into other organs
- S/S: abd. pain, abd. mass, fever, leukocytosis
- treatment: prompt drainage
acute pancreatitis complication: pseudocysts Correct Answers
- cavity outside pancreas filled w/ necrotic products & liquid
secretion
- S/S: abdominal pain
- treatment: drain
acute pancreatitis: ambulatory & home care Correct Answers -
PT
- abstinence from alcohol, caffeine, smoking
,- assess narcotic addiction
- dietary teaching
- signs of infection, high blood glucose, steatorrhea
acute pancreatitis: complications (2) Correct Answers -
pseudocyst
- abscess
acute pancreatitis: diagnostic lab tests Correct Answers -
serum/urinary amylase
- serum lipase
- CBC
- liver enzymes
- blood glucose
- triglycerides
- bilirubin
- serum calcium
- other electrolytes
- ABGs
acute pancreatitis: dietary considerations (home care) Correct
Answers - high-carb
,- high protein
- low-fat
- fat soluble vitamins may be needed
acute pancreatitis: electrolyte balance Correct Answers - blood
glucose (hyperglycemia)
- monitor for signs of hypocalcemia
- risk for hypomagnesemia, hypokalemia, hyponatremia,
hypochloridemia
acute pancreatitis: local complications Correct Answers
[occurs after 1st week]
- acute fluid collection
- sterile/infected pancreatic necrosis
- pseudoaneurysm
- pancreatic abscess
- splenic vein thrombosis
acute pancreatitis: NG suction & NG tube care Correct Answers
- decreases gastric HCL acid secretion & subsequent stimulation
of pancreatic enzymes
- relieves urge to vomit
, - decreases abd. distention
- treats asso. ileus
- helps prevent aspiration
acute pancreatitis: nursing diagnoses Correct Answers - acute
pain
- fluid volume deficit
- imbalanced nutrition (less than body requirements)
- ineffective self-health management
acute pancreatitis: nursing interventions Correct Answers -
monitor vital signs [signs of ARDs!]
- IV fluids
- assessment of respiratory function [lung sounds/crackles]
- pain assessment & management
- electrolyte balance
- keep NPO
- NG suction & NG tube care
- frequent nasal/oral care
- progress diet as tolerated
Liver] Questions With Complete Solutions
acute pancreatitis Correct Answers - acute inflammatory
process of the pancreas
- degree varies from mild edema to severe necrosis
acute pancreatitis complication: abscess Correct Answers -
large fluid filled cavity within pancreas
- secondary to necrosis
- may perforate into other organs
- S/S: abd. pain, abd. mass, fever, leukocytosis
- treatment: prompt drainage
acute pancreatitis complication: pseudocysts Correct Answers
- cavity outside pancreas filled w/ necrotic products & liquid
secretion
- S/S: abdominal pain
- treatment: drain
acute pancreatitis: ambulatory & home care Correct Answers -
PT
- abstinence from alcohol, caffeine, smoking
,- assess narcotic addiction
- dietary teaching
- signs of infection, high blood glucose, steatorrhea
acute pancreatitis: complications (2) Correct Answers -
pseudocyst
- abscess
acute pancreatitis: diagnostic lab tests Correct Answers -
serum/urinary amylase
- serum lipase
- CBC
- liver enzymes
- blood glucose
- triglycerides
- bilirubin
- serum calcium
- other electrolytes
- ABGs
acute pancreatitis: dietary considerations (home care) Correct
Answers - high-carb
,- high protein
- low-fat
- fat soluble vitamins may be needed
acute pancreatitis: electrolyte balance Correct Answers - blood
glucose (hyperglycemia)
- monitor for signs of hypocalcemia
- risk for hypomagnesemia, hypokalemia, hyponatremia,
hypochloridemia
acute pancreatitis: local complications Correct Answers
[occurs after 1st week]
- acute fluid collection
- sterile/infected pancreatic necrosis
- pseudoaneurysm
- pancreatic abscess
- splenic vein thrombosis
acute pancreatitis: NG suction & NG tube care Correct Answers
- decreases gastric HCL acid secretion & subsequent stimulation
of pancreatic enzymes
- relieves urge to vomit
, - decreases abd. distention
- treats asso. ileus
- helps prevent aspiration
acute pancreatitis: nursing diagnoses Correct Answers - acute
pain
- fluid volume deficit
- imbalanced nutrition (less than body requirements)
- ineffective self-health management
acute pancreatitis: nursing interventions Correct Answers -
monitor vital signs [signs of ARDs!]
- IV fluids
- assessment of respiratory function [lung sounds/crackles]
- pain assessment & management
- electrolyte balance
- keep NPO
- NG suction & NG tube care
- frequent nasal/oral care
- progress diet as tolerated
