HACC Nursing 241 Quiz 1 Questions With Complete
Solutions
Define Acute Pancreatitis Correct Answers Mild to fatal - how
much of pancreas has been "eaten"?
Mild: confined to pancreas
Severe: also systemic complications
Define Ascities Correct Answers Na+ and Water Retention 3rd
Spacing
↓serum albumin
↑abdominal girth
Weight gain
Pedal edema
Dyspnea
Define Asterixis Correct Answers -abnormal tremor consisting
of involuntary jerking movements, especially in hands, freq
occurring w/ impending hepatic coma & other forms of
metabolic (hepatic) encephalopathy
-tremor is usually induced by extending arm, wrist/fingers
Define Hepatic Encephalopathy Correct Answers caused by
elevated ammonia; a by-product of protein metabolism which
disrupts mental status. The damage liver is unable to make the
ammonia water
Define Pancreatitis Correct Answers When the pancreatic
enzymes digest the pancreases instead of nutrients within the
duodenum
,How can you prevent Hep A? Correct Answers Prevention:
vaccination, handwashing, bottled
water, peel raw fruit/vegetable
How do we reduce the risk of Aspiration when using a feeding
tube? Correct Answers HOB elevated 30 degrees
Turn off feeding when HOB is lowered
Check residual q 4 hours: may not be able to do this d/t small
diameter of tube
In regards to Chronic Pancreatitis, how will we as nurses
address Nutrition? Correct Answers Pancrelipase to help digest
fat/proteins
Fat- soluble vitamin replacement
CC diet if DM develops
In regards to Chronic Pancreatitis, how will we as nurses
address Pain? Correct Answers Opiods - stool softeners for
constipation
Higher doses to manage chronic pain
In regards to liver disease, what are some client education
points? Correct Answers Avoid alcohol - counseling referral
Diet: sodium, protein, fluid restrictions
Signs of GI bleeding to report
Skin care
In regards to liver disease, what nursing care items will you do
for Balanced Fluid volume? Correct Answers Daily weight,
I&O
, Measure abdominal girth
Respiratory: O2 saturation, dyspnea, breath sounds
Diuretics, fluid and sodium restriction
In regards to liver disease, what nursing care items will you do
for Bleeding risk? Correct Answers Monitor vital signs:
hypotension, tachycardia
Institute bleeding precautions
Check coagulation studies, platelet count
Test stool, emesis for blood
In regards to liver disease, what nursing care items will you do
for maintaining skin integrity? Correct Answers Use warm
water
Lotion for dry skin
Mitts/antihistamines
Prevent skin breakdown
In regards to liver disease, what nursing care items will you do
for Nurtrition? Correct Answers Weigh daily
Small meals with snacks
Vitamin supplements
Diet: ↑carbohydrate and protein, ↓ sodium
With encephalopathy: restrict protein
List S&S of Esophageal Varices (Distended Vessels within the
Esophagus) Correct Answers Distended vessels in
esophagus/stomach are easily ruptured
Hematemesis
Melena (Stool that has blood in it)
S/S shock
Solutions
Define Acute Pancreatitis Correct Answers Mild to fatal - how
much of pancreas has been "eaten"?
Mild: confined to pancreas
Severe: also systemic complications
Define Ascities Correct Answers Na+ and Water Retention 3rd
Spacing
↓serum albumin
↑abdominal girth
Weight gain
Pedal edema
Dyspnea
Define Asterixis Correct Answers -abnormal tremor consisting
of involuntary jerking movements, especially in hands, freq
occurring w/ impending hepatic coma & other forms of
metabolic (hepatic) encephalopathy
-tremor is usually induced by extending arm, wrist/fingers
Define Hepatic Encephalopathy Correct Answers caused by
elevated ammonia; a by-product of protein metabolism which
disrupts mental status. The damage liver is unable to make the
ammonia water
Define Pancreatitis Correct Answers When the pancreatic
enzymes digest the pancreases instead of nutrients within the
duodenum
,How can you prevent Hep A? Correct Answers Prevention:
vaccination, handwashing, bottled
water, peel raw fruit/vegetable
How do we reduce the risk of Aspiration when using a feeding
tube? Correct Answers HOB elevated 30 degrees
Turn off feeding when HOB is lowered
Check residual q 4 hours: may not be able to do this d/t small
diameter of tube
In regards to Chronic Pancreatitis, how will we as nurses
address Nutrition? Correct Answers Pancrelipase to help digest
fat/proteins
Fat- soluble vitamin replacement
CC diet if DM develops
In regards to Chronic Pancreatitis, how will we as nurses
address Pain? Correct Answers Opiods - stool softeners for
constipation
Higher doses to manage chronic pain
In regards to liver disease, what are some client education
points? Correct Answers Avoid alcohol - counseling referral
Diet: sodium, protein, fluid restrictions
Signs of GI bleeding to report
Skin care
In regards to liver disease, what nursing care items will you do
for Balanced Fluid volume? Correct Answers Daily weight,
I&O
, Measure abdominal girth
Respiratory: O2 saturation, dyspnea, breath sounds
Diuretics, fluid and sodium restriction
In regards to liver disease, what nursing care items will you do
for Bleeding risk? Correct Answers Monitor vital signs:
hypotension, tachycardia
Institute bleeding precautions
Check coagulation studies, platelet count
Test stool, emesis for blood
In regards to liver disease, what nursing care items will you do
for maintaining skin integrity? Correct Answers Use warm
water
Lotion for dry skin
Mitts/antihistamines
Prevent skin breakdown
In regards to liver disease, what nursing care items will you do
for Nurtrition? Correct Answers Weigh daily
Small meals with snacks
Vitamin supplements
Diet: ↑carbohydrate and protein, ↓ sodium
With encephalopathy: restrict protein
List S&S of Esophageal Varices (Distended Vessels within the
Esophagus) Correct Answers Distended vessels in
esophagus/stomach are easily ruptured
Hematemesis
Melena (Stool that has blood in it)
S/S shock
