Chapter 38: Disorders of Hepatobiliary and Exocrine Pancreas Function Question Bank

When explaining the role of liver Kupffer cells to a group of nursing students, which of the following statements about the function of these cells is most accurate?

A) The primary function of Kupffer cells is to secrete bile.

B) These cells are the functional unit of the liver and are responsible for all liver secretions.

C) The cells are capable of removing and phagocytizing old and defective blood cells.

D) The role of the Kupffer cells is to provide at least 50% of cardiac output each minute to each lobular of the liver.

C

Feedback: Kupffer cells are reticuloendothelial cells that are capable of removing and phagocytizing old and defective blood cells, bacteria, and other foreign material from the portal blood as it flows through the sinusoid. This phagocytic action removes enteric bacilli and other harmful substances that filter into the blood from the intestine. Small tubular channels in the liver secrete bile. The functional unit of the liver is lobule. Approximately 25% of blood per minute enters the liver through the hepatic artery.

A 51-year-old male has been diagnosed with alcohol-induced liver disease. He admits to the nurse providing his care that, “I know what the lungs do, and I know what the heart does, but honestly I have no idea what the liver does in the body.” Which of the following statements would best underlie the explanation that the nurse provides?

A) The liver is responsible for the absorption of most dietary nutrients as well as the production of growth hormones.

B) The liver contributes to the metabolism of ingested food and provides the fluids that the GI tract requires.

C) The liver metabolizes most components of food and also cleans the blood of bacteria and drugs.

D) The liver maintains a balanced level of electrolytes and pH in the body and stores glucose, minerals, and vitamins.

C

Feedback: The liver metabolizes protein, carbohydrate, and fat. As well, it metabolizes drugs and removes bacteria by Kupffer cells. Absorption of nutrients takes place in the intestines, and the liver does not produce the bulk of fluids secreted in the GI tract. The liver does not have a primary role in the maintenance of acid–base or electrolyte balance.

A patient being seen in the clinic has just received his routine lab results. The patient has been told that his cholesterol level is extremely elevated. The physician plans to give the patient a prescription for medication to help control this condition. Which of the following medications should the nurse prepare to educate the patient on?

A) Atorvastatin (Lipitor)

B) Abilify (aripiprazole)

C) Pancrecarb (Pancrelipase)

D) Pancrelipase (Ultrase)

A

Feedback: The HMG-CoA reductase inhibitors or statins are used to treat high cholesterol levels by inhibiting this step in cholesterol synthesis. Abilify is for schizophrenia; Pancrecarb and Pancrelipase are pancreatic enzymes used for pancreatitis.

A 48-year-old woman has been diagnosed with extrahepatic cholestasis following a thorough history, ultrasound, and blood work. Which of the following symptoms most likely caused her to seek medical treatment, and what consequence to her health problem would the medical team anticipate?

A) Complaints of lower flank pain with consequences of impaired fat metabolism

B) Anorexia with consequences of impaired drug metabolism and blood filtration

C) Skin xanthomas (focal accumulations of cholesterol) with consequences of increased risk of bleeding due to deficient clotting factors

D) Pruritus with consequences of deficient levels of fat-soluble vitamins

D

Feedback: Pruritus is the most common symptom of cholestasis, and deficiencies in fat-soluble vitamins such as A, D, and K are frequent. Flank pain is not a noted complaint, and bile does not contribute to drug metabolism, blood filtration, or clotting factor production.

A male infant who is 48 hours postpartum is undergoing phototherapy for the treatment of jaundice and accompanying high levels of bilirubin. Place the following components of the production of bilirubin in the correct chronological order. Use all the options.

A) Conjugated bilirubin

B) Urobilinogen

C) Red blood cells

D) Biliverdin

E) Free bilirubin

Ans: C, D, E, A, B

Feedback: Hemoglobin from the red blood cell is broken down to form biliverdin, which is rapidly converted to free bilirubin. Inside the hepatocytes, free bilirubin is converted to conjugated bilirubin. Conjugated bilirubin is secreted as a constituent of bile, and in this form, it passes through the bile ducts into the small intestine. In the intestine, approximately one half of the bilirubin is converted into a highly soluble substance called urobilinogen by the intestinal flora.

A patient has just been admitted to a nursing unit with the diagnosis of obstructive jaundice. Which of the following assessment findings would the nurse expect to see in this patient? Select all that apply.

A) Clay-colored stools

B) Dark urine

C) Elevated conjugated bilirubin levels

D) Decreased serum alkaline phosphatase levels

E) Severe itching

Ans: A, B, C, E

Feedback: Obstructive jaundice occurs when bile flow is obstructed between the liver and the intestine. Among the causes are strictures of the bile duct, gallstones, and tumors of the bile duct or the pancreas. Conjugated bilirubin levels usually are elevated; the stools are clay colored; the urine is dark; the levels of serum alkaline phosphatase are markedly elevated; and the aminotransferase levels are slightly increased. The accumulation of bile acids in the blood leads to the development of pruritus (itching).

A 29-year-old female has been admitted to the emergency department following a suicide attempt by overdose of acetaminophen. What changes in the client's liver and diagnostic results would the care team most likely anticipate?

A) Hepatocellular necrosis evidenced by increased ALT and AST levels

B) Allergic inflammation accompanied by an increase in serum IgE and basophils

C) Cholestatic reaction with increased bilirubin count

D) Rapid onset of hepatitis and increased GGT, ALT, and bilirubin

A

Feedback: Acetaminophen is commonly implicated in cases of direct hepatotoxicity, a situation that is characterized by hepatocellular necrosis and increased ALT and AST levels. An allergic-type reaction is associated with idiosyncratic drug reactions, and cholestatic reactions and development of hepatitis are not noted to be associated with acetaminophen.

Four weeks after returning from a tropical vacation, a 40-year-old man has presented to the emergency department with malaise, nausea, and “yellow eyes.” Serology has confirmed a diagnosis of hepatitis A (HAV), to the shock of the client. What teaching is most appropriate for this client?

A) “You can expect these symptoms to disappear after about 2 months, but you'll be a carrier of the disease indefinitely.”

B) “A vaccine before your trip would have prevented this, but be assured your body will rid itself of the virus in time.”

C) “You likely came in contact with blood or body fluids at some point, and you'll have to ensure no one is subsequently exposed to your own blood or body fluids.”

D) “You likely got this by way of what we call the 'fecal–oral' route; you will have chronic hepatitis now, but the symptoms can be controlled with medication.”

B

Feedback: HAV is normally self-limiting and does not result in chronic hepatitis or carrier status. A vaccine is available, and the fecal–oral route of transmission, rather than contact with blood and body fluids, is typical.

A 53-year-old woman with a history of chronic alcohol abuse but without visible jaundice comes to the clinic complaining of nausea and weakness. She admits to taking acetaminophen for persistent headaches but denies exceeding the recommended daily dose; she has not taken any other medications. She is suspected of having acetaminophen toxicity. Which of the following diagnostic test findings would implicate a different cause of her symptoms?

A) Normal serum acetaminophen level

B) Elevated serum HBsAg level

C) Evidence of steatosis on liver biopsy tissue sample

D) Hypoglycemia

B

Feedback: The presence of HBsAg would suggest that this woman is in the prodromal phase of hepatitis B infection. A normal serum acetaminophen level does not preclude toxicity if the drug is taken over a period of time. Steatosis is fatty infiltration of the liver. Steatosis is often but not exclusively an early histological feature of alcoholic liver disease (therefore, with chronic alcohol abuse, the nurse should expect the patient may have steatosis). Drinking heavily without eating can block your liver from releasing stored glucose into your bloodstream, causing hypoglycemia.

A male patient comes to the clinic asking to speak to a health care provider privately. He reveals that he had shared a needle/syringe with a prostitute (shooting up cocaine) and then had unprotected sex. Upon questioning, it was revealed that the patient had not had any immunization for hepatitis B. Which of the following medications would the nurse anticipate administering today to this patient?

A) Tenofovir disoproxil fumarate plus emtricitabine

B) Hepatitis B immunoglobulin (HBIG)

C) Hepatitis C immunoglobulin (HCIG)

D) Hepatitis A vaccine

B

Feedback: HBIG is used as an adjunct to hepatitis B vaccine for postexposure immunoprophylaxis to prevent HBV infections in high-risk populations. Tenofovir disoproxil fumarate plus emtricitabine is for HIV preexposure coverage. There is no hepatitis C vaccine available on the market yet. Hepatitis A vaccine is for HAV, which is usually spread from fecal–oral routes.

A 40-year-old man who uses heroin intravenously was diagnosed with hepatitis C (HCV) 1 year ago and is now considered to have chronic viral hepatitis. Which of the following statements by the client to his care provider would warrant correction?

A) “I know the medications to treat this aren't fantastic, but at least there are some options for controlling the virus.”

B) “It's at least a bit reassuring that my liver isn't undergoing damage when I'm not experiencing symptoms.”

C) “Even though I'm sick, at least I won't feel sick most of the time.”

D) “I'm not looking forward to all the side effects of the drug treatments for my HCV, but I hope I don't end up needing a liver transplant.”

B

Feedback: Liver damage persists both during symptomatic and asymptomatic periods of acute viral hepatitis. Medications do exist for treatment of the disease, and asymptomatic periods are more common than symptomatic episodes. Side effects of drug treatment are common, and transplant is a potential end-stage treatment option.

A 24-year-old woman undergoing a premarital screening test is found to have elevated levels of AST, ALT, and IgG, but no antibody-specific markers for viral hepatitis. A liver biopsy reveals inflammation and cellular damage. Which of the following treatments is most likely to be effective for her?

A) Lamivudine

B) Peginterferon and ribavirin

C) Interferon alfa-2b

D) Corticosteroids and immunosuppressant drugs

D

Feedback: This woman's hepatitis is probably caused by an autoimmune disorder rather than a virus. Lamivudine, peginterferon/ribavirin, and interferon alfa-2b are all antiviral agents. Autoimmune hepatitis is a chronic, usually progressive, inflammatory disease of the liver. Corticosteroids are the mainstay of treatment and have been shown to produce remission. Azathioprine, an immunosuppressant medication, is sometimes used along with prednisone. Using both medications may allow you to take a smaller dose of prednisone, reducing its side effects. Most people with this disease require long-term maintenance treatment.

A 51-year-old male professional is in the habit of consuming six to eight rum and cokes each evening after work. He assures the nurse practitioner who is performing his regular physical exam that his drinking is under control and does not have negative implications for his work or family life. How could the nurse best respond to the client's statement?

A) “You are more than likely inflicting damage on your liver, but this damage would cease as soon as you quit drinking.”

B) “That may be the case, but you are still creating a high risk of hepatitis A or B or liver cancer.”

C) “In spite of that, the amount of alcohol you are drinking is likely to result first in cirrhosis and, if you continue, in hepatitis or fatty liver changes.”

D) “When your body has to regularly break down that much alcohol, your blood and the functional cells in your liver accumulate a lot of potentially damaging toxic byproducts.”

D

Feedback: The hepatic effects of alcohol use are related to the accumulation of toxic metabolites in the hepatocytes and blood. Damage can continue even after an individual stops drinking. Specific consequences do not usually include HAV, HBV, or liver cancer. Cirrhosis represents the culmination, not the beginning, of negative hepatic effects.

For several years, a 39-year-old female has been averaging two to three bottles of wine each night after her children go to sleep and has included several ounces of brandy in recent years as well. Despite negative consequences to her career and the dissolution of her marriage, her drinking has culminated in a diagnosis of cirrhosis. Which of the following physical manifestations of the health problem would her care team anticipate? Select all that apply.

A) Ascites

B) Anorexia

C) Fever

D) Bleeding tendencies

E) Epigastric pain

F) Obesity

A, B, D, E

Feedback: Ascites, anorexia, bleeding tendencies due to neurological effects, and epigastric pain are common accompaniments to cirrhosis. Ascites occurs when the amount of fluid in the peritoneal cavity is increased and is a late-stage manifestation of cirrhosis and portal hypertension. Epigastric pain is caused by liver enlargement or peritonitis. The peritoneal fluid is seeded with bacteria from the blood or lymph or from passage of bacteria through the bowel wall. Because factors V, VII, IX, and X, prothrombin, and fibrinogen are synthesized by the liver, their decline in liver disease contributes to bleeding tendencies. Fever and obesity would be less likely to exist, as the pathology is not infectious in nature and malnutrition and impaired food metabolism are common.

A patient with pancreatic cancer is admitted for portal hypertension in which he is symptomatic with ascites. Following paracentesis and removal of 7.5 L of ascitic fluid, the nurse should anticipate that the physician will order which of the following medications to assist in maintaining an effective circulating fluid volume?

A) Bumetanide (Bumex)

B) Furosemide (Lasix)

C) Albumin (human) 5%

D) Epogen (epoetin alfa)

C

Feedback: Complications of portal hypertension include ascites, splenomegaly, and hepatic encephalopathy. Following paracentesis, to remove ascitic fluid, a volume expander such as albumin is usually administered to maintain the effective circulating volume. Lasix and Bumex are diuretics that decrease circulating fluid volume. Epogen stimulates red blood cell production and ultimately increases O2-carrying capacity.

To reduce hepatic blood flow and decrease portal pressures in persons with cirrhosis, the nurse should be prepared to administer which of the following medications?

A) Bevacizumab, an angiogenesis inhibitor

B) Octreotide, a long-acting synthetic analog of somatostatin

C) Filgrastim, granulocyte colony-stimulating factor (G-CSF) analog

D) Diltiazem (Cardizem), a calcium channel blocker

B

Feedback: Ocetrotide, a long-acting synthetic analog of somatostatin, reduces splanchnic and hepatic blood flow and portal pressures in persons with cirrhosis. Bevacizumab was the first angiogenesis inhibitor that was shown to slow tumor growth and, more importantly, to extend the lives of patients with some cancers. Filgrastim rapidly reverses neutropenia and maintains normal ANC in patients with HIV infection. Diltiazem is used to treat a variety of conditions, such as high blood pressure, migraines, and Raynaud disease.

Which of the following clients in a hospital medical unit is most clearly demonstrating the signs and symptoms of liver failure? An adult with

A) low hemoglobin levels, low platelet levels, and spider angiomas present.

B) blood pressure of 189/103, jaundice, and multiple thromboses.

C) sudden onset of confusion, a history of alcohol abuse, and low levels of serum AST and ALT.

D) ascites, fever, and recent onset of atrial fibrillation.

A

Feedback: Anemia, thrombocytopenia, and the presence of spider angiomas are characteristic of liver failure. High blood pressure, excessive clotting, fever, and cardiac arrhythmias are not common symptoms of liver failure, and AST and ALT levels would rise, not fall.

Following several days of intermittent upper right quadrant pain, a 29-year-old obese, Native American woman has been diagnosed with cholelithiasis. The nurse at the clinic has taught the client about the pathophysiology and contributing factors to her health problem, as well as some of the likely treatment options. Which of the following statements by the client demonstrates a sound understanding of her diagnosis?

A) “All in all, I guess this is a result of the fact that I've been eating a diet too high in cholesterol for too long.”

B) “Several factors like my genetics and gender may have contributed to this, but I'm glad that medications can cure it.”

C) “This explains why my skin was yellow-tinged lately and why I had those pains that spread to my upper back and right shoulder.”

D) “I suppose the fever and vomiting I had this week was probably a sign of my gallstones too.”

C

Feedback: Gallstones can be caused by abnormalities in the composition of bile (increased cholesterol) and stasis of bile. The formation of cholesterol stones is associated with obesity and occurs more frequently in women. These factors cause the liver to excrete more cholesterol into the bile. Estrogen reduces the synthesis of bile acid in women. Cholesterol stones are extremely common in Native Americans. Jaundice and pain that radiates to the upper back and right shoulder are noted signs and symptoms of cholelithiasis. While cholesterol is a key element in the formation of gallstones, the particular amount ingested in the diet is not central to the development of the problem. Surgery, not medication, is the normal treatment modality, and fever and nausea are more closely associated with cholecystitis rather than cholelithiasis.

While on tour, a 32-year-old male musician has presented to the emergency department of a hospital after a concert complaining of severe and sudden abdominal pain. He admits to a history of copious alcohol use in recent years, and his vital signs include temperature 46.8°C (101.8°F), blood pressure 89/48 mm Hg, and heart rate 116 beats/minute. Blood work indicates that his serum levels of C-reactive protein, amylase, and lipase are all elevated. Which of the following diagnoses would the care team suspect first?

A) Hepatitis C

B) Cholecystitis

C) Liver cirrhosis

D) Acute pancreatitis

D

Feedback: Alcohol use, fever, hypotension, and tachycardia are often associated with pancreatitis, as are elevated serum amylase and lipase levels. These enzymes would unlikely rise in cases of hepatitis, cholecystitis, or cirrhosis. The precise mechanisms whereby alcohol exerts its action are largely unknown. The capacity for oxidative and nonoxidative metabolism of ethanol by the pancreas and the harmful by-products that result have been related to the disease process. Hepatitis C has an incubation period. Most adults who acquire the infection usually are asymptomatic. Jaundice is uncommon. Direct measurement of HCV in the serum remains the most accurate test for infection. Cirrhosis represents the end stage of chronic liver disease. The end result is liver failure that affects many organs. The patients usually have anemia, thrombocytopenia, endocrine disorders, skin lesions, azotemia and renal failure, and hepatic encephalopathy.

A 70-year-old male with a 40 pack-year history of smoking and long-standing non–insulin-dependent diabetes has been diagnosed with pancreatic cancer. Which of the following teaching points should the physician provide?

A) “While this is indeed serious, you should know that you have a good chance of beating this disease with appropriate treatment.”

B) “Most likely your pattern of high alcohol intake over the years contributed to your cancer.”

C) “You will likely be facing surgery in the near future, but know that this is very unlikely to eliminate your cancer.”

D) “I know it may seem trivial at this point, but the levels of pain that accompany cancer of the pancreas are normally quite low.”

C

Feedback: Surgery is the most common treatment modality for pancreatic cancer, but it does not commonly result in the resolution of the disease. Pancreatic cancer has a very poor prognosis, and alcohol is not a common contributor. Pancreatic cancer is noted to be exceptionally painful.