Silvestri Chapter 46 Ed56A

Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 046 (edited file)"Gastrointestinal System" 10/14/08, Page 1 of 31, 0 Figure(s), 0 Table(s), 12 Box(es)
46: Gastrointestinal System

PRACTICE QUESTIONS
1. A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. Which nursing action would be the priority for this client? 1. Thorough investigation of the precipitating events 2. Insertion of a nasogastric tube and Hematest the emesis 3. Complete abdominal physical examination 4. Determination of vital signs Answer: 4 Rationale: The determination of vital signs indicates whether the client is in shock from blood loss and also provides a baseline blood pressure and pulse by which to monitor the progress of treatment. Signs and symptoms of shock include low blood pressure; rapid, weak pulse; increased thirst; cold, clammy skin; and restlessness. Vital signs should be monitored every 15 to 30 minutes, and the physician should be informed of any significant changes. The client may not be able to provide subjective data until the immediate physical needs are met. Although options 2 and 3 may be a component of care, they are not the priority. Test-Taking Strategy: Note the word, priority, and use the ABCsairway, breathing, and circulation. A client with an acute upper GI bleed is at risk for shock. Monitoring vital signs is the nursing action that will assess circulation, provide information about the clients circulating volume status, and alert the nurse to early stages of shock. Review care of the client with a GI bleed if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 192. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 688. 2. A nurse is caring for a client with possible cholelithiasis who is being prepared for a cholangiogram and provides instructions to the client about the procedure. Which client statement indicates that the client understands the purpose of this test? 1. They are going to look at my gallbladder and ducts. 2. This procedure will drain my gallbladder. 3. My gallbladder will be irrigated. 4. They will put medication in my gallbladder. Answer: 1 Rationale: A cholangiogram is for diagnostic purposes. It outlines both the gallbladder and the ducts, so gallstones that have moved into the ductal system can be detected. X-rays are used to visualize the biliary duct system after an IV injection of radiopaque dye. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate options 2, 3 and 4 because they
are similar. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Gastrointestinal References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 718. Thompson, J., McFarland, G., Hirsch, J., & Tucker, S. (2002). Mosbys clinical nursing (5th ed.). St. Louis: Mosby, pp. 1378-1379. 3. A nurse is caring for a client with acute pancreatitis and a history of alcoholism and is monitoring the client for complications. Which of the following data would be a sign of paralytic ileus? 1. Firm, nontender mass palpable at the lower right costal margin 2. Severe, constant pain with rapid onset 3. Inability to pass flatus 4. Loss of anal sphincter control Answer: 3 Rationale: An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Option 1 is the description of the physical finding of liver enlargement. The liver is usually enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. Loss of sphincter control is not a sign of paralytic ileus. Test-Taking Strategy: Use the process of elimination. Note the relationship between the words paralytic ileus and option 3. Review these clinical manifestations if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 223. 4. A nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The client has tolerated the tube being clamped every 2 hours for 1 hour and the physician has now ordered the nasogastric tube to be discontinued. To determine the clients readiness for discontinuation of the nasogastric tube, the nurse should check for: 1. Proper nasogastric tube placement 2. The clients serum electrolyte levels 3. Presence of bowel sounds in all four quadrants 4. The pH of the gastric aspirate Answer: 3 Rationale: Distention, vomiting, and abdominal pain are a few of the symptoms associated with
intestinal obstruction and a nasogastric tube may be used to empty the stomach and relieve distention and vomiting. Bowel sounds return to normal as the obstruction is relieved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function returns may result in a return of the symptoms necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, tube placement, and pH of gastric aspirate are important assessments for the client with a nasogastric tube in place, but would not assist in determining the readiness for removing the nasogastric tube. Test-Taking Strategy: Use the process of elimination and focus on the issue, removing the nasogastric tube. Recalling the pathophysiology for intestinal obstruction and purpose of a nasogastric tube as a therapy will direct you to option 3. Review care of the client with an intestinal obstruction if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 660, 662. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp.762, 1183. 5. A sexually active 20-year-old client has developed viral hepatitis. Which of the following statements if made by the client would indicate a need for teaching? 1. A condom should be used for sexual intercourse. 2. I can never drink alcohol again. 3. I wont go back to work right away. 4. My close friends should get the vaccine. Answer: 2 Rationale: To prevent transmission of hepatitis, a condom is advised during sexual intercourse as well as vaccination of the partner or close friends. Alcohol should be avoided for 1 year, because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that the liver function has returned to normal. The clients activity is increased gradually. Test-Taking Strategy: Use the process of elimination and note the key words, need for teaching. These words indicate a false response question and that you need to select the incorrect client statement. Recalling the pathophysiology related to hepatitis and the key word never in option 2 will direct you to this option. Review client instructions regarding hepatitis if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 731. 6. A client is admitted to the hospital with severe jaundice and is having diagnostic testing. Because the client has no complaints of fatigue, the client is encouraged to ambulate in the hall
to maintain muscle strength. The client paces around the room, but will not enter the hall. Which of the following problems most likely is the reason for the clients reluctance to walk in the hall? 1. Fear of catching another disease 2. Not wanting to overexert and get overtired 3. Feeling self conscious about appearance 4. Unfamiliarity with the hospital Answer: 3 Rationale: Clients with jaundice frequently have a body image disturbance because of a change in appearance. This can be manifested in negative verbal or nonverbal behavior. Options 1, 2, and 4 are unrelated to the data in the question. Test-Taking Strategy: Use the process of elimination. Noting the key words, severe jaundice, will direct you to option 3. Review the psychosocial issues related to jaundice if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 723. 7. A client with viral hepatitis has no appetite and food makes the client nauseated. Which nursing intervention would be most appropriate? 1. Explain that high-fat diets are usually better tolerated. 2. Encourage foods low in calories. 3. Explain that the majority of calories need to be consumed in the evening hours. 4. Monitor for fluid and electrolyte imbalances. Answer: 4 Rationale: If nausea persists, the client will need to be assessed for fluid and electrolyte imbalances. It is important to explain to the client that the majority of calories should be eaten in the morning hours, because nausea most often occurs in the afternoon and evening. Clients should select a diet high in calories, because energy is required for healing. Changes in bilirubin interfere with fat absorption, so low fat-diets are better tolerated. Test-Taking Strategy: Use the process of elimination. Recalling the nutritional aspects of care for clients with viral hepatitis will direct you to option 4. Review care of the client with viral hepatitis if you had difficulty answering this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, pp. 233-234. 8. A nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer. The nurse would plan to include which most important risk factor for colorectal cancer in the material?
1. Age of 20 years 2. High-fiber, low-fat diet 3. Distant relative with colorectal cancer 4. Personal history of ulcerative colitis or gastrointestinal polyps Answer: 4 Rationale: Common risk factors for colorectal cancer include age over 40 years, first-degree relative with colorectal cancer, high-fat, low-fiber diet, and history of bowel problems such as ulcerative colitis or familial polyposis. Test-Taking Strategy: Use the process of elimination. Noting the key words, personal history, in option 4 will direct you to this option. Review these risk factors if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 682. 9. A hospitalized client with gastroesophageal reflux disease (GERD) is complaining of chest discomfort that feels like heartburn following a meal. After administering a prescribed antacid, the nurse would encourage the client to lie in which position? 1. Supine, with the head of bed flat 2. On the stomach, with the head flat 3. On the left side, with the head of bed elevated 30 degrees 4. On the right side, with the head of bed elevated 30 degrees Answer: 3 Rationale: The discomfort of reflux is aggravated by positions that compress the abdomen and the stomach. These include lying flat either on the back or stomach after a meal, or lying on the right side. The left side-lying position with the head of the bed elevated is most likely to give relief to the client. Test-Taking Strategy: Use the process of elimination. Evaluate each of the positions described in terms of their ability to put pressure on the stomach and cause reflux. Using knowledge of anatomy and these basic nursing positions, you should be able to eliminate each of the incorrect options. Review the measures to relieve reflux if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 682. 10. A nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances that will increase the lower esophageal sphincter (LES) pressure. The nurse tells the client to include which item in the diet? 1. Fatty foods 2. Nonfat milk
3. Tea 4. Coffee Answer: 2 Rationale: Foods that increase the LES pressure will decrease reflux, and lessen the symptoms of GERD. The food item that will increase the LES pressure is nonfat milk. The other items listed decrease the LES pressure, thus increasing reflux symptoms. Aggravating substances include chocolate, coffee, fatty foods and alcohol. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are similar and both contain caffeine. From the remaining options, recalling the effects of fatty foods will direct you to option 2. Review these food items if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 682. 11. A client has undergone esophagogastroduodenoscopy (EGD). The nurse places highest priority on which of the following items as part of the clients care plan? 1. Checking for return of a gag reflex 2. Giving warm gargles for a sore throat 3. Monitoring the temperature 4. Monitoring for complaints of heartburn Answer: 1 Rationale: The nurse places highest priority on managing the clients airway. This includes assessing for return of the gag reflex. The clients vital signs are also monitored and a sudden sharp increase in temperature could indicate perforation of the gastrointestinal tract. This would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; the clients airway still takes priority however. Test-Taking Strategy: Use the process of elimination. Note that the question contains the key words, highest priority. Use the ABCsairway, breathing, and circulation. This will direct you to option 1. Review postprocedure care following EGD if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Delegating/Prioritizing Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 510. 12. A nurse has taught a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs additional information if the client makes which statement? 1. I know I must sign a consent form. 2. Im glad I dont have to lie still for this procedure. 3. Im glad some medication will be given IV to relax me.
4. I hope the throat spray keeps me from gagging. Answer: 2 Rationale: The client needs to lie still for ERCP, which takes about an hour to perform. The client also needs to sign a consent form. IV sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed. Test-Taking Strategy: Use the process of elimination. Note the key words, needs additional information. These words indicate a false response question and that you need to select the incorrect client statement. Invasive procedures require consent, so option 1 can be eliminated. Noting the name of the procedure and considering the anatomical location will assist in eliminating options 3 and 4. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Gastrointestinal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 501. 13. A client being seen in a physicians office has just been scheduled for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test? 1. Remove all metal and jewelry before the test. 2. Eat a regular supper and breakfast. 3. Continue to take all oral medications as scheduled. 4. Monitor own bowel movement pattern for constipation. Answer: 1 Rationale: A barium swallow is an x-ray that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal (GI) tract. The client is told to remove all jewelry before the test, so it wont interfere with x-ray visualization of the field. The client should fast for 8 to 12 hours before the test, depending on the physicians instructions. Most oral medications are also withheld before the test, depending on the physicians instructions. It is important after the procedure to monitor for constipation following the procedure, which can occur as a result of the presence of barium in the GI tract. Test-Taking Strategy: Use the process of elimination. Note that the key words in the stem of the question are barium swallow and before. This tells you that the correct option is an item that the client needs to comply with before the test is done. Eliminate option 4 first, because it is a part of aftercare. Eliminate option 3 next because of the word all. Recalling that the procedure is a type of x-ray that involves barium for contrast and an NPO status will direct you to option 1. Review preprocedure instructions for this test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal References: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 360. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 961.
14. A nurse is teaching the client about an upcoming colonoscopy procedure. The nurse would include in the instructions that the client will be placed in which of the following positions for the procedure? 1. Left Sims position 2. Right Sims position 3. Knee-chest position 4. Lithotomy position Answer: 1 Rationale: The client is placed in the left Sims position for the procedure. This position takes the best advantage of the clients anatomy for ease in introducing the colonoscope. The other options are incorrect. Test-Taking Strategy: Use concepts related to gastrointestinal anatomy to answer this question. The answer would be the same as would be utilized for giving the client an enema while lying down. When answering factual questions such as these, remember the guiding principles and attempt to visualize the procedure to help you select the correct option. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 390. 15. A nurse has given postprocedure instructions to a client who has undergone a colonoscopy. The nurse determines that the client did not fully understand the directions if the client states that: 1. Intake should be light at first, then progress to regular intake. 2. It is normal to feel gassy or bloated after the procedure. 3. The abdominal muscles may be tender from stretching during the procedure. 4. It is all right to drive once the client has been home for an hour or so. Answer: 4 Rationale: The client should not drive for several hours after this test because the client would have received sedative medications during the procedure. The client should resume intake slowly, and progress as tolerated. The client may experience gas or abdominal tenderness for a short while after the procedure, and this is normal. Test-Taking Strategy: Use the process of elimination. Note that the question contains the key words, did not fully understand. This tells you that the correct option is an incorrect statement on the part of the client. Use knowledge of events during the procedure to choose the correct option. Recalling that sedating medications are administered will direct you to option 4. Review postprocedure instructions if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th
ed.). Philadelphia: W.B. Saunders, p. 391. 16. A nurse is preparing to perform an abdominal examination. The initial step would be which of the following? 1. Auscultation 2. Inspection 3. Palpation 4. Percussion Answer: 2 Rationale: The appropriate technique for abdominal examination is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection and before percussion and palpation to ensure that the motility of the bowel and bowel sounds are not altered. The sequence of maneuvers is inspect, auscultate, percuss, and palpate. Test-Taking Strategy: Use the process of elimination and think about the procedure. Remember that the sequence for abdominal examination is different than the usual systematic approach. Review this technique if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed). St. Louis: Mosby, pp. 67-68. 17. A client is scheduled for an oral cholecystography. The nurse would plan to obtain what type of diet for the evening meal before the test? 1. Low-protein 2. High-carbohydrate 3. Fat-free 4. Liquid Answer: 3 Rationale: Normal dietary intake of fat should be maintained during the days preceding the test in order to empty bile from the gallbladder. A fat-free diet is ordered on the evening before the test. The fat-free supper prevents contraction of the gallbladder and allows accumulation of the contrast substance needed for x-ray visualization. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Recalling that an oral cholecystogram is an x-ray of the gallbladder and thinking about the function of the gallbladder will assist in selecting the correct option. Review this test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 1144-1145. 18. A client with viral hepatitis states to the nurse, I am so yellow. The nurse would most appropriately:
1. Assist the client in expressing feelings. 2. Keep the client isolated from other clients and visitors. 3. Provide information to the client about hepatitis. 4. Restrict visitors until the jaundice subsides. Answer: 1 Rationale: The clients feelings should be explored to discover how the client feels about the disease process and appearance so appropriate interventions can be planned. Options 2, 3, and 4 are inappropriate. Test-Taking Strategy: Use the process of elimination and focus on the clients concern. Remembering to address the clients feelings will direct you to option 1. Review the psychosocial issues related to hepatitis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 723. 19. A nurse provides instructions to a client following a liver biopsy. The nurse tells the client to: 1. Avoid alcohol for 8 hours. 2. Save all stools to be checked for blood. 3. Remain NPO for 24 hours. 4. Lie on the right side for 2 hours. Answer: 4 Rationale: In order to splint the puncture site, the client is kept on his or her right side for a minimum of 2 hours. It is not necessary to remain NPO for 24 hours. Permission regarding the consumption of alcohol should be obtained from the physician. It is not necessary to save all stools. Test-Taking Strategy: Use the process of elimination and focus on the issue, a liver biopsy. Recalling the anatomical location of this procedure will direct you to option 4. Review postprocedure instructions following a liver biopsy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Pagana, K., & Pagana, T. (2003). Mosbys diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 569. 20. A nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that this client is at risk for which vitamin deficiency? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E Answer: 2
Rationale: Deterioration and atrophy of the lining of the stomach lead to the loss of function of the parietal cells. When the acid secretion decreases, the source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. Options 1, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Knowledge regarding the pathophysiology related to the lining of the stomach is required to answer this question. If you are unfamiliar with vitamin B12 deficiency and its relationship to gastric disorders, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 690. 21. A nurse is reviewing the medication record of a client with acute gastritis. Which of the following medications, if noted on the clients record, would the nurse question? 1. Digoxin (Lanoxin) 2. Ibuprofen (Motrin) 3. Furosemide (Lasix) 4. Propranolol hydrochloride (Inderal) Answer: 2 Rationale: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) and can cause ulceration of the esophagus, stomach, duodenum or small intestine. It is contraindicated in a client with a gastrointestinal disorder. Furosemide is a loop diuretic. Digoxin is an antidysrhythmic. Propranolol hydrochloride is a beta-adrenergic blocker. Furosemide, digoxin, and propranolol hydrochloride are not contraindicated in clients with gastric disorders. Test-Taking Strategy: Knowledge regarding the side effects associated with the medications identified in the options is required to answer this question. Remember, a nonsteroidal antiinflammatory drug (NSAID) can cause ulceration of the esophagus, stomach, duodenum or small intestine. If you are unfamiliar with these medications, review this content. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: McKenry, L., & Salerno, E. (2003). Mosbys pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 290. 22. A nurse is monitoring a client with a diagnosis of peptic ulcer. Which finding would most likely indicate perforation of the ulcer? 1. Bradycardia 2. Numbness in the legs 3. Nausea and vomiting 4. A rigid, boardlike abdomen Answer: 4
Rationale: Perforation is a surgical emergency. It is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding. Test-Taking Strategy: Use the process of elimination. Note the key words, most likely, in the stem of the question. Option 2 can be eliminated first. Eliminate option 1 next because tachycardia rather that bradycardia would develop if the client is bleeding. From the remaining options, focusing on the key words will assist in directing you to option 4. Review the signs of perforation if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 688-689. 23. A client with peptic ulcer disease is scheduled for a pyloroplasty and the client asks the nurse about the procedure. The nurse bases the response on which of the following? 1. A pyloroplasty involves cutting the vagus nerve. 2. A pyloroplasty involves removing the distal portion of the stomach. 3. A pyloroplasty involves removal of the ulcer and a large portion of the cells that produce hydrochloric acid. 4. A pyloroplasty involves an incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum. Answer: 4 Rationale: Option 4 describes the procedure for a pyloroplasty. A vagotomy involves cutting the vagus nerve. A subtotal gastrectomy involves removing the distal portion of the stomach. A Billroth II procedure involves removal of the ulcer and a large portion of the cells that produce hydrochloric acid. Test-Taking Strategy: Use the process of elimination. Note the relationship between the words pyloroplasty in the question and pylorus in the correct option. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 687. 24. A client with a peptic ulcer is scheduled for a vagotomy and the client asks the nurse about the purpose of this procedure. The nurse tells the client that a vagotomy: 1. Decreases food absorption in the stomach 2. Heals the gastric mucosa 3. Halts stress reactions 4. Reduces the stimulus to acid secretions Answer: 4
Rationale: A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. Options 1, 2, and 3 are incorrect descriptions of a vagotomy. Test-Taking Strategy: Knowledge regarding the procedure and purpose of a vagotomy is required to answer this question. Remember, a vagotomy is done to eliminate parasympathetic stimulation of gastric secretion. If you are unfamiliar with this procedure, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 687. 25. A nurse is caring for a client following a Billroth II procedure. On review of the postoperative orders, which of the following, if prescribed, would the nurse question and verify? 1. Irrigating the nasogastric (NG) tube 2. Coughing and deep breathing exercises 3. Leg exercises 4. Early ambulation Answer: 1 Rationale: In a Billroth II resection, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the NG tube is critical for preventing the retention of gastric secretions. The nurse however, should never irrigate or reposition the gastric tube after gastric surgery unless specifically ordered by the physician. In this situation, the nurse should clarify the order. Options 2, 3, and 4 are appropriate postoperative interventions. Test-Taking Strategy: Use the process of elimination. Eliminate options 2, 3, and 4 because they are general postoperative measures. Also, consider the anatomical location of the surgical procedure to assist in directing you to option 1. Review these postoperative measures if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 190. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 689. 26. The nurse is providing discharge instructions to a client following gastrectomy. Which measure will the nurse instruct the client to follow to help prevent dumping syndrome? 1. Eat high-carbohydrate foods. 2. Limit the fluids taken with meals. 3. Ambulate following a meal. 4. Sit in a high-Fowlers position during meals. Answer: 2 Rationale: The client should be instructed to decrease the amount of fluid taken at meals. The client should also be instructed to avoid high-carbohydrate foods including fluids, such as fruit
nectars; to assume a low-Fowlers position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because these measures will promote gastric emptying. From the remaining options, select option 2 because this measure will delay gastric emptying. If you are unfamiliar with this syndrome, review these client teaching points. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 692. 27. A nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which of the following symptoms will indicate this occurrence? 1. Dry skin and stomach pain 2. Bradycardia and indigestion 3. Sweating and pallor 4. Double vision and chest pain Answer: 3 Rationale: Early manifestations occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. Test-Taking Strategy: Knowledge regarding the early manifestations associated with dumping syndrome is required to answer this question. Remember, sweating and pallor occur and are early signs of dumping syndrome. If you are unfamiliar with these manifestations, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 662. 28. A nurse is instructing the client who had a herniorrhaphy how to reduce postoperative swelling following the procedure. Which of the following would the nurse suggest to the client to prevent swelling? 1. Apply heat to the abdomen. 2. Elevate the scrotum. 3. Limit fluids. 4. Maintain a low-roughage diet. Answer: 2 Rationale: Following herniorrhaphy, the client should be instructed to elevate the scrotum and apply ice packs while in bed to decrease pain and swelling. The client is also instructed to apply a scrotal support when out of bed. Options 1, 3, and 4 are incorrect. Test-Taking Strategy: The issue of the question is to prevent swelling. Basic knowledge regarding the effects of heat and cold will assist in eliminating option 1. Options 3 and 4 can be
eliminated next by focusing on the issue. Review postoperative care following herniorrhaphy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes. (7th ed.). Philadelphia: W.B. Saunders, p. 841. 29. A nurse is reviewing the record of a client with Crohns disease. Which of the following stool characteristics would the nurse expect to note documented in the record? 1. Bloody stools 2. Diarrhea 3. Constipation 4. Stool constantly oozing from the rectum Answer: 2 Rationale: Crohns disease is characterized by nonbloody diarrhea of usually not more than four or five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options 3 and 4 are not characteristics of Crohns disease. Test-Taking Strategy: Use the process of elimination. Recalling the pathophysiology related to Crohns disease will direct you to option 2. If you are unfamiliar with this disorder, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 202. 30. A nurse is performing a colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. Which of the following is the appropriate nursing action? 1. Notify the registered nurse immediately. 2. Increase the height of the irrigation. 3. Stop the irrigation temporarily. 4. Medicate for pain and resume irrigation. Answer: 3 Rationale: If cramping occurs during colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from infusion that is too rapid or is causing too much pressure. Increasing the height of the irrigation will cause further discomfort. The registered nurse does not need to be notified immediately. Medicating the client for pain is not the most appropriate action. Test-Taking Strategy: Use the process of elimination and focus on the issue of the question. Using the principles related to administering an enema will direct you to option 3. Review the procedure for colostomy irrigation if you had difficulty with this question. Level of Cognitive Ability: Application
Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1092. 31. A nurse is teaching a client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation, what measure should the nurse instruct the client to do? 1. Increase fluid intake. 2. Reduce the amount of irrigation solution. 3. Massage the abdomen gently. 4. Place heat on the abdomen. Answer: 3 Rationale: To enhance effectiveness of the irrigation, the client is instructed to change position, ambulate, massage the abdomen gently, and drink something warm. Options 1, 2, and 4 will not enhance the effectiveness of this procedure. Test-Taking Strategy: Focus on the issue of the question, which is the measure that will enhance the effectiveness of the irrigation. This focus will assist in eliminating options 1, 2, and 4. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1092. 32. A nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. To check for the presence of this sign, the nurse would do which of the following? 1. Ask the client to extend the arms. 2. Check for the presence of Homans sign. 3. Instruct the client to lean forward. 4. Measure the abdominal girth. Answer: 1 Rationale: Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. It is the most common sign that hepatic encephalopathy is developing. Test-Taking Strategy: Use the process of elimination. Recalling the definition of asterixis will direct you to option 1. If you are unfamiliar with this data collection procedure, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 229.
33. A client with ascites is scheduled for a paracentesis. The nurse is assisting the physician in performing the procedure. Which of the following positions will the nurse assist the client to assume for this procedure? 1. Flat 2. Left side-lying 3. Right side-lying 4. Upright Answer: 4 Rationale: An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. Options 1, 2, and 3 are incorrect positions. Test-Taking Strategy: Use the process of elimination and visualize this procedure in selecting the correct option. Knowing that fluid will be aspirated from the abdominal cavity will assist in directing you to option 4. If you had difficulty with this question, review this procedure. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 843. 34. A nurse is reviewing the laboratory results of a client with cirrhosis and notes that the ammonia level is elevated. Which of the following diets would the nurse anticipate would most likely be prescribed for this client? 1. High-carbohydrate 2. Moderate-fat 3. High-protein 4. Low-protein Answer: 4 Rationale: Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein and this results in the formation of ammonia. A low-protein diet would be prescribed. The diets in options 1, 2, and 3 are incorrect. Test-Taking Strategy: Use the process of elimination. Note that options 3 and 4 are opposite, which should provide you with the clue that one of these options is correct. Recalling the physiology of the liver will direct you to option 4. Review care of the client with cirrhosis if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 231. 35. Lactulose (Chronulac) is prescribed for a client with a diagnosis of hepatic encephalopathy. Which finding indicates that the client is responding to this medication therapy as anticipated?
1. The fecal pH is acidic 2. The client experiences diarrhea 3. The client is able to tolerate a full diet 4. Vomiting occurs Answer: 1 Rationale: Lactulose is an osmotic laxative. The desired effect is two or three soft stools per day, with an acid fecal pH. Lactulose creates an acid environment in the bowel, resulting in a fall of the colons pH from 7 to 5. This causes ammonia to leave the circulatory system and move into the colon. Diarrhea may indicate excessive administration of the medication. Options 3 and 4 do not determine that a desired effect has occurred. Test-Taking Strategy: Knowledge regarding the purpose and action of this medication is required to answer this question. Remember the desired effect is two or three soft stools per day, with an acid fecal pH. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Gastrointestinal Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W. B. Saunders, pp. 611-612. 36. An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. The nurse explains to the client that this test: 1. Requires the client to lie still for short intervals 2. Requires that the client be NPO 3. Is preceded by the administration of oral tablets 4. Is uncomfortable Answer: 1 Rationale: Ultrasound of the gallbladder is a noninvasive procedure and is frequently used for emergency diagnosis of acute cholecystitis. The client does not need to be NPO but may be instructed to avoid carbonated beverages for 48 hours before the test to help decrease intestinal gas. It is a painless test and does not require the administration of oral tablets as preparation. Test-Taking Strategy: Focus on the issue, an ultrasound. Visualizing this procedure will direct you to option 1. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 484. 37. A nurse is providing preoperative teaching to a client scheduled for a cholecystectomy. Which intervention would be the highest priority in the preoperative teaching plan? 1. Teaching coughing and deep breathing exercises 2. Teaching leg exercises 3. Instructions regarding fluid intake and diet 4. Checking the clients understanding of the surgical procedure
Answer: 1 Rationale: After cholecystectomy, breathing tends to be shallow, because deep breathing is painful as a result of the location of the surgical procedure. Teaching the importance of performing coughing and deep breathing exercises is the priority. Test-Taking Strategy: Note the key words, highest priority. Use the process of elimination and recall the anatomical location of this surgical procedure. Use of the ABCsairway, breathing, and circulationwill direct you to option 1. Review preoperative teaching for a cholecystectomy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 737. 38. A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is appropriate? 1. Notify the physician immediately. 2. Change the dressing. 3. Circle the amount on the dressing with a pen. 4. Continue to monitor the drainage. Answer: 2 Rationale: Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases and the drain is removed usually in 48 hours. The registered nurse does not need to be notified immediately. A sterile dressing covers the site and should be changed to prevent infection and skin excoriation. Test-Taking Strategy: Use the process of elimination and note the key words, most appropriate. Eliminate options 3 and 4 first because they are similar. From the remaining options, recalling the expected findings following this surgical procedure will direct you to option 2. Review care of the client following cholecystectomy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 241. 39. A client is admitted to the hospital for treatment of acute hepatitis B. Which activity order would the nurse expect to be prescribed? 1. Bed rest 2. Encourage ambulation 3. Out of bed in a chair continuously during the day 4. No activity restrictions Answer: 1 Rationale: Fatigue is a normal response to hepatic cellular damage. During the acute stage, rest
is an essential intervention to reduce the livers metabolic demands and increase its blood supply. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Note the key word, acute, in the question. Knowing that the liver will need to rest in order to heal will assist you to option 1. If you are unfamiliar with the care of a client with hepatitis, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 233. 40. It has been determined that a client with hepatitis has contracted the infection from contaminated food. What type of hepatitis is this client most likely experiencing? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D Answer: 1 Rationale: Hepatitis A is transmitted by the fecal oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are most commonly transmitted via infected blood or body fluids. Test-Taking Strategy: Knowledge regarding the modes of transmission of the various types of hepatitis is required to answer this question. Remember, hepatitis A is transmitted by the fecal oral route via contaminated food or infected food handlers. If you are unfamiliar with the modes of transmission of hepatitis, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 232. 41. A nurse is reviewing the physicians orders written for a client admitted with acute pancreatitis. Which physician order would the nurse verify if noted on the clients chart? 1. NPO status 2. Prepare to insert a nasogastric tube 3. An anticholinergic medication 4. Morphine sulfate for pain Answer: 4 Rationale: Meperidine (Demerol) rather than morphine sulfate is the medication of choice, because morphine sulfate can cause spasms in the sphincter of Oddi. Therefore, the nurse would verify this order. Options 1, 2, and 3 are appropriate interventions for the client with acute pancreatitis. Test-Taking Strategy: Use the process of elimination and note the key word, acute, in the question. Recalling the treatment measures for acute pancreatitis and the contraindications in the
care of the client will direct you to option 4. Review these measures if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 243. 42. A client with peptic ulcer states that stress frequently causes exacerbation of the disease. The nurse would interpret that which of the following items mentioned by the client is most likely responsible for the exacerbations? 1. Sleeping 8 to 10 hours a night 2. Eating five or six small meals per day 3. Ability to work at home periodically 4. Frequent need to work overtime on short notice Answer: 4 Rationale: Psychological or emotional stressors that exacerbate peptic ulcer disease may be found either at home or in the workplace. The frequent need to work overtime on short notice is the option that is potentially most stressful, because it is the item over which the client has least control. An ability to work at home periodically is not necessarily stressful, because there is increased client control over timing of work and location. Adequate rest and proper dietary pattern (options 1 and 2) should alleviate symptoms, not worsen them. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating options 1 and 2, because they are healthy living habits. Recall that psychological stress may be worsened in situations where there is little client control. This will direct you to option 4. Review the causes of exacerbation of this disease if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, pp. 192-193. 43. A client with peptic ulcer disease needs dietary modification to reduce episodes of epigastric pain. The nurse would teach the client that which of the following items does not need to be limited or eliminated with this disease? 1. Wine 2. Baked chicken 3. Coffee 4. Fresh fruit Answer: 2 Rationale: Dietary modification for the client with peptic ulcer disease includes eliminating foods that are irritating to the client. Items that are generally eliminated or avoided are highly spiced foods, alcohol, caffeine, chocolate, and fresh fruits. Other foods may be taken according
to the clients tolerance of that specific food. Test-Taking Strategy: Use the process of elimination and focus on the clients diagnosis. Note the key words, does not need to be limited or eliminated. Recalling which types of foods and beverages are irritating to the gastrointestinal mucosa will direct you to option 2. Review the dietary measures for peptic ulcer disease if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 193. 44. A nurse instructs the ileostomy client to do which of the following as part of essential care of the stoma? 1. Cleanse the peristomal skin meticulously. 2. Eat high-fiber foods, such as nuts. 3. Massage the area below the stoma every morning and every evening. 4. Limit fluid intake to prevent diarrhea. Answer: 1 Rationale: The peristomal skin must receive meticulous cleansing because the ileostomy drainage has more enzymes and is more caustic to the skin than colostomy drainage. Foods such as nuts and those with seeds will pass through the ileostomy. The client should be taught that these foods will remain undigested. The area below the ileostomy may be massaged as needed if the ileostomy becomes blocked by high-fiber foods. Fluid intake should be maintained by at least six to eight glasses of water per day to prevent dehydration. Test-Taking Strategy: Use the process of elimination. Note the key words, essential care and stoma. This tells you that the correct option will be the option that deals with the stoma directly. This focus will direct you to option 1. Review client teaching regarding ileostomy care if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, pp. 201-202. 45. A client with hiatal hernia chronically experiences heartburn following meals. The nurse would teach the client to avoid which of the following, which is contraindicated with hiatal hernia? 1. Eating small, frequent, bland meals 2. Lying recumbent following meals 3. Raising the head of the bed on 6-inch blocks 4. Taking histamine receptor antagonist medication, as prescribed Answer: 2 Rationale: Hiatal hernia is due to a protrusion of a portion of the stomach above the diaphragm, where the esophagus usually is positioned. The client generally experiences pain caused by
reflux resulting from ingestion of irritating foods, lying flat following meals or at night, and consuming large or fatty meals. Relief is obtained by eating small, frequent, and bland meals; by histamine antagonists and antacids; and by elevation of the thorax following meals and during sleep. Test-Taking Strategy: Use the process of elimination. Note the key word, contraindicated. This tells you that the correct answer will be the option that represents an aggravating factor for hiatal hernia discomfort. Visualize each option and think about the anatomical location of a hiatal hernia to direct you to option 2. Review these teaching points if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 682. 46. A nurse is monitoring for stoma prolapse in a client with a colostomy. The nurse would observe which of the following appearances in the stoma if prolapse occurred? 1. Sunken and hidden 2. Dark and bluish in color 3. Narrowed and flattened 4. Protruding and swollen Answer: 4 Rationale: A prolapsed stoma is one in which bowel protrudes through the stoma, with an elongated and swollen appearance. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with dusky or bluish color. A stoma with a narrowed opening, either at the level of the skin or fascia, is said to be stenosed. Test-Taking Strategy: Use the process of elimination. Focusing on the key word, prolapse, will direct you to option 4. Review the different complications that can occur with ostomy formation if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 355. 47. A client with a new colostomy is concerned about odor from stool in the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor? 1. Yogurt 2. Broccoli 3. Cucumbers 4. Eggs Answer: 1 Rationale: The client should be taught to include deodorizing foods in the diet, such as beet
greens, parsley, buttermilk, and yogurt. Spinach also reduces odor, but is a gas-forming food as well. Broccoli, cucumbers, and eggs are gas-forming foods. Test-Taking Strategy: Use the process of elimination. Recalling the effect of various foods on the gastrointestinal tract of the client with an ostomy will direct you to option 1. If this question was difficult, review foods that cause odor or gas and those that have a deodorizing effect. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 827. 48. A nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client did not fully understand the instructions if the client states that he or she eats which of the following foods to make the stool less watery? 1. Pasta 2. Boiled rice 3. Bran 4. Low-fat cheese Answer: 3 Rationale: Foods that help to thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese. Bran is high in dietary fiber, and thus will increase the output of watery stool by increasing propulsion through the bowel. Ileostomy output is liquid by nature. Addition or elimination of various foods can help thicken or loosen this liquid drainage. Test-Taking Strategy: Use the process of elimination and note the key words, did not fully understand. These words indicate a false response question and that you need to select the incorrect food item. Recalling that high-fiber foods such as bran can aggravate watery stools will direct you to option 3. Review dietary measures for the client with an ileostomy if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 827. 49. A nurse is doing preoperative teaching with the client who is about to undergo creation of a Kock pouch. The nurse determines that the client has the best understanding of the nature of the surgery if the client makes which statement? 1. I will need to drain the pouch regularly with a catheter. 2. I will need to wear a drainage bag for the rest of my life. 3. The drainage from this type of ostomy will be formed. 4. I will be able to pass stool by the rectum eventually. Answer: 1 Rationale: A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it with a catheter every 3 to 4 hours, which is then decreased to about three times a
day or as needed when full. The client does not need to wear a drainage bag, but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid in nature. The client would only be able to pass stool from the rectum if an ileal-anal pouch or anastomosis were created. Test-Taking Strategy: To answer this question accurately, it is necessary to understand the different surgical procedures that are performed with ileostomy and their consequences on the bowel habits of the client. Remember, a Kock pouch is a continent ileostomy. If this question was difficult, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 447. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 362-363. 50. The client with chronic pancreatitis needs information on dietary modification to manage health problems. The nurse teaches the client to limit which of the following items in the diet? 1. Carbohydrate 2. Protein 3. Fat 4. Water-soluble vitamins Answer: 3 Rationale: The client should limit fat in the diet. The client should also eat small meals. This will also reduce the amount of carbohydrate and protein that the client must digest at any one time. The client does not need to limit water-soluble vitamins in the diet. Test-Taking Strategy: Use the process of elimination. Recalling the pathophysiology related to pancreatic function will direct you to option 3. Review these dietary measures if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 745. 51. A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse tells the client to avoid which position that could aggravate the pain? 1. Sitting up 2. Lying flat 3. Leaning forward 4. Flexing the left leg Answer: 2 Rationale: Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) may alleviate some of the pain associated with pancreatitis. The pain is aggravated by lying
supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation intensify the irritation of the posterior peritoneal wall with these positions. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 first because they are similar. From the remaining options, visualize the pancreas and the potential effects of stretching associated with the various positions listed. This will direct you to option 2. Review care of the client with pancreatitis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 243. 52. A nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse determines that the client understands the instructions given if the client states that which food item is acceptable to include in the diet? 1. Baked scrod 2. Sauces and gravies 3. Fried chicken 4. Fresh whipped cream Answer: 1 Rationale: The client with cholecystitis should decrease overall intake of dietary fat. Foods that should be generally avoided to achieve this end include sauces and gravies, fatty meats, fried foods, products made with cream, and heavy desserts. The correct food item is baked scrod, which is low in fat. Test-Taking Strategy: Use the process of elimination and recall that clients with cholecystitis should decrease fat intake. Also note that options 2, 3, and 4 are similar and are low in fat. Review dietary instructions for the client with cholecystitis if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Gastrointestinal Reference: Nix, S. (2005). Williams basic nutrition and diet therapy (11th ed.). St. Louis: Mosby, p. 343. 53. A client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse would plan a dietary consult to limit the amount of which ingredient in the clients diet? 1. Fat 2. Carbohydrate 3. Protein 4. Minerals Answer: 3 Rationale: Ammonia is formed as a product of protein metabolism. Clients with hepatic encephalopathy have high serum ammonia levels, which is responsible for the encephalopathy symptoms. Limiting protein intake will curb the elevation in the serum ammonia level and
prevent further deterioration of the clients mental status. Test-Taking Strategy: Use the process of elimination. Recalling the relationships between cirrhosis, encephalopathy, and protein intake will direct you to option 3. If needed, take a few moments to review these key concepts at this time. Review dietary measures for the client with cirrhosis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: Nix, S. (2005). Williams basic nutrition and diet therapy (11th ed.). St. Louis: Mosby., pp. 342-343. 54. A client with Crohns disease has an order to begin taking antispasmodic medication. The nurse should time the medication so that each dose is taken: 1. 30 minutes before meals 2. During meals 3. 60 minutes after meals 4. On arising and at bedtime Answer: 1 Rationale: In order to be effective in decreasing bowel motility, antispasmodic medications should be administered 30 minutes before mealtime. The other options are incorrect. Test-Taking Strategy: Use the process of elimination. Recalling that antispasmodics slow down gut motility, it can be reasoned that they should be taken before meals, which normally stimulates increased gastrointestinal motility. Review the purpose of antispasmodic medications if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 848. 55. A client is admitted to the hospital with acute viral hepatitis. Which of the following signs or symptoms would the nurse expect to note based upon this diagnosis? 1. Spider angiomas 2. Fatigue 3. Pale urine 4. Weight gain Answer: 2 Rationale: Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas, small, dilated blood vessels, are commonly seen in cirrhosis of the liver. Test-Taking Strategy: Use the process of elimination. Recalling the function of the liver will direct you to option 2. Remember, lethargy is a classic symptom associated with hepatitis. If you had difficulty with this question, review the manifestations associated with hepatitis.
Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 232. 56. A client with viral hepatitis who is discussing with the nurse the need to avoid alcohol states, Im not sure I can do that. The nurse would respond by saying: 1. Everything will be all right. 2. I think you should talk more with the doctor about this. 3. I dont believe that. 4. Im not sure that I understand. Would you please explain? Answer: 4 Rationale: Clarifying the meaning of what has been said increases understanding for both the client and the nurse. Providing false reassurance is inappropriate. Telling the client what to do implies that the nurse knows what is best and discourages independent thinking. Refusing to consider the clients ideas may cause the client to discontinue interaction with the nurse for fear of further rejection. Placing the clients feelings on hold by referring the client to the physician for further information is a block to communication. Test-Taking Strategy: Use therapeutic communication techniques. Remember always to focus on the clients feelings first. This will direct you to option 4. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Adult Health/Gastrointestinal Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 57. Of the following infection control methods, which would be the priority to include in the plan of care to prevent hepatitis B in a client considered to be at high risk for exposure? 1. Correct hand washing technique 2. Hepatitis B vaccine 3. Proper personal hygiene 4. Use of immune globulin Answer: 2 Rationale: Immunization is the most effective method of preventing hepatitis B infection. Other general measures include hand washing. Immune globulin is used to prevent hepatitis A and is used for prophylaxis if traveling to endemic areas. Personal hygiene, such as hand washing after a bowel movement and before eating, also helps prevent the transmission of hepatitis A. Test-Taking Strategy: Use the process of elimination and note the key word, priority. Although two of the options are correct for preventing transmission of hepatitis B, the priority is immunization with hepatitis B vaccine. If you had difficulty with this question, review content associated with hepatitis. Level of Cognitive Ability: Application
Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 723. 58. A nurse provides home care instructions to a client with hepatitis B. Which statement by the client indicates the best understanding of how to prevent transmission of the disease? 1. I should be vaccinated as soon as possible. 2. I will never share a towel with anyone else. 3. It is all right to kiss my wife. 4. My wife should get the vaccine. Answer: 4 Rationale: Hepatitis B is transmitted through body fluids. The vaccine is recommended for both sexual and household contacts of clients with hepatitis B. Hepatitis B can be transmitted through intimate contact, such as kissing or sexual intercourse. The vaccine is used for prevention. Test-Taking Strategy: Use the process of elimination. Eliminate option 2 because of the absolute word never. Recalling the mode of transmission and the measures to prevent hepatitis will direct you to option 4. Review this content if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 723. 59. A client is admitted to the hospital with viral hepatitis and is complaining of a loss of appetite. In order to provide adequate nutrition, the nurse encourages the client to: 1. Eat a large supper when anorexia is most likely not as severe. 2. Eat less often, preferably only three large meals daily. 3. Increase intake of fluids including juices. 4. Select foods high in fat. Answer: 3 Rationale: Although no special diet is required in the treatment of viral hepatitis, it is generally recommended that clients have a diet with low fat content, because fat may be poorly tolerated because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, the appetite is better in the morning, so it is easier to eat a healthy breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional fluids is also important. Test-Taking Strategy: Use the process of elimination and focus on the issue, a lack of appetite. Eliminate option 4 because of the words high in fat. Eliminate options 1 and 2 next because of the word large. Review dietary measures for the client with hepatitis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Gastrointestinal References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed). St. Louis: Mosby, p. 231. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1113. 60. An African American client has a diagnosis of acute viral hepatitis. Which of the following specific areas would the nurse inspect for jaundice in this client? 1. Flexor surfaces of the extremities 2. Hard palate of the mouth 3. Nail beds 4. Skin Answer: 2 Rationale: Jaundice occurs in the skin and mucous membranes. In light-skinned persons, it is first seen in the sclera of the eyes and later in the skin. In dark-skinned persons, jaundice is observed in the inner canthus of the eyes and hard palate of the mouth. Pallor is detected in the nail beds and flushing is detected in the flexor surfaces of the extremities. Test-Taking Strategy: Use the process of elimination and focus on the client. Recalling that jaundice occurs in the skin and mucous membranes will direct you to option 2. Review data collection techniques for jaundice if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 715. <AQ>61. A nurse is reviewing the orders of a client admitted to the hospital with a diagnosis of acute pancreatitis. Select the interventions that the nurse would expect to be prescribed for the client. ____Provide small, frequent high calorie feedings. ____Administer meperidine (Demerol), as prescribed, for pain. ____Maintain the client in a supine and flat position. ____Encourage coughing and deep breathing. ____Administer antacids, as prescribed. ____Administer anticholinergics, as prescribed. Answers: Administer meperidine (Demerol), as prescribed, for pain. Encourage coughing and deep breathing. Administer antacids, as prescribed. Administer anticholinergics, as prescribed. Rationale: The client with acute pancreatitis is normally placed on an NPO status to rest the pancreas and suppress GI secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication such as meperidine will be prescribed. Some clients experience lessened pain by assuming positions that flex the trunk and draw the knees up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may
also help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress GI secretions. Test-Taking Strategy: Focus on the pathophysiology associated with pancreatitis and note the word acute in the question. This will assist in selecting the correct interventions. Review treatment measures for acute pancreatitis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1138.

Silvestri Chapter 46 Ed56A

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Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 046 (edited file)"Gastrointestinal System" 10/14/08, Page 1 of 31, 0 Figure(s), 0 Table(s), 12 Box(es)

46: Gastrointestinal System

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