Chapter 25: The Child with Gastrointestinal Dysfunction

An adolescent with irritable bowel syndrome comes to see the school nurse. What information should the nurse share with the adolescent? a. A low-fiber diet is required. b. Stress management may be helpful. c. Milk products are a contributing factor. d. Pantoprazole (a proton pump inhibitor) is effective in treatment.

ANS: B Irritable bowel syndrome is believed to involve motor, autonomic, and psychologic factors. Stress management, environmental modification, and psychosocial intervention may reduce stress and gastrointestinal symptoms. A high-fiber diet with psyllium supplement is often beneficial. Milk products can exacerbate bowel problems caused by lactose intolerance. Antispasmodic drugs, antidiarrheal drugs, and simethicone are beneficial for some individuals. Proton pump inhibitors have no effect.

An infant with short bowel syndrome is receiving total parenteral nutrition (TPN). The practitioner has added continuous enteral feedings through a gastrostomy tube. The nurse recognizes this as important for which reason? a. Wean the infant from TPN the next day b. Stimulate adaptation of the small intestine c. Give additional nutrients that cannot be included in the TPN d. Provide parents with hope that the child is close to discharge

ANS: B Long-term survival without TPN depends on the small intestine's ability to increase its absorptive capacity. Continuous enteral feedings facilitate the adaptation. TPN is indicated until the child is able to receive all nutrition via the enteral route. Before this is accomplished, the small intestine must adapt and increase in cell number and cell mass per villus column. TPN is formulated to meet the infant's nutritional needs. Continuous enteral feedings through a gastrostomy tube is a positive sign, but the infant's ability to tolerate increasing amounts of enteral nutrition is only one factor that determines readiness for discharge.

What procedure is most appropriate for assessment of an abdominal circumference related to a bowel obstruction? a. Measuring the abdomen after feedings b. Marking the point of measurement with a pen c. Measuring the circumference at the symphysis pubis d. Using a new tape measure with each assessment to ensure accuracy

ANS: B Pen marks on either side of the tape measure allow the nurse to measure the same spot on the child's abdomen at each assessment. The child most likely will be kept NPO (nothing by mouth) if a bowel obstruction is present. If the child is being fed, the assessment should be done before feedings. The symphysis pubis is too low. Usually the largest part of the abdomen is at the umbilicus. Leaving the tape measure in place reduces the trauma to the child.

What is a high-fiber food that the nurse should recommend for a child with chronic constipation? a.White rice b.Popcorn c.Fruit juice d.Ripe bananas

ANS: B Popcorn is a high-fiber food. Refined rice is not a significant source of fiber. Unrefined brown rice is a fiber source. Fruit juices are not a significant source of fiber. Raw fruits, especially those with skins and seeds, other than ripe bananas, have high fiber.

One of the major differences in clinical presentation between Crohn disease (CD) and ulcerative colitis (UC) is that UC is more likely to cause which clinical manifestation? a. Pain b. Rectal bleeding c. Perianal lesions d. Growth retardation

ANS: B Rectal bleeding is more common in UC than CD. Pain, perianal lesions, and growth retardation are common manifestations of CD.

A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. How should the nurse prepare this child? a. It is unnecessary because of child's age. b. It is essential because it will be an adjustment. c. Preparation is not needed because the colostomy is temporary. d. Preparation is important because the child needs to deal with negative body image.

ANS: B The child's age dictates the type and extent of psychologic preparation. When a colostomy is performed, it is necessary to prepare the child who is at least preschool age by telling him or her about the procedure and what to expect in concrete terms, with the use of visual aids. The preschooler is not yet concerned with body image.

The parents of a newborn with an umbilical hernia ask about treatment options. The nurse's response should be based on which knowledge? a. Surgery is recommended as soon as possible. b. The defect usually resolves spontaneously by 3 to 5 years of age. c. Aggressive treatment is necessary to reduce its high mortality. d. Taping the abdomen to flatten the protrusion is sometimes helpful.

ANS: B The umbilical hernia usually resolves by ages 3 to 5 years of age without intervention. Umbilical hernias rarely become problematic. Incarceration, where the hernia is constricted and cannot be reduced manually, is rare. Umbilical hernias are not associated with a high mortality rate. Taping the abdomen flat does not help heal the hernia; it can cause skin irritation.

What immunization is recommended for all newborns? a. Hepatitis A vaccine b. Hepatitis B vaccine c. Hepatitis C vaccine d. Hepatitis A, B, and C vaccines

ANS: B Universal vaccination for hepatitis B is recommended for all newborns. Hepatitis A vaccine is recommended for infants starting at 12 months. No vaccine is currently available for hepatitis C.

The nurse is preparing to admit a 5-year-old child with hepatitis A. What clinical features of hepatitis A should the nurse recognize? (Select all that apply.) a.The onset is rapid. b.Fever occurs early. c.There is usually a pruritic rash. d.Nausea and vomiting are common. e.The mode of transmission is primarily by the parenteral route.

ANS: A, B, D Clinical features of hepatitis A include a rapid onset, fever occurring early, and nausea and vomiting. A rash is rare, and the mode of transmission is by the fecal-oral route, rarely by the parenteral route.

The nurse is preparing to admit a 7-year-old child with Crohn disease. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a.Pain is common. b.Weight loss is severe. c.Rectal bleeding is common. d.Diarrhea is moderate to severe. e.Anal and perianal lesions are rare.

ANS: A, B, D Clinical manifestations of Crohn disease include pain, severe weight loss, and moderate to severe diarrhea. Rectal bleeding is rare, but anal and perianal lesions are common.

The nurse is preparing to admit a 6-year-old child with irritable bowel syndrome (IBS). What clinical manifestations should the nurse expect to observe? (Select all that apply.) a.Flatulence b.Constipation c.No urge to defecate d.Absence of abdominal pain e.Feeling of incomplete evacuation of the bowel

ANS: A, B, E Children with IBS often have alternating diarrhea and constipation, flatulence, bloating or a feeling of abdominal distention, lower abdominal pain, a feeling of urgency when needing to defecate, and a feeling of incomplete evacuation of the bowel.

What statement is most descriptive of Meckel diverticulum? a. It is acquired during childhood. b. Intestinal bleeding may be mild or profuse. c. It occurs more frequently in females than in males. d. Medical interventions are usually sufficient to treat the problem.

ANS: B Bloody stools are often a presenting sign of Meckel diverticulum. It is associated with mild to profuse intestinal bleeding. Meckel diverticulum is the most common congenital malformation of the gastrointestinal tract and is present in 1% to 4% of the general population. It is more common in males than in females. The standard therapy is surgical removal of the diverticulum.

What should preoperative care of a newborn with an anorectal malformation include? a. Frequent suctioning b. Gastrointestinal decompression c. Feedings with sterile water only d. Supine position with head elevated

ANS: B Gastrointestinal decompression is an essential part of nursing care for a newborn with an anorectal malformation. This helps alleviate intraabdominal pressure until surgical intervention. Suctioning is not necessary for an infant with this type of anomaly. Feedings are not indicated until it is determined that the gastrointestinal tract is intact. Supine position with head elevated is indicated for infants with a tracheoesophageal fistula, not anorectal malformations.

The nurse is discussing home care with a mother whose 6-year-old child has hepatitis A. What information should the nurse include? a. Advise bed rest until 1 week after the icteric phase. b. Teach infection control measures to family members. c. Inform the mother that the child cannot return to school until 3 weeks after onset of jaundice. d. Reassure the mother that hepatitis A cannot be transmitted to other family members.

ANS: B Hand washing is the single most effective measure in preventing and controlling hepatitis. Hepatitis A can be transmitted through the fecal-oral route. Family members must be taught preventive measures. Rest and quiet activities are essential and adjusted to the child's condition, but bed rest is not necessary. The child is not infectious 1 week after the onset of jaundice and may return to school as activity level allows.

A toddler's mother calls the nurse because she thinks her son has swallowed a button type of battery. He has no signs of respiratory distress. The nurse's response should be based on which premise? a. An emergency laparotomy is very likely. b. The location needs to be confirmed by radiographic examination. c. Surgery will be necessary if the battery has not passed in the stool in 48 hours. d. Careful observation is essential because an ingested battery cannot be accurately detected.

ANS: B Button batteries can cause severe damage if lodged in the esophagus. If both poles of the battery come in contact with the wall of the esophagus, acid burns, necrosis, and perforation can occur. If the battery is in the stomach, it will most likely be passed without incident. Surgery is not indicated. The battery is metallic and is readily seen on radiologic examination.

What clinical manifestation should be the most suggestive of acute appendicitis? a. Rebound tenderness b. Bright red or dark red rectal bleeding c. Abdominal pain that is relieved by eating d. Colicky, cramping, abdominal pain around the umbilicus

ANS: D Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain becomes constant and may shift to the right lower quadrant. Rebound tenderness is not a reliable sign and is extremely painful to the child. Bright or dark red rectal bleeding and abdominal pain that is relieved by eating are not signs of acute appendicitis.

A child who has just had definitive repair of a high rectal malformation is to be discharged. What should the nurse address in the discharge preparation of this family? a. Safe administration of daily enemas b. Necessity of firm stools to keep suture line clean c. Bowel training beginning as soon as the child returns home d. Changes in stooling patterns to report to the practitioner

ANS: D The parents are taught to notify the practitioner if any signs of an anal stricture or other complications develop. Constipation is avoided because a firm stool will place strain on the suture line. Daily enemas are contraindicated after surgical repair of a rectal malformation. Fiber and stool softeners are often given to keep stools soft and avoid tension on the suture line. The child needs to recover from the surgical procedure. Then bowel training may begin, depending on the child's developmental and physiologic readiness.

digestion, absorption, and metabolism

are necessary for the body to convert nutrients into forms it can use. Nutrients are composed of six major substances: carbohydrates, proteins, fats, vitamins, minerals, and water. The most common consequences of gastrointestinal (GI) disease in children include malabsorption, fluid and electrolyte disturbances, malnutrition, and poor growth.

Constipation

is a symptom, not a disease. It is defined as a decrease in bowel movement frequency or increased stool hardness for more than 2 weeks. Constipation with fecal soiling is encopresis. The majority of children have idiopathic or functional constipation because no underlying cause can be identified. Transient illness, withholding and avoidance secondary to painful or negative experiences with stooling, and dietary intake with decreased fluid and fiber all play a role in the etiology of constipation.

Inflammatory bowel disease Treatment

it is individualized and managed according to the type and the severity of the disease, its location, and the response to therapy.

GI bleeding in infants and children/mgmt

an uncommon but potentially serious problem. The first step in management is to assess the magnitude of blood loss and restore the child's hemodynamic stability. Investigation for the source and cause is undertaken because treatment in children depends on the severity and cause of the GI bleeding.

Anorectal malformations

are among the more common congenital malformations caused by abnormal development. These malformations may range from simple imperforate anus to include other associated complex anomalies of genitourinary and pelvic organs, which may require extensive treatment for fecal, urinary, and sexual function.

Hirschsprung disease

(also known as congenital aganglionic megacolon) is a mechanical obstruction caused by inadequate motility of part of the intestine. Hirschsprung disease requires surgical removal of aganglionic segments of bowel.

What intervention is contraindicated in a suspected case of appendicitis? a. Enemas b. Palpating the abdomen c. Administration of antibiotics d. Administration of antipyretics for fever

ANS: A In any instance in which severe abdominal pain is observed and appendicitis is suspected, the nurse must be aware of the danger of administering laxatives or enemas. Such measures stimulate bowel motility and increase the risk of perforation. The abdomen is palpated after other assessments are made. Antibiotics should be administered, and antipyretics are not contraindicated.

The nurse is preparing to admit a 10-year-old child with appendicitis. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a.Fever b.Vomiting c.Tachycardia d.Flushed face e.Hyperactive bowel sounds

ANS: A, B, C Clinical manifestations of appendicitis include fever, vomiting, and tachycardia. Pallor is seen, not a flushed face, and the bowel sounds are hypoactive or absent, not hyperactive.

The nurse is teaching parents of a child with gastroesophageal reflux (GER) disease foods that can exacerbate acid reflux. What foods should be included in the teaching session? (Select all that apply.) a.Citrus b.Bananas c.Spicy foods d.Peppermint e.Whole wheat bread

ANS: A, C, D Avoidance of certain foods that exacerbate acid reflux (e.g., caffeine, citrus, tomatoes, alcohol, peppermint, spicy or fried foods) can improve mild GER symptoms. Bananas and whole wheat bread will not exacerbate acid reflux.

The nurse is preparing to admit a 6-month-old child with gastroesophageal reflux disease. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a.Spitting up b.Bilious vomiting c.Failure to thrive d.Excessive crying e.Respiratory problems

ANS: A, C, D, E Clinical manifestations of gastroesophageal reflux disease include spitting up, failure to thrive, excessive crying, and respiratory problems. Hematemesis, not bilious vomiting, is a manifestation.

The nurse is preparing to admit a 6-year-old child with celiac disease. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a.Steatorrhea b.Polycythemia c.Malnutrition d.Melena stools e.Foul-smelling stools

ANS: A, C, E Clinical manifestations of celiac disease include impaired fat absorption (steatorrhea and foul-smelling stools) and impaired nutrient absorption (malnutrition). Anemia, not polycythemia, is a manifestation, and melena stools do not occur.

The nurse is preparing to admit a 2-month-old child with hypertrophic pyloric stenosis. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a.Weight loss b.Bilious vomiting c.Abdominal pain d.Projectile vomiting e.The infant is hungry after vomiting

ANS: A, D, E Clinical manifestations of hypertrophic pyloric stenosis include weight loss, projectile vomiting, and hunger after vomiting. The vomitus is nonbilious, and there is no evidence of pain or discomfort, just chronic hunger.

The nurse is preparing to admit a 3-year-old child with intussusception. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Absent bowel sounds b. Passage of red, currant jelly-like stools c. Anorexia d. Tender, distended abdomen e. Hematemesis f. Sudden acute abdominal pain

ANS: B, D, F Intussusception occurs when a proximal segment of the bowel telescopes into a more distal segment, pulling the mesentery with it and leading to obstruction. Clinical manifestations of intussusception include the passage of red, currant jelly-like stools; a tender, distended abdomen; and sudden acute abdominal pain. Absent bowel sounds, anorexia, and hematemesis are clinical manifestations observed in other types of gastrointestinal dysfunction.

14. When caring for a child with probable appendicitis, the nurse should be alert to recognize which sign or symptom as a manifestation of perforation? a. Anorexia b. Bradycardia c. Sudden relief from pain d. Decreased abdominal distention

ANS: C Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Anorexia is already a clinical manifestation of appendicitis. Tachycardia, not bradycardia, is a manifestation of peritonitis. Abdominal distention usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen).

A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what potential complication? a. Hyperkalemia b. Hyperchloremia c. Metabolic acidosis d. Metabolic alkalosis

ANS: D Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Potassium and chloride ions are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.

Treatment options for viral hepatitis/ goals of mgmt

Are limited. Goals include early detection, support and monitoring of the disease, recognition of chronic liver disease, and prevention of spread of the disease. The most effective measure in prevention and control of hepatitis in any setting is hand washing.

Viral hepatitis

Is caused by five types of virus: hepatitis A, B, C, D, and E virus. Whereas hepatitis A and E viruses are spread by the fecal-oral route, hepatitis B and C viruses are transmitted primarily by the parenteral route. Transmission of hepatitis D occurs from blood or sexual contact.

Biliary atresia causes

The exact cause of biliary atresia is unknown, although immune- or infection-mediated mechanisms may cause the progressive process. Early diagnosis is critical; the outcome in children surgically treated before 2 months of age is much better than in patients with delayed treatment.

Meckel diverticulum

a congenital malformation of the GI tract characterized by bloody stools

Short-bowel syndrome (SBS)

a malabsorptive disorder that occurs as a result of decreased mucosal surface area, usually because of extensive resection of the small intestine, resulting in a diminished ability to absorb a regular diet normally. Specialized enteral and parenteral nutrition is a major element of care for children with SBS.

Biliary atresia

a progressive inflammatory process that causes both intrahepatic and extrahepatic bile duct fibrosis, resulting in eventual ductal obstruction.

A hernia

a protrusion of a portion of an organ or organs through an abnormal opening. The danger of herniation arises when the protrusion is constricted, impairing circulation, or when the protrusion interferes with the function or development of other structures.

Intussusception is characterized by

abdominal pain and blood in stools. It occurs when a proximal segment of the bowel telescopes into a more distal segment, pulling the mesentery with it.

Symptoms of celiac disease

appear when solid foods such as beans and pasta are introduced in the child's diet between the ages of 1 and 5 years.

Gastroschisis and omphalocele

are two of the more common forms of congenital abdominal wall defects.

Hepatitis causes

by viruses such as the hepatitis viruses, Epstein-Barr virus (EBV), and cytomegalovirus (CMV). Other causes are nonviral (abscess, amebiasis), autoimmune, metabolic, drug induced, anatomic (choledochal duct cyst and biliary atresia), hemodynamic (shock, heart failure), and idiopathic (sclerosing cholangitis and Reye syndrome).

Hypertrophic pyloric stenosis is recognized by

characteristic projectile vomiting, malnutrition, dehydration, and a palpable mass in the epigastrium. Surgical relief of the pyloric obstruction by pyloromyotomy is the standard therapy for this disorder.

Treatment of celiac disease

consists primarily of dietary management.

Acute diarrhea

defined as a sudden increase in frequency and a change in consistency of stools, often caused by an infectious agent in the GI tract.

Malabsorption syndromes

disorders associated with some degree of impaired digestion or absorption. They include digestive defects, absorptive defects, and anatomic defects.

Management of PUD

primarily medical and consists of administration of medications to treat the infection and to reduce or neutralize gastric acid secretion.

Inflammatory bowel disease

refers to ulcerative colitis (UC) and Crohn disease (CD).

Appendicitis common signs & symptoms

right lower quadrant abdominal pain, tenderness, and fever. Diagnosis is not always straightforward. Prolonged symptoms and delayed diagnosis often occur in younger children, in whom the risk of perforation is greatest because of their inability to verbalize their complaints.

symptomatic Meckel diverticulum treatment

surgical removal

Treatment for appendicitis before perforation

surgical removal of the appendix (appendectomy).

Appendicitis

typically a result of obstruction of the lumen, usually by a fecalith.

Nutritional management of the child with Crohn disease includes a diet that has which component? a. High fiber b. Increased protein c. Reduced calories d. Herbal supplements

ANS: B The child with Crohn disease often has growth failure. Nutritional support is planned to reduce ongoing losses and provide adequate energy and protein for healing. Fiber is mechanically hard to digest. Foods containing seeds may contribute to obstruction. A high-calorie diet is necessary to minimize growth failure. Herbal supplements should not be used unless discussed with the practitioner. Vitamin supplementation with folic acid, iron, and multivitamins is recommended.

The nurse is evaluating the laboratory results of a stool sample. What is a normal finding? a.The laboratory reports a stool pH of 5.0. b.The laboratory reports a negative guaiac. c.The laboratory reports low levels of enzymes. d.The laboratory reports reducing substances present.

ANS: B The normal stool finding is a negative guaiac. Stool pH should be 7.0 to 7.5. A stool pH <5.0 is suggestive of carbohydrate malabsorption; colonic bacterial fermentation produces short-chain fatty acids, which lower stool pH. There should be no enzymes or reducing substances present in a normal stool sample.

What signs or symptoms are most commonly associated with the prodromal phase of acute viral hepatitis? a. Bruising and lethargy b. Anorexia and malaise c. Fatigability and jaundice d. Dark urine and pale stools

ANS: B The signs and symptoms most common in the prodromal phase are anorexia, malaise, lethargy, and easy fatigability. Bruising would not be an issue unless liver damage has occurred. Jaundice is a late sign and often does not occur in children. Dark urine and pale stools would occur during the onset of jaundice (icteric phase) if it occurs.

Cirrhosis

occurs as an end stage of many chronic liver diseases, including biliary atresia and chronic hepatitis. Infectious, autoimmune, or toxic factors and chronic diseases such as hemophilia and cystic fibrosis can cause severe liver damage. A cirrhotic liver is irreversibly damaged.

Hypertrophic pyloric stenosis

occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric channel.

Meckel diverticulum most common clinical presentation in children

painless rectal bleeding, abdominal pain, or signs of intestinal obstruction

The clinical manifestations and course of uncomplicated acute viral hepatitis

similar for most of the hepatitis viruses. Usually the prodromal, or anicteric, phase (absence of jaundice) lasts 5 to 7 days. Anorexia, malaise, lethargy, and easy fatigability are the most common symptoms. The transaminases, rather than the bilirubin, will often be elevated in acute hepatitis, and hepatomegaly may be present. Some mild cases of acute viral hepatitis do not cause symptoms or can be mistaken for influenza.

Inflammatory bowel disease most common feature

Chronic diarrhea In addition to GI symptoms, both CD and UC are characterized by extraintestinal and systemic inflammatory responses. Whereas the inflammation found with UC is limited to the colon and rectum, the chronic inflammatory process of CD can involve any part of the GI tract from the mouth to the anus. The natural history of both diseases continues to be unpredictable and characterized by recurrent flare-ups that can severely impair patients' physical and social functioning.

Treatment of EA and TEF

includes maintenance of a patent airway, prevention of pneumonia, gastric or blind pouch decompression, supportive therapy, and surgical repair of the anomaly.

Postoperative care of the child with abdominal surgery

involves assessing the abdomen, providing hydration and nutrition, intravenous fluids, proper positioning, wound care, and psychologic support.

Intussusception

is one of the most common causes of intestinal obstruction during infancy

Omphalocele

occurs when there is failure of the caudal or lateral infolding of the abdominal wall at approximately the third week of gestation. With the deficiency in the abdominal wall, the bowel is unable to complete its return to the abdomen between the tenth and twelfth week of gestation and is usually covered by a translucent peritoneal sac.

Malrotation of the intestine

occurs as a result of the abnormal rotation of the intestine around the superior mesenteric artery during embryologic development and may manifest in utero or be asymptomatic throughout life. It is the most serious type of intestinal obstruction because, if the intestine undergoes complete volvulus (the intestine twisting around itself), compromise of the blood supply will result in intestinal necrosis, peritonitis, perforation, and death.

Gastroschisis

occurs when the bowel herniates through a defect in the abdominal wall to the right of the umbilical cord and through the rectus muscle.

Cause of peptic ulcers

poorly understood, but contributing factors include interference with the normal protective mechanisms of the mucosal lining and the presence of Helicobacter pylori

A parent of an infant with gastroesophageal reflux asks how to decrease the number and total volume of emesis. What recommendation should the nurse include in teaching this parent? a. Surgical therapy is indicated. b. Place in prone position for sleep after feeding. c. Thicken feedings and enlarge the nipple hole. d. Reduce the frequency of feeding by encouraging larger volumes of formula.

ANS: C Thickened feedings decrease the child's crying and increase the caloric density of the feeding. Although it does not decrease the pH, the number and volume of emesis are reduced. Surgical therapy is reserved for children who have failed to respond to medical therapy or who have an anatomic abnormality. The prone position is not recommended because of the risk of sudden infant death syndrome. Smaller, more frequent feedings are more effective than less frequent, larger volumes of formula.

The nurse is assisting a child with celiac disease to select foods from a menu. What foods should the nurse suggest? a. Hamburger on a bun b. Spaghetti with meat sauce c. Corn on the cob with butter d. Peanut butter and crackers

ANS: C Treatment of celiac disease consists primarily of dietary management. Although a gluten-free diet is prescribed, it is difficult to remove every source of this protein. Some patients are able to tolerate restricted amounts of gluten. Because gluten occurs mainly in the grains of wheat and rye but also in smaller quantities in barley and oats, these foods are eliminated. Corn, rice, and millet are substitute grain foods. Corn on the cob with butter would be gluten free.

The nurse is teaching parents about high-fiber foods that can prevent constipation. What foods should the nurse include in the teaching? (Select all that apply.) a. Oranges b. Bananas c. Lima beans d. Baked beans e. Raisin bran cereal

ANS: C, D, E Lima beans have 13.2 g of fiber in 1 cup, baked beans have 10.4 g of fiber in 1 cup, and raisin bran cereal has 7.3 g of fiber in 1 cup. One orange has only 3.1 g of fiber, and 1 banana has only 3.1 g of fiber, so they are not recommended as high-fiber foods.

Chronic diarrhea

an increase in stool frequency and increased water content with duration of more than 14 days and is often caused by chronic conditions.

What statement best describes Hirschsprung disease? a.The colon has an aganglionic segment. b.It results in frequent evacuation of solids, liquid, and gas. c.The neonate passes excessive amounts of meconium. d.It results in excessive peristaltic movements within the gastrointestinal tract.

ANS: A Mechanical obstruction in the colon results from a lack of innervation. In most cases, the aganglionic segment includes the rectum and some portion of the distal colon. There is decreased evacuation of the large intestine secondary to the aganglionic segment. Liquid stool may ooze around the blockage. The obstruction does not affect meconium production. The infant may not be able to pass the meconium stool. There is decreased movement in the colon.

The nurse should instruct parents to administer a daily proton pump inhibitor to their child with gastroesophageal reflux at which time? a. Bedtime b. With a meal c. Midmorning d. 30 minutes before breakfast

ANS: D Proton pump inhibitors are most effective when administered 30 minutes before breakfast so that the peak plasma concentrations occur with mealtime. If they are given twice a day, the second best time for administration is 30 minutes before the evening meal.

Obstruction in the GI tract

occurs when the passage of nutrients and secretions is impeded by a constricted or occluded lumen or when there is impaired motility (paralytic ileus).

Irritable bowel syndrome (IBS)

one of the most common adult problems treated by gastroenterologists. Recently, IBS has been identified as a cause of recurrent abdominal pain in 21% to 45% of school-age children. The cause of IBS is not clear, but it is believed to involve a combination of autonomic and psychologic factors.

A child is being admitted to the hospital with acute gastroenteritis. The health care provider prescribes an antiemetic. What antiemetic does the nurse anticipate being prescribed? a. Ondansetron (Zofran) b. Promethazine (Phenergan) c. Metoclopramide (Reglan) d. Dimenhydrinate (Dramamine)

ANS: A Ondansetron reduces the duration of vomiting in children with acute gastroenteritis. This would be the expected prescribed antiemetic. Adverse effects with earlier generation antiemetics (e.g., promethazine and metoclopramide) include somnolence, nervousness, irritability, and dystonic reactions and should not be routinely administered to children. For children who are prone to motion sickness, it is often helpful to administer an appropriate dose of dimenhydrinate (Dramamine) before a trip, but it would not be ordered as an antiemetic.

What is the purpose in using cimetidine (Tagamet) for gastroesophageal reflux? a. The medication reduces gastric acid secretion. b. The medication neutralizes the acid in the stomach. c. The medication increases the rate of gastric emptying time. d. The medication coats the lining of the stomach and esophagus.

ANS: A Pharmacologic therapy may be used to treat infants and children with gastroesophageal reflux disease. Both H2-receptor antagonists (cimetidine [Tagamet], ranitidine [Zantac], or famotidine [Pepcid]) and proton pump inhibitors (esomeprazole [Nexium], lansoprazole [Prevacid], omeprazole [Prilosec], pantoprazole [Protonix], and rabeprazole [Aciphex]) reduce gastric hydrochloric acid secretion.

The nurse observes that a newborn is having problems after birth. What should indicate a tracheoesophageal fistula? a. Jitteriness b. Meconium ileus c. Excessive frothy saliva d. Increased need for sleep

ANS: C Excessive frothy saliva is indicative of a tracheoesophageal fistula. The child is unable to swallow the secretions, so there are excessive amounts of saliva in the mouth. Jitteriness is associated with several disorders, including electrolyte imbalances. Meconium ileus is associated with cystic fibrosis. Increased need for sleep is not associated with a tracheoesophageal fistula.

The school nurse is teaching a group of adolescents about avoiding contaminated water during a mission trip. What should the nurse include in the teaching? (Select all that apply.) a. Ice b. Meats c. Raw vegetables d. Unpeeled fruits e. Carbonated beverages

ANS: A, B, C, D The best measure during travel to areas where water may be contaminated is to allow children to drink only bottled water and carbonated beverages (from the container through a straw supplied from home). Children should also avoid tap water, ice, unpasteurized dairy products, raw vegetables, unpeeled fruits, meats, and seafood.

Pica

an eating disorder characterized by the compulsive and excessive ingestion of both food and nonfood substances. Pica is more common in children, women (especially during pregnancy), individuals who have autism or cognitive impairment, and individuals with anemia or chronic renal failure.

Congenital esophageal atresia (EA) and tracheoesophageal fistula (TEF)

are rare malformations that represent a failure of the esophagus to develop as a continuous passage and a failure of the trachea and esophagus to separate into distinct structures.

Gastroesophageal reflux (GER)

defined as the transfer of gastric contents into the esophagus. This phenomenon is physiologic, occurring throughout the day, most frequently after meals and at night; therefore, it is important to differentiate GER from gastroesophageal reflux disease (GERD). GERD represents symptoms or tissue damage that result from GER.

Therapeutic management of GER

depends on its severity. No therapy is needed for an infant who is thriving and has no respiratory complications. Nursing care of GI reflux is aimed at identifying children with suggestive symptoms, helping parents with home care feeding and positioning and caring for a child undergoing surgical intervention.

Peptic ulcers

may be classified as acute or chronic, and peptic ulcer disease (PUD) is a chronic condition that affects the stomach or duodenum

A 2-year-old child has a chronic history of constipation and is brought to the clinic for evaluation. What should the therapeutic plan initially include? a.Bowel cleansing b.Dietary modification c.Structured toilet training d.Behavior modification

ANS: A The first step in the treatment of chronic constipation is to empty the bowel and allow the distended rectum to return to normal size. Dietary modification is an important part of the treatment. Increased fiber and fluids should be gradually added to the child's diet. A 2-year-old child is too young for structured toilet training. For an older child, a regular schedule for toileting should be established. Behavior modification is part of the overall treatment plan. The child practices releasing the anal sphincter and recognizing cues for defecation.

After surgery yesterday for gastroesophageal reflux, the nurse finds that the infant has somehow removed the nasogastric (NG) tube. What nursing action is most appropriate to perform at this time? a. Notify the practitioner. b. Insert the NG tube so feedings can be given. c. Replace the NG tube to maintain gastric decompression. d. Leave the NG tube out because it has probably been in long enough.

ANS: A When surgery is performed on the upper gastrointestinal tract, usually the surgical team replaces the NG tube because of potential injury to the operative site. The decision to replace the tube or leave it out is made by the surgical team. Replacing the tube is also usually done by the practitioner because of the surgical site.

A 6-month-old infant with Hirschsprung disease is scheduled for a temporary colostomy. What should postoperative teaching to the parents include? a. Dilating the stoma b. Assessing bowel function c. Limitation of physical activities d. Measures to prevent prolapse of the rectum

ANS: B In the postoperative period, the nurse involves the parents in the care of the child with a temporary colostomy, allowing them to help with feedings and observe for signs of wound infection or irregular passage of stool (constipation or true incontinence). Some children will require daily anal dilatations in the postoperative period to avoid anastomotic strictures but not stoma dilatations. Physical activities should be encouraged. There is not a risk of prolapse of the rectum in Hirschsprung disease, just strictures.

What therapeutic intervention provides the best chance of survival for a child with cirrhosis? a. Nutritional support b. Liver transplantation c. Blood component therapy d. Treatment with corticosteroids

ANS: B The only successful treatment for end-stage liver disease and liver failure may be liver transplantation, which has improved the prognosis for many children with cirrhosis. Liver transplantation reflects the failure of other medical and surgical measures to prevent or treat cirrhosis. Nutritional support is necessary for the child with cirrhosis, but it does not stop the progression of the disease. Blood components are indicated when the liver can no longer produce clotting factors. It is supportive therapy, not curative. Corticosteroids are not used in end-stage liver disease.

A 3-day-old infant presents with abdominal distention, is vomiting, and has not passed any meconium stools. What disease should the nurse suspect? a. Pyloric stenosis b. Intussusception c. Hirschsprung disease d. Celiac disease

ANS: C The clinical manifestations of Hirschsprung disease in a 3-day-old infant include abdominal distention, vomiting, and failure to pass meconium stools. Pyloric stenosis would present with vomiting but not distention or failure to pass meconium stools. Intussusception presents with abdominal cramping and celiac disease presents with malabsorption.

Hepatitis

is an acute or chronic inflammation of the liver that can result from infectious or noninfectious causes.

Intussusception treatment

either nonsurgical hydrostatic reduction or surgical reduction.

Celiac disease

An absorptive defect characterized by intolerance to gluten. It is thought to be either an inborn error of metabolism or an immunologic response

General signs of obstruction in the GI tract

include colicky abdominal pain, nausea and vomiting, abdominal distention, and decreased stool output.

Diarrhea

is caused by abnormal intestinal water and electrolyte transport.

What information should the nurse include when teaching an adolescent with Crohn disease (CD)? a. How to cope with stress and adjust to chronic illness b. Preparation for surgical treatment and cure of CD c. Nutritional guidance and prevention of constipation d. Prevention of spread of illness to others and principles of high-fiber diet

ANS: A CD is a chronic illness with a variable course and many potential complications. Guidance about living with chronic illness is essential for adolescents. Stress management techniques can help with exacerbations and possible limitations caused by the illness. At this time, there is no cure for CD. Surgical intervention may be indicated for complications that cannot be controlled by medical and nutritional therapy. Nutritional guidance is an essential part of management. Constipation is not usually an issue with CD. CD is not infectious, so transmission is not a concern. A low-fiber diet is indicated.

Melena, the passage of black, tarry stools, suggests bleeding from which source? a. The perianal or rectal area b. The upper gastrointestinal (GI) tract c. The lower GI tract d. Hemorrhoids or anal fissures

ANS: B Melena is denatured blood from the upper GI tract or bleeding from the right colon. Blood from the perianal or rectal area, hemorrhoids, or lower GI tract would be bright red.

The nurse is teaching a parent of a 6-month-old infant with gastroesophageal reflux (GER) before discharge. What instructions should the nurse include? (Select all that apply.) a. Elevate the head of the bed in the crib to a 90-degree angle while the infant is sleeping. b. Hold the infant in the prone position after a feeding. c. Discontinue breastfeeding so that a formula and rice cereal mixture can be used. d. The infant will require the Nissen fundoplication after 1 year of age. e. Prescribed cimetidine (Tagamet) should be given 30 minutes before feedings.

ANS: B, E Discharge instructions for an infant with GER should include the prone position (up on the shoulder or across the lap) after a feeding. Use of the prone position while the infant is sleeping is still controversial. The American Academy of Pediatrics recommends the supine position to decrease the risk of sudden infant death syndrome even in infants with GER. Prescribed cimetidine or another proton pump inhibitor should be given 30 minutes before the morning and evening feeding so that peak plasma concentrations occur with mealtime. The head of the bed in the crib does not need to be elevated. The mother may continue to breastfeed or express breast milk to add rice cereal if recommended by the health care provider; thickening breast milk or formula with cereal is not recommended by all practitioners. The Nissen fundoplication is only done on infants with GER in severe cases with complications.

A school-age child with celiac disease asks for guidance about snacks that will not exacerbate the disease. What snack should the nurse suggest? a. Pizza b. Pretzels c. Popcorn d. Oatmeal cookies

ANS: C Celiac disease symptoms result from ingestion of gluten. Corn and rice do not contain gluten. Popcorn or corn chips will not exacerbate the intestinal symptoms. Pizza and pretzels are usually made from wheat flour that contains gluten. Also, in the early stages of celiac disease, the child may be lactose intolerant. Oatmeal contains gluten.

An infant had a gastrostomy tube placed for feedings after a Nissen fundoplication and bolus feedings are initiated. Between feedings while the tube is clamped, the infant becomes irritable, and there is evidence of cramping. What action should the nurse implement? a. Burp the infant. b. Withhold the next feeding. c. Vent the gastrostomy tube. d. Notify the health care provider.

ANS: C If bolus feedings are initiated through a gastrostomy after a Nissen fundoplication, the tube may need to remain vented for several days or longer to avoid gastric distention from swallowed air. Edema surrounding the surgical site and a tight gastric wrap may prohibit the infant from expelling air through the esophagus, so burping does not relieve the distention. Some infants benefit from clamping of the tube for increasingly longer intervals until they are able to tolerate continuous clamping between feedings. During this time, if the infant displays increasing irritability and evidence of cramping, some relief may be provided by venting the tube. The next feeding should not be withheld, and calling the health care provider is not necessary.

The nurse is caring for a child with Meckel diverticulum. What type of stool does the nurse expect to observe? a. Steatorrhea b. Clay colored c. Currant jelly-like d. Loose stools with undigested food

ANS: C In Meckel diverticulum the bleeding is usually painless and may be dramatic and occur as bright red or currant jelly-like stools, or it may occur intermittently and appear as tarry stools. The stools are not clay colored, steatorrhea, or loose with undigested food.

A health care provider prescribes feedings of 1 to 2 oz Pedialyte every 3 hours and to advance to 1/2 strength Similac with iron as tolerated postoperatively for an infant who had a pyloromyotomy. The nurse should decide to advance the feeding if which occurs? a. The infant's IV line has infiltrated. b. The infant has not voided since surgery. c. The infant's mother states the infant is tolerating the feeding okay. d. The infant is taking the Pedialyte without vomiting or distention.

ANS: D After a pyloromyotomy, feedings are usually instituted within 12 to 24 hours, beginning with clear liquids. They are offered in small quantities at frequent intervals. Supervision of feedings is an important part of postoperative care. The feedings are advanced only if the infant is taking the clear liquids without vomiting or distention. Feedings would not be advanced if the infant has not voided, the IV line becomes infiltrated, or the mother states the infant is tolerating the feedings.

An infant with short bowel syndrome will be on total parenteral nutrition (TPN) for an extended period of time. What should the nurse monitor the infant for ? a. Central venous catheter infection, electrolyte losses, and hyperglycemia b. Hypoglycemia, catheter migration, and weight gain c. Venous thrombosis, hyperlipidemia, and constipation d. Catheter damage, red currant jelly stools, and hypoglycemia

ANS: A Numerous complications are associated with short bowel syndrome and long-term TPN. Infectious, metabolic, and technical complications can occur. Sepsis can occur after improper care of the catheter. The gastrointestinal tract can also be a source of microbial seeding of the catheter. The nurse should monitor for catheter infection, electrolyte losses, and hyperglycemia. Hypoglycemia, weight gain, constipation, or red currant jelly stools are not characteristics of short bowel syndrome with extended TPN.

A child with acute gastrointestinal bleeding is admitted to the hospital. The nurse observes which sign or symptom as an early manifestation of shock? a. Restlessness b. Rapid capillary refill c. Increased temperature d. Increased blood pressure

ANS: A Restlessness is an indication of impending shock in a child. Capillary refill is slowed in shock. The child will feel cool. The blood pressure initially remains within the normal range and then declines.

What test is used to screen for carbohydrate malabsorption? a. Stool pH b. Urine ketones c. C urea breath test d. ELISA stool assay

ANS: A The anticipated pH of a stool specimen is 7.0. A stool pH of less than 5.0 is indicative of carbohydrate malabsorption. The bacterial fermentation of carbohydrates in the colon produces short-chain fatty acids, which lower the stool pH. Urine ketones detect the presence of ketones in the urine, which indicates the use of alternative sources of energy to glucose. The C urea breath test measures the amount of carbon dioxide exhaled. It is used to determine the presence of Helicobacter pylori. ELISA (enzyme-linked immunosorbent assay) detects the presence of antigens and antibodies. It is not useful for disorders of metabolism.

The nurse is caring for a child with celiac disease. The nurse understands that what may precipitate a celiac crisis? (Select all that apply.) a.Exercise b.Infections c.Fluid overload d.Electrolyte depletion e.Emotional disturbance

ANS: B, D, E A celiac crisis can be precipitated by infections, electrolyte depletion, and emotional disturbance. Exercise or fluid overload does not precipitate a crisis.

The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include? a. Keep the tube clamped. b. Suction the tube as needed. c. Leave the tube open to gravity drainage. d. Lower the tube to a point below the level of the stomach.

ANS: C In the immediate postoperative period, the gastrostomy tube is open to gravity drainage. This usually is continued until the infant is able to tolerate feedings. The tube is unclamped in the postoperative period to allow for the drainage of secretions and air. Gastrostomy tubes are not suctioned on an as-needed basis. They may be connected to low suction to facilitate drainage of secretions. Lowering the tube to a point below the level of the stomach would create too much pressure.

The nurse is preparing to care for a newborn with an omphalocele. The nurse should understand that care of the infant should include what intervention? a. Initiating breast- or bottle-feedings to stabilize the blood glucose level b. Maintaining pain management with an intravenous opioid c. Covering the intact bowel with a nonadherent dressing to prevent injury d. Performing immediate surgery

ANS: C Nursing care of an infant with an omphalocele includes covering the intact bowel with a nonadherent dressing to prevent injury or placing a bowel bag or moist dressings and a plastic drape if the abdominal contents are exposed. The infant is not started on any type of feeding but has a nasogastric tube placed for gastric decompression. Pain management is started after surgery, but surgery is not done immediately after birth. The infant is medically stabilized before different surgical options are considered.

A child has a nasogastric (NG) tube after surgery for Hirschsprung disease. What is the purpose of the NG tube? a. Prevent spread of infection. b. Monitor electrolyte balance. c. Prevent abdominal distention. d. Maintain accurate record of output.

ANS: C The NG tube is placed to suction out gastrointestinal secretions and prevent abdominal distention. The NG tube would not affect infection. Electrolyte content of the NG drainage can be monitored. Without the NG tube, there would be no drainage. After the NG tube is placed, it is important to maintain an accurate record of intake and output. This is not the reason for placement of the tube.

The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis. What intervention is appropriate to relieve the abdominal discomfort during the evaluation? a. Place in the Trendelenburg position. b. Apply moist heat to the abdomen. c. Allow the child to assume a position of comfort. d. Administer a saline enema to cleanse the bowel.

ANS: C The child should be allowed to take a position of comfort, usually with the legs flexed. The Trendelenburg position will not help with the discomfort. If appendicitis is a possibility, administering laxative or enemas or applying heat to the area is dangerous. Such measures stimulate bowel motility and increase the risk of perforation.

What should the nurse consider when providing support to a family whose infant has just been diagnosed with biliary atresia? a. The prognosis for full recovery is excellent. b. Death usually occurs by 6 months of age. c. Liver transplantation may be needed eventually. d. Children with surgical correction live normal lives.

ANS: C Untreated biliary atresia results in progressive cirrhosis and death usually by 2 years of age. Surgical intervention at 8 weeks of age is associated with somewhat better outcomes. Liver transplantation is also improving outcomes for 10-year survival. Even with surgical intervention, most children require supportive therapy. With early intervention, 10-year survival rates range from 27% to 75%.

The nurse is caring for a neonate with a suspected tracheoesophageal fistula. What should nursing care include? a. Feed glucose water only. b. Elevate the patient's head for feedings. c. Raise the patient's head and give nothing by mouth. d. Avoid suctioning unless the infant is cyanotic.

ANS: C When a newborn is suspected of having a tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. The oral pharynx should be kept clear of secretions by oral suctioning. This is to prevent the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.

The mother of a child with cognitive impairment calls the nurse because her son has been gagging and drooling all morning. The nurse suspects foreign body ingestion. What physiologic occurrence is most likely responsible for the presenting signs? a.Gastrointestinal perforation may have occurred. b.The object may have been aspirated. c.The object may be lodged in the esophagus. d.The object may be embedded in stomach wall.

ANS: C Gagging and drooling may be signs of esophageal obstruction. The child is unable to swallow saliva, which contributes to the drooling. Signs of gastrointestinal (GI) perforation include chest or abdominal pain and evidence of bleeding in the GI tract. If the object was aspirated, the child would most likely have coughing, choking, inability to speak, or difficulty breathing. If the object was embedded in the stomach wall, it would not result in symptoms of gagging and drooling.

An infant is born with a gastroschisis. Care preoperatively should include which priority intervention? a. Prone position b. Sterile water feedings c. Monitoring serum laboratory electrolytes d. Covering the defect with a sterile bowel bag

ANS: D Initial management of a gastroschisis involves covering the exposed bowel with a transparent plastic bowel bag or loose, moist dressings. The infant cannot be placed prone, and feedings will be withheld until surgery is performed. Electrolyte laboratory values will be monitored but not before covering the defect with a sterile bowel bag.

What term describes invagination of one segment of bowel within another? a. Atresia b. Stenosis c. Herniation d. Intussusception

ANS: D Intussusception occurs when a proximal section of the bowel telescopes into a more distal segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and venous obstruction. Atresia is the absence or closure of a natural opening in the body. Stenosis is a narrowing or constriction of the diameter of a bodily passage or orifice. Herniation is the protrusion of an organ or part through connective tissue or through a wall of the cavity in which it is normally enclosed.