Chapter 55: Care of Patients with Stomach Disorders

The nurse is monitoring a client with gastric cancer for signs and symptoms of upper gastrointestinal bleeding. Which change in vital signs is most indicative of bleeding related to cancer? A. Respiratory rate from 24 to 20 breaths/min B. Apical pulse from 80 to 72 beats/min C. Temperature from 98.9° F to 97.9° F D. Blood pressure from 140/90 to 110/70 mm Hg Correct

A decrease in blood pressure is the most indicative sign of bleeding. A slight decrease in respiratory rate, apical pulse, and temperature is not the primary indication of bleeding.

The nurse and the dietitian are planning sample diet menus for a client who is experiencing dumping syndrome. Which sample meal is best for this client? A. Chicken salad on whole wheat bread B. Liver and onions C. Chicken and rice Correct D. Cobb salad with buttermilk ranch dressing

Chicken and rice is the only selection suitable for the client who is experiencing dumping syndrome because it contains high protein without the addition of milk or wheat products. The client with dumping syndrome should not be allowed to have mayonnaise, onions, or buttermilk ranch dressing; the dressing is made from milk products. The client can have whole wheat bread only in very limited amounts.

A client has a long-term history of Crohn's disease and has recently developed acute gastritis. The client asks the nurse whether Crohn's disease was a direct cause of the gastritis. What is the nurse's best response? A. "Yes, Crohn's disease is known to be a direct cause of the development of chronic gastritis." B. "We know that there can be an association between Crohn's disease and chronic gastritis, but Crohn's does not directly cause acute gastritis to develop." Correct C. "What has your doctor told you about how your gastritis developed?" D. "Yes, a familial tendency to inherit Crohn's disease and gastritis has been reported. Have your other family members been tested for Crohn's disease?"

Crohn's disease may be an underlying disease process when chronic gastritis develops, but not when acute gastritis occurs. It is not known to be a direct cause of the disease. Although Crohn's disease tends to run in families, gastritis is a symptom of other disease processes and is not a disease process in and of itself. Asking the client what the doctor has said is an evasive response on the part of the nurse and does not help answer the client's question.

The nurse has placed a nasogastric (NG) tube in a client with upper gastrointestinal (GI) bleeding to administer gastric lavage. The client asks the nurse about the purpose of the NG tube for the procedure. What is the nurse's best response? A. "Saline goes down the tube to help clean out your stomach." Correct B. "Medication goes down the tube to help clean out your stomach." C. "The provider requested the tube to be placed just in case it was needed." D. "We'll start feeding you through it once your stomach is cleaned out."

Gastric lavage involves the instillation of water or saline through an NG tube to clear out stomach contents and blood clots. It does not involve the instillation of medication. An NG tube is not typically placed in a client without a particular purpose in mind. Gastric lavage does not involve enteral feeding.

The nurse reviews a medication history for a client newly diagnosed with peptic ulcer disease (PUD) who has a history of using ibuprofen (Advil) frequently for chronic knee pain. The nurse anticipates that the health care provider will request which medication for this client? Bismuth subsalicylate (Pepto-Bismol) Magnesium hydroxide (Maalox) Metronidazole (Flagyl) Misoprostol (Cytotec) Correct

Misoprostol is a prostaglandin analogue that protects against nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers. Bismuth subsalicylate is an antidiarrheal drug that contains salicylates, which can cause bleeding and should be avoided in clients who have PUD. Magnesium hydroxide is an antacid that may be used to neutralize stomach secretions, but is not used specifically to help prevent NSAID-induced ulcers. Metronidazole is an antimicrobial agent used to treat Helicobacter pylori infection.

Which nursing action is best for the charge nurse to delegate to an experienced LPN/LVN? A. Retape the nasogastric tube for a client who has had a subtotal gastrectomy and vagotomy. Incorrect B. Reinforce the teaching about avoiding alcohol and caffeine for a client with chronic gastritis. Correct C. Document instructions for a client with chronic gastritis about how to use "triple therapy." D. Assess the gag reflex for a client who has arrived from the postanesthesia care unit after a laparoscopic gastrectomy.

Reinforcement of teaching done by the RN is within the scope of practice for an LPN/LVN. Retaping the nasogastric tube for a client who has had a subtotal gastrectomy and vagotomy is a complex task that should be done by the RN. Assessment and documenting instructions about how to use triple therapy are nursing functions that should be done by the RN.

The nurse is teaching a client about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the client indicates a need for further teaching? A. "I will need to avoid sweetened fruit juice beverages." B. "I can eat ice cream in moderation." Correct C. "I cannot drink alcohol at all." D. "It is okay to have a serving of sugar-free pudding."

Milk products such as ice cream must be eliminated from the diet of the client with dumping syndrome. The client with dumping syndrome can no longer consume sweetened drinks. Alcohol must be eliminated from the diet. The client can eat sugar-free pudding, custard, and gelatin with caution.

A client has been diagnosed with terminal gastric cancer and is interested in obtaining support from hospice, but expresses concern that pain management will not be adequate. What is the nurse's best response? A. "Pain control is a major component of the care provided by hospice and its staff members." Correct B. "What has your provider told you about participating in hospice?" C. "I can speak to your provider about requesting adequate pain medication." D. "You don't want to become too dependent on pain medication and become an addict."

Telling the client that pain control is a major component of hospice care correctly describes the services provided by hospice and its staff members, and reassures the client about their expertise in pain management. Asking the client what the provider has said is an evasive response by the nurse and does not address the client's concerns. The nurse does not need to speak to the provider because pain control is an integral part of hospice services. It is inappropriate to tell a terminally ill client in need of pain control that he or she may become too dependent on pain medication.

The nurse is reviewing admitting requests for a client admitted to the intensive care unit with perforation of a duodenal ulcer. Which request does the nurse implement first? A. Apply antiembolism stockings. B. Place a nasogastric (NG) tube, and connect to suction. Correct C. Insert an indwelling catheter, and check output hourly. D. Give famotidine (Pepcid) 20 mg IV every 12 hours.

To decrease spillage of duodenal contents into the peritoneum, NG suction should be rapidly initiated. This will minimize the risk for peritonitis. Antiembolism stockings will need to be applied, monitoring output is important, and famotidine (Pepcid) will need to be administered, but the nurse's first priority is to minimize the risk for peritonitis.

The nurse finds a client vomiting coffee-ground emesis. On assessment, the client has blood pressure of 100/74 mm Hg, is acutely confused, and has a weak and thready pulse. Which intervention is the nurse's first priority? A. Administering a histamine2 (H2) antagonist B. Initiating enteral nutrition C. Administering intravenous (IV) fluids Correct D. Administering antianxiety medication

Administering IV fluids is necessary to treat the hypovolemia caused by acute gastrointestinal (GI) bleeding. Administration of an H2 antagonist will not treat the basic problem, which is upper GI bleeding. Enteral nutrition will not be part of the treatment plan for acute GI bleeding. Administration of antianxiety medication will not treat the basic problem causing the client's change in mental status, which is hypovolemia.

A client with peptic ulcer disease (PUD) asks the nurse whether licorice and slippery elm might be useful in managing the disease. What is the nurse's best response? A. "No, they probably won't be useful. You should use only prescription medications in your treatment plan." B. "These herbs could be helpful. However, you should talk with your provider before adding them to your treatment regimen." Correct C. "Yes, these are known to be effective in managing this disease, but make sure you research the herbs thoroughly before taking them." D. "No, herbs are not useful for managing this disease. You can use any type of over-the-counter drugs though. They have been shown to be safe."

Although licorice and slippery elm may be helpful in managing PUD, the client should consult his or her health care provider before making a change in the treatment regimen. Alternative therapies may or may not be helpful in managing PUD. The client should not use over-the-counter medications without first discussing it with his or her provider.

The nurse is caring for an older adult male client who reports stomach pain and heartburn. Which symptom is most significant in determining whether the client's ulceration is gastric or duodenal in origin? A. Pain occurs 1½ to 3 hours after a meal, usually at night. Correct B. Pain is worsened by the ingestion of food. C. The client has a malnourished appearance. D. The client is a man older than 50 years.

A key symptom of duodenal ulcers is that pain usually awakens the client between 1:00 a.m. and 2:00 a.m., occurring 1½ to 3 hours after a meal. Pain that is worsened with ingestion of food and a malnourished appearance are key features of gastric ulcers. A male over 50 years is a finding that could apply to either type of ulcer.

A client is experiencing bleeding related to peptic ulcer disease (PUD). Which nursing intervention is the highest priority? A. Starting a large-bore IV Correct B. Administering IV pain medication C. Preparing equipment for intubation D. Monitoring the client's anxiety level

A large-bore IV should be placed as requested, so that blood products can be administered. IV pain medication is not a recommended treatment for gastrointestinal bleeding. Intubation is not a recommended treatment for bleeding related to PUD. The mental status of the client should be monitored, but it is not necessary to monitor the anxiety level of the client.

A client with gastric cancer is scheduled to undergo surgery to remove the tumor once 5 pounds of body weight has been regained. The client is not drinking the vanilla-flavored enteral supplements that have been prescribed. Which is the highest priority nursing intervention for this client? A. Explain to the client the importance of drinking the enteral supplements prescribed. B. Ask the client's family to try to persuade the client to drink the supplements. C. Inform the client that a nasogastric tube may be necessary if he or she fails to comply. D. Ask the client if a change in flavor would make the supplement more palatable. Correct

Asking the client if a change in flavor would help shows that the nurse is attempting to determine why the client is not drinking the supplements. Many clients don't like certain supplement flavors. The nurse should not assume that the client does not understand the importance of drinking the supplements or that the client requires persuasion to drink the supplements. The problem may be entirely different. Telling the client that a nasogastric tube may be necessary could be construed as threatening the client.

A client has been discharged home after surgery for gastric cancer, and a case manager will follow up with the client. To ensure a smooth transition from the hospital to the home setting, which information provided by the hospital nurse to the case manager is given the highest priority? A. Schedule of the client's follow-up examinations and x-ray assessments Correct B. Information on family members' progress in learning how to perform dressing changes C. Copy of the diet plan prepared for the client by the hospital dietitian Incorrect D. Detailed account of what occurred during the client's surgical procedure

Because recurrence of gastric cancer is common, it will be a priority for the client to have follow-up examinations and x-rays, so that a recurrence can be detected quickly. It may take family members a long time to become proficient at tasks such as dressing changes. Although the case manager should be aware of the diet, family members will likely be preparing the client's daily diet, and they should be provided with this information. It is not necessary for the case manager to have details of the client's surgical procedure unless a significant event has occurred during the procedure.

A client with peptic ulcer disease asks the nurse whether a maternal history of gastric cancer will cause the client to develop gastric cancer. What is the nurse's best response? A. "Yes, it is known that a family history of gastric cancer will cause someone to develop gastric cancer." Incorrect B. "If you are concerned that you are at high risk, I recommend speaking to your provider about the possibility of genetic testing." Correct C. "Have you spoken to your health care provider about your concerns?" D. "I wouldn't be too concerned about that as long as your diet limits pickled, salted, and processed food."

Genetic counseling will help the client determine whether he or she is at exceptionally high risk to develop gastric cancer. The client cannot know for certain whether family history places him or her at exceptionally high risk to develop gastric cancer unless specific testing is done. Asking the client what the provider has said is an evasive answer by the nurse and does not help answer the client's question. Although a diet high in pickled, salted, and processed foods does increase the risk for gastric cancer, a family history of specific types of cancer can also increase the risk.

An older female client is diagnosed with gastric cancer. Which statement made by the client's family demonstrates a correct understanding of the disorder? A. "This may be related to her recurring ulcer disease." Correct B. "This is probably curable with surgery." C. "Gastric cancer has a strong genetic component." D. "Thank goodness she won't have to undergo surgery."

Infection with Helicobacter pylori is the largest risk factor for gastric cancer because it carries the cytotoxin-associated antigen A (CagA) gene. Clients with chronic ulcers are probably infected with this organism. Surgery is not curative; most gastric cancers do not present with symptoms until late in the disease and have a high fatality rate. There is no strong genetic predisposition to gastric cancer. Surgery is part of the treatment.

The nurse is teaching a client with peptic ulcer disease about the prescribed drug regimen. Which statement made by the client indicates a need for further teaching before discharge? A. "Nizatidine (Axid) needs to be taken three times a day to be effective." Correct B. "Taking ranitidine (Zantac) at bedtime should decrease acid production at night." C. "Sucralfate (Carafate) should be taken 1 hour before and 2 hours after meals." D. "Omeprazole (Prilosec) should be swallowed whole and not crushed."

Nizatidine is most effective if administered once daily. A dose of ranitidine at bedtime should decrease acid production throughout the night. Sucralfate should be taken 1 hour before and 2 hours after meals. Because omeprazole is a delayed-release capsule, it should be swallowed whole and not crushed.

A client is scheduled to be discharged after a gastrectomy. The client's spouse expresses concern that the client will be unable to change the surgical dressing adequately. What is the nurse's highest priority intervention? A. Providing both oral and written instructions on changing the dressing and on symptoms of infection that must be reported to the provider Correct B. Asking the provider for a referral for home health services to assist with dressing changes C. Asking the spouse whether other family members could be taught how to change the dressing D. Trying to determine specific concerns that the spouse has regarding dressing changes

Providing the client and spouse with both oral and written instructions on symptoms to report to the provider, as well as on how to perform the dressing change, will reinforce important points and boost the spouse's confidence. Obtaining a referral and recruiting other family members prevent the client and spouse from taking responsibility for the client's care. The spouse's concerns have already been clearly expressed.

The nurse is teaching a client how to prevent recurrent chronic gastritis symptoms before discharge. Which statement by the client demonstrates a correct understanding of the nurse's instruction? A. "It is okay to continue to drink coffee in the morning when I get to work." B. "I will need to take vitamin B12 shots for the rest of my life." C. "I should avoid alcohol and tobacco." Correct D. "I should eat small meals about six times a day."

The client with chronic gastritis should avoid alcohol and tobacco. The client should eliminate caffeine from the diet. The client will need to take vitamin B12 shots only if he or she has pernicious anemia. The client should not eat six small meals daily. This practice may actually stimulate gastric acid secretion.

The nurse working during the day shift on the medical unit has just received report. Which client does the nurse plan to assess first? A. Young adult with epigastric pain, hiccups, and abdominal distention after having a total gastrectomy Correct B. Adult who had a subtotal gastrectomy and is experiencing dizziness and diaphoresis after each meal Incorrect C. Middle-aged client with gastric cancer who needs to receive omeprazole (Prilosec) before breakfast D. Older adult with advanced gastric cancer who is scheduled to receive combination chemotherapy

The client with epigastric pain is experiencing symptoms of acute gastric dilation, which can disrupt the suture line. The surgeon should be notified immediately because the nasogastric tube may need irrigation or re-positioning. The client who had a subtotal gastrectomy is not in a life-threatening situation and does not require immediate assessment. The client with gastric cancer and the older adult with advanced gastric cancer are in stable condition and do not require immediate assessment.

The admission assessment for a client with acute gastric bleeding indicates blood pressure 82/40 mm Hg, pulse 124 beats/min, and respiratory rate 26 breaths/min. Which admission request does the nurse implement first? A. Type and crossmatch for 4 units of packed red blood cells. B. Infuse lactated Ringer's solution at 200 mL/hr. Correct C. Give pantoprazole (Protonix) 40 mg IV now and then daily. D. Insert a nasogastric tube and connect to low intermittent suction. Incorrect

The client's most immediate concern is the hypotension associated with volume loss. The most rapidly available volume expanders are crystalloids to treat hypovolemia. A type and crossmatch, administration of pantoprazole, and insertion of a nasogastric tube must all be done, but the nurse's immediate concern is correcting the client's hypovolemia.

Which client assessment information is correlated with a diagnosis of chronic gastritis? A. Anorexia, nausea, and vomiting Incorrect B. Frequent use of corticosteroids C. Hematemesis and anorexia D. Treatment with radiation therapy Correct

Treatment with radiation therapy is known to be associated with the development of chronic gastritis. Anorexia, nausea, and vomiting are all symptoms of acute gastritis. Corticosteroid use and hematemesis are also more likely to be signs of acute gastritis.