Lewis - Med Surg - Ch 38: Nursing Assessment: Gastrointestinal System

A 58-year-old woman has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by unlicensed assistive personnel (UAP) requires that the registered nurse (RN) intervene? a. Offering the patient a drink of water b. Positioning the patient on the right side c. Checking the vital signs every 30 minutes d. Swabbing the patient's mouth with cold water

A

A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to teach the patient about the purpose of A. echocardiography. B. daily blood cultures. C. cardiac catheterization. D. 24-hour Holter monitor.

A

A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which actions from the agency policy for ERCP should the nurse take first? a. Place the patient on NPO status. b. Administer sedative medications. c. Ensure the consent form is signed. d. Teach the patient about the procedure.

A

The nurse is caring for a 64-year-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately? A. The patient has bilateral crackles. B. The patient has bilateral, 4+ peripheral edema. C. The patient has a loud systolic murmur across the precordium. D. The patient has a palpable thrill felt over the left anterior chest.

A

The nurse is caring for a 78-year-old patient with aortic stenosis. Which assessment data obtained by the nurse would be most important to report to the health care provider? A. The patient complains of chest pressure when ambulating. B. A loud systolic murmur is heard along the right sternal border. C. A thrill is palpated at the second intercostal space, right sternal border. D. The point of maximum impulse (PMI) is at the left midclavicular line.

A

The nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should A. note when Korotkoff sounds are auscultated during both inspiration and expiration. B. subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP). C. check the electrocardiogram (ECG) for variations in rate during the respiratory cycle. D. listen for a pericardial friction rub that persists when the patient is instructed to stop breathing.

A

To palpate the liver during a head-to-toe physical assessment, the nurse a. places one hand on the patient's back and presses upward and inward with the other hand below the patient's right costal margin. b. places one hand on top of the other and uses the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. c. presses slowly and firmly over the right costal margin with one hand and withdraws the fingers quickly after the liver edge is felt. d. places one hand under the patient's lower ribs and presses the left lower rib cage forward, palpating below the costal margin with the other hand.

A

A 30-year-old man is being admitted to the hospital for elective knee surgery. Which assessment finding is most important to report to the health care provider? a. Tympany on percussion of the abdomen b. Liver edge 3 cm below the costal margin c. Bowel sounds of 20/minute in each quadrant d. Aortic pulsations visible in the epigastric area

B

A 62- year-old man reports chronic constipation. To promote bowel evacuation, the nurse will suggest that the patient attempt defecation a. in the mid-afternoon. b. after eating breakfast. c. right after getting up in the morning. d. immediately before the first daily meal.

B

A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. Based on these findings, which nursing diagnosis would be most appropriate? A. Pain related to permanent joint fixation B. Activity intolerance related to arthralgia C. Risk for infection related to open skin lesions D. Risk for impaired skin integrity related to pruritus

B

After receiving report on the following patients, which patient should the nurse assess first? A. Patient with rheumatic fever who has sharp chest pain with a deep breath B. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg C. Patient with infective endocarditis who has a murmur and splinter hemorrhages D. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases

B

The nurse is assessing an alert and independent 78-year-old woman for malnutrition risk. The most appropriate initial question is which of the following? a. "How do you get to the store to buy your food?" b. "Can you tell me the food that you ate yesterday?" c. "Do you have any difficulty in preparing or eating food?" d. "Are you taking any medications that alter your taste for food?"

B

The nurse will plan to monitor a patient with an obstructed common bile duct for a. melena. b. steatorrhea. c. decreased serum cholesterol levels. d. increased serum indirect bilirubin levels.

B

Which information about an 80-year-old man at the senior center is of most concern to the nurse? a. Decreased appetite b. Unintended weight loss c. Difficulty chewing food d. Complaints of indigestion

B

A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient? A. Biologic valves will require immunosuppressive drugs after surgery. B. Mechanical mitral valves need to be replaced sooner than biologic valves. C. Lifelong anticoagulant therapy will be needed after mechanical valve replacement. D. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.

C

A 54-year-old man has just arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? a. The patient is very drowsy. b. The patient reports a sore throat. c. The oral temperature is 101.6° F. d. The apical pulse is 104 beats/minute.

C

A patient recovering from heart surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest pain with deep breathing. Which ordered PRN medication will be the most appropriate for the nurse to give? A. Fentanyl 1 mg IV B. IV morphine sulfate 4 mg C. Oral ibuprofen (Motrin) 600 mg D. Oral acetaminophen (Tylenol) 650 mg

C

After assisting with a needle biopsy of the liver at a patient's bedside, the nurse should a. put pressure on the biopsy site using a sandbag. b. elevate the head of the bed to facilitate breathing. c. place the patient on the right side with the bed flat. d. check the patient's postbiopsy coagulation studies.

C

During discharge teaching with a 68-year-old patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient on the A. use of daily aspirin for anticoagulation. B. correct method for taking the radial pulse. C. need for frequent laboratory blood testing. D. need to avoid any physical activity for 1 month.

C

When caring for a patient with infective endocarditis of the tricuspid valve, the nurse should monitor the patient for the development of A. flank pain. B. splenomegaly. C. shortness of breath. D. mental status changes.

C

While interviewing a 30-year-old man, the nurse learns that the patient has a family history of familial adenomatous polyposis (FAP). The nurse will plan to assess the patient's knowledge about a. preventing noninfectious hepatitis. b. treating inflammatory bowel disease. c. risk for developing colorectal cancer. d. using antacids and proton pump inhibitors.

C

A 42-year-old woman is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? a. The patient took a laxative the previous evening. b. The patient had a high-fat meal the previous evening. c. The patient has a permanent gastrostomy tube in place. d. The patient ate a low-fat bagel 4 hours ago for breakfast.

D

A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient about managing this disorder? A. A heart transplant should be scheduled as soon as possible. B. Elevating the legs above the heart will help relieve dyspnea. C. Careful compliance with diet and medications will prevent heart failure. D. Notify the doctor about any symptoms of heart failure such as shortness of breath.

D

The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. The priority intervention by the nurse for this problem is to A. teach the patient to take deep, slow breaths to control the pain. B. force fluids to 3000 mL/day to decrease fever and inflammation. C. remind the patient to request opioid pain medication every 4 hours. D. place the patient in Fowler's position, leaning forward on the overbed table.

D

The nurse is obtaining a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC). Which information obtained by the nurse is most important? A. The patient has a history of a recent upper respiratory infection. B. The patient has a family history of coronary artery disease (CAD). C. The patient reports using cocaine a "couple of times" as a teenager. D. The patient's 29-year-old brother died from a sudden cardiac arrest.

D

Two days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first? A. Auscultate the heart sounds. B. Check the patient's temperature. C. Notify the patient's health care provider. D. Give the PRN acetaminophen (Tylenol).

A

While caring for a patient with aortic stenosis, the nurse identifies a nursing diagnosis of acute pain related to decreased coronary blood flow. A priority nursing intervention for this patient would be to A. promote rest to decrease myocardial oxygen demand. B. teach the patient about the need for anticoagulant therapy. C. teach the patient to use sublingual nitroglycerin for chest pain. D. raise the head of the bed 60 degrees to decrease venous return.

A

After receiving the following information about four patients during change-of-shift report, which patient should the nurse assess first? A. Patient with acute pericarditis who has a pericardial friction rub B. Patient who has just returned to the unit after balloon valvuloplasty C. Patient who has hypertrophic cardiomyopathy and a heart rate of 116 D. Patient with a mitral valve replacement who has an anticoagulant scheduled

B

During the assessment of a 25-year-old patient with infective endocarditis (IE), the nurse would expect to find A. substernal chest pressure. B. a new regurgitant murmur. C. a pruritic rash on the chest. D. involuntary muscle movement.

B

The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)? A. Fever, chills, and diaphoresis B. Urine output less than 30 mL/hr C. Petechiae on the inside of the mouth and conjunctiva D. Increase in heart rate of 15 beats/minute with walking

B

The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history will be most pertinent to ask? A. "Do you use any illegal IV drugs?" B. "Have you had a recent sore throat?" C. "Have you injured your chest in the last few weeks?" D. "Do you have a family history of congenital heart disease?"

B

The nurse is assessing a patient with myocarditis before administering the scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider? A. Leukocytosis B. Irregular pulse C. Generalized myalgia D. Complaint of fatigue

B

To assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should A. listen for a rumbling, low-pitched, systolic murmur over the left anterior chest. B. auscultate by placing the diaphragm of the stethoscope on the lower left sternal border. C. ask the patient to cough during auscultation to distinguish the sound from a pleural friction rub. D. feel the precordial area with the palm of the hand to detect vibrations with cardiac contraction.

B

When developing a community health program to decrease the incidence of rheumatic fever, which action would be most important for the community health nurse to include? A. Vaccinate high-risk groups in the community with streptococcal vaccine. B. Teach community members to seek treatment for streptococcal pharyngitis. C. Teach about the importance of monitoring temperature when sore throats occur. D. Teach about prophylactic antibiotics to those with a family history of rheumatic fever.

B

When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is a priority for the nurse to include? A. Monitor labs for streptococcal antibodies. B. Arrange for placement of a long-term IV catheter. C. Teach the importance of completing all oral antibiotics. D. Encourage the patient to begin regular aerobic exercise.

B

Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement? A. Administer ceftriaxone (Rocephin) 1 g IV. B. Order blood cultures drawn from two sites. C. Give acetaminophen (Tylenol) PRN for fever. D. Arrange for a transesophageal echocardiogram.

B

Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider? A. Generalized muscle aching B. Sudden onset right flank pain C. Janeway's lesions on the palms D. Temperature 100.7° F (38.1° C)

B

The nurse will plan discharge teaching about the need for prophylactic antibiotics when having dental procedures for which patient? A. Patient admitted with a large acute myocardial infarction. B. Patient being discharged after an exacerbation of heart failure. C. Patient who had a mitral valve replacement with a mechanical valve. D. Patient being treated for rheumatic fever after a streptococcal infection.

C

When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for A. diastolic murmur. B. peripheral edema. C. shortness of breath on exertion. D. right upper quadrant tenderness.

C

Which action by the nurse will determine if the therapies ordered for a patient with chronic constrictive pericarditis are effective? A. Assess for the presence of a paradoxical pulse. B. Monitor for changes in the patient's sedimentation rate. C. Assess for the presence of jugular venous distention (JVD). D. Check the electrocardiogram (ECG) for ST segment changes.

C

Which assessment finding obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider? A. Pulsus paradoxus 8 mm Hg B. Blood pressure (BP) of 168/94 C. Jugular venous distention (JVD) to jaw level D. Level 6 (0 to 10 scale) chest pain with a deep breath

C

Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? a. Loud gurgles b. High-pitched gurgles c. Absent bowel sounds d. Frequent clicking sounds

C

Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge teaching about self-management has been most effective? A. "I will avoid taking aspirin or other antiinflammatory drugs." B. "I will need to limit my intake of salt and fluids even in hot weather." C. "I will take antibiotics when my teeth are cleaned at the dental office." D. "I should begin an exercise program that includes things like biking or swimming."

C

Which statement to the nurse from a patient with jaundice indicates a need for teaching? a. "I used cough syrup several times a day last week." b. "I take a baby aspirin every day to prevent strokes." c. "I use acetaminophen (Tylenol) every 4 hours for back pain." d. "I need to take an antacid for indigestion several times a week"

C

The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge regarding long-term management of rheumatic fever when a 30-year-old recovering from rheumatic fever without carditis says which of the following? A. "I will need prophylactic antibiotic therapy for 5 years." B. "I will need to take aspirin or ibuprofen (Motrin) to relieve my joint pain." C. "I will call the doctor if I develop excessive fatigue or difficulty breathing." D. "I will be immune to further episodes of rheumatic fever after this infection."

D

The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate? A. "Do you have a history of a heart attack?" B. "Is there a family history of endocarditis?" C. "Have you had any recent immunizations?" D. "Have you had dental work done recently?"

D

The nurse receives the following information about a 51-year-old woman who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient has a permanent pacemaker to prevent bradycardia. b. The patient is worried about discomfort during the examination. c. The patient has had an allergic reaction to shellfish and iodine in the past. d. The patient refused to drink the ordered polyethylene glycol (GoLYTELY).

D

When caring for a patient with a history of a total gastrectomy, the nurse will monitor for a. constipation. b. dehydration. c. elevated total serum cholesterol. d. cobalamin (vitamin B12) deficiency.

D

Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit? A. Select the best lead for monitoring a patient with an admission diagnosis of Dressler syndrome. B. Obtain a list of herbal medications used at home while admitting a new patient with pericarditis. C. Teach about the need to monitor the weight daily for a patient who has hypertrophic cardiomyopathy. D. Check the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates.

D

While caring for a 23-year-old patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to A. take antibiotics before any dental appointments. B. limit physical activity to avoid stressing the heart. C. take an aspirin a day to prevent clots from forming on the valve. D. avoid use of over-the-counter (OTC) medications that contain stimulant drugs.

D