Medical-Surgical Nursing - Gastrointestinal system
A client is admitted to the hospital with jaundiced skin and acute abdominal pain. What is the nurse's most therapeutic response when the client refuses all visitors? 1 Listen to the client's fears 2 Encourage the client to socialize 3 Grant the client's request about visitors 4 Darken the client's room by pulling the drapes
1 - Listen to the client's fears Voicing fears often reduces the associated anxiety. Socialization, when feelings need exploration, is not therapeutic. Although the client's request about visitors should be granted, simply accepting the client's wishes is not by itself therapeutic. Darkening the client's room avoids the problem and is not therapeutic.
A client reports experiencing nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. The pain occurs most often after eating in fast-food restaurants. Which diet should the nurse instruct the client to follow? 1 Low fat 2 Low carbohydrate 3 Soft-textured and bland 4 High protein and kilocalories
1 - Low fat The presence of fat in the duodenum stimulates painful contractions of the gallbladder to release bile, causing right upper quadrant pain; fat intake should be restricted. Carbohydrates do not have to be restricted. A reduction in spices and bulk is not necessary. Although a diet high in protein and kilocalories might be desirable as long as the protein is not high in saturated fat, a high-calorie diet generally is not prescribed.
A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply. 1 Oliguria 2 Lethargy 3 Irritability 4 Hypotension 5 Slurred speech
1 - Oliguria 3 - Irritability 4 - Hypotension Decreased blood flow to the kidneys leads to oliguria or anuria. Irritability, along with restlessness and anxiety, occurs because of a decrease in oxygen to the brain. Hypotension and a narrowing of the pulse pressure occur because of declining blood volume. Restlessness, not lethargy, usually occurs because of decreased cerebral blood flow. There are various changes in sensorium, but slurred speech is not a manifestation of shock.
A client who had an abdominoperineal resection and colostomy refuses to allow any family members to see the incision or stoma. The client is noncompliant with most of the dietary recommendations. The nurse concludes that the client is experiencing what response? 1 Reaction formation; this is related to the client's recent altered body image 2 Denial; the client is having difficulty accepting reality 3 Impotency resulting from the surgery; sexual counseling may be indicated 4 Suicidal thoughts; consultation with a psychiatrist should be prescribed
2 - Denial; the client is having difficulty accepting reality As long as no one else confirms the presence of the stoma and the client does not adhere to a prescribed regimen, the client's denial is supported. There is no evidence to document that reaction formation is being used. There are no data to support the conclusion that the client has an inability to function sexually. There is no evidence that suicidal thoughts are present or will be acted upon.
A nurse is evaluating a client's response to receiving an intermittent gravity flow percutaneous endoscopic gastrostomy (PEG) tube feeding. Which clinical finding indicates that the client is unable to tolerate a continuation of the feeding? 1 Passage of flatus 2 Rise of formula in the tube 3 Rapid inflow of the feeding 4 Tenderness of epigastric area
2 - Rise of formula in the tube A rise in the level of formula within the tube indicates a full stomach. Passage of flatus reflects intestinal motility, which does not pose a potential problem. A rapid inflow is the result of positioning the container too high or using a feeding tube with too large a lumen. Epigastric tenderness is not necessarily caused by a full stomach.
A client is admitted to the hospital for a laparoscopic cholecystectomy. What should the nurse encourage the client to add to the diet to help normalize bowel function after surgery? 1 Vitamins 2 Whole bran 3 Cod liver oil 4 Amino acids
2 - Whole bran Whole bran provides bulk that promotes intestinal motility and a regular bowel movement. Vitamins are not related to normalizing bowel function. Cod liver oil is not related to regulating bowel function. Amino acids are not related to regulating bowel function.
A nurse is reviewing preoperative instructions with a client who is scheduled for orthopedic surgery at 8:00 AM the next day. What advice does the nurse give the client? 1 "Have your dinner completed by 6:00 PM tonight and then no food or fluids after that." 2 "Drink whatever liquids you want tonight and then only clear liquids tomorrow morning." 3 "Consume a light evening meal tonight and then no food or fluids after midnight." 4 "Eat lunch today and then do not drink or eat anything until after your surgery."
3 - "Consume a light evening meal tonight and then no food or fluids after midnight." By eating a light meal and eliminating food and fluids after midnight, complications are limited during and after surgery; these include aspiration, nausea, dehydration, and possible ileus. A large meal the evening before surgery may not clear before peristalsis is slowed by anesthesia, resulting in abdominal distention and discomfort after surgery. Clear liquids in the morning can cause nausea, vomiting, and aspiration. Fluids should not be withheld for more than eight hours to prevent dehydration. Not eating or drinking anything after lunch is an excessive amount of time to restrict food and fluids before surgery the next morning.
The nurse provides discharge teaching to a client related to management of the client's new colostomy. The client states, "I hope I can handle all of this at home; it's a lot to remember." What is the nurse's best response? 1 "I'm sure you will be able to do it." 2 "Maybe a family member can do it for you." 3 "You seem to be nervous about going home." 4 "Perhaps you can stay in the hospital another day."
3 - "You seem to be nervous about going home." Reflection of feelings conveys acceptance and encourages further communication. The response "I'm sure you will be able to do it" is false reassurance that does not help to reduce anxiety. The response "Maybe a family member can do it for you" provides false reassurance and promotes dependence. The response "Perhaps you can stay in the hospital another day" is unrealistic and does not address the client's concern in a way that supports the ventilation of feelings.
A client, experiencing an exacerbation of Crohn disease, is admitted to the hospital for intravenous steroid therapy. The nurse should not assign this client to a room with a roommate who has which illness? 1 Pancreatitis 2 Thrombophlebitis 3 Bacterial meningitis 4 Acute cholecystitis
3 - Bacterial meningitis The bacteria that cause meningitis are transmitted via air currents; the client should be in a private room with airborne precautions to protect other people. Pancreatitis is not a communicable disease; it is most often caused by autodigestion of pancreatic tissue by its own enzymes. Thrombophlebitis is not a communicable disease; it is inflammation of a vein (phlebitis) associated with thrombus formation. Cholecystitis is not a communicable disease; it is inflammation of the gallbladder.
A client has a hiatal hernia. The client is 5 feet 3 inches tall (163 cm) and weighs 160 pounds (72.6 kg). Which information should the nurse include when discussing prevention of esophageal reflux? 1 Increase your intake of fat with each meal. 2 Lie down after eating to help your digestion. 3 Reduce your caloric intake to foster weight reduction. 4 Drink several glasses of fluid during each of your meals.
3 - Reduce your caloric intake to foster weight reduction. Weight reduction decreases intraabdominal pressure, thereby decreasing the tendency to reflux into the esophagus. Fats decrease emptying of the stomach, extending the period that reflux can occur; fats should be decreased. Lying down after eating increases the pressure against the diaphragmatic hernia, increasing symptoms. Drinking several glasses of fluid during each meal will increase pressure; fluid should be discouraged with meals.
A client with gastroesophageal reflux disease (GERD) is being treated with dietary management. The client states, "I like to have a glass of juice every day." Which juice will the nurse recommend? 1 Apple 2 Orange 3 Tomato 4 Grapefruit
1 - Apple Apple juice is nonirritating to the stomach and intestine. Orange juice, tomato juice, and grapefruit juice are acidic juices that decrease the pH of the stomach and irritate the gastrointestinal mucosa.
A client with colitis inquires as to whether surgery eventually will be necessary. When teaching about the disease and its treatment, what should the nurse emphasize? 1 Medical treatment is curative; surgery is not required. 2 For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful. 3 For most clients, surgery is recommended early in the course of treatment. 4 Medical treatment is all that will be needed if the client can maintain emotional stability.
2 - For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful. Medical treatment is directed toward reducing motility of the inflamed bowel, restoring nutrition, and preventing and treating infection; surgery is used selectively for those who are acutely ill or have excessive exacerbations. That medical treatment for colitis is curative and that surgery is not required is untrue; medical treatment is symptomatic, not curative. It usually is performed as a last resort. Although there is an emotional component, the physiological adaptations determine whether surgery is necessary.
A client tells the nurse about recent recurrent episodes of bleeding hemorrhoids. What should the nurse advise the client to do to help prevent future hemorrhoidal episodes? 1 Exercise to improve circulation 2 Eat bland foods and avoid spices 3 Consume a high-fiber diet and drink adequate water 4 Use laxatives to avoid constipation and the Valsalva maneuver
3 - Consume a high-fiber diet and drink adequate water Consuming a high-fiber diet and drinking adequate water promote regular bowel function, prevents constipation, and prevent straining, which can make hemorrhoids worse; a high-fiber diet provides bulk that stimulates peristalsis, and water promotes a soft stool. Exercise is advisable, but the purpose in this instance is to increase peristalsis, not improve circulation. Bland foods and spices are unrelated to hemorrhoids; bland foods are preferred for clients with gastric or intestinal problems. Laxatives are contraindicated because they are irritating to the bowel, decrease intestinal tone, and promote dependency. The Valsalva maneuver should also be avoided.
A client is diagnosed with hepatitis A. The nurse provides the client with information about untoward signs and symptoms related to hepatitis. The nurse instructs the client to contact the primary healthcare provider if the client develops what symptom? 1 Fatigue 2 Anorexia 3 Yellow urine 4 Clay-colored stools
4 - Clay-colored stools Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines. It is unnecessary to call the healthcare provider because fatigue and anorexia are characteristic of hepatitis from the onset of clinical manifestations. Yellow is the expected color of urine.
A nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease? 1 Inclusion of transmural involvement of the small bowel wall 2 Higher occurrence of fistulas and abscesses from changes in the bowel wall 3 Pathology beginning proximally with intermittent plaques found along the colon 4 Involvement starting distally with rectal bleeding that spreads continuously up the colon
4 - Involvement starting distally with rectal bleeding that spreads continuously up the colon Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon; in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. Intermittent areas of pathology occur in Crohn. In ulcerative colitis, the pathology is in the inner layer and does not extend throughout the entire bowel wall; therefore, abscesses and fistulas are rare. Abscesses and fistulas occur more frequently in Crohn disease.