Chapter 29: Gastrointestinal Disorders and Therapeutic Management Urden
2. A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The nurse knows that varices are caused by which pathophysiologic mechanism? a. Portal hypertension resulting in diversion of blood from a high-pressure area to a low-pressure area b. Superficial mucosal erosions as a result of increased stress levels c. Loss of protective mechanisms resulting in the breakdown the mucosal resistance d. Inflammation and ulceration secondary to nonsteroidal antiinflammatory drug use
*ANS:* A Esophagogastric varices are engorged and distended blood vessels of the esophagus and proximal stomach that develop as a result of portal hypertension secondary to hepatic cirrhosis, a chronic disease of the liver that results in damage to the liver sinusoids. Without adequate sinusoid function, resistance to portal blood flow is increased, and pressures within the liver are elevated. This leads to a rise in portal venous pressure (portal hypertension), causing collateral circulation to divert portal blood from areas of high pressure within the liver to adjacent areas of low pressure outside the liver, such as into the veins of the esophagus, spleen, intestines, and stomach. PTS: 1 DIF: Cognitive Level: Understanding REF: pp. 681-682 OBJ: Nursing Process Step: General TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
4. A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. What medication would the nurse expect the practitioner to order for this patient? a. Histamine2 (H2) antagonists b. Vasopressin c. Heparin d. Antacids
*ANS:* B In acute variceal hemorrhage, control of bleeding can be accomplished through the use of pharmacologic agents. Intravenous vasopressin, somatostatin, and octreotide have been shown to reduce portal venous pressure and slow variceal hemorrhaging by constricting the splanchnic arteriolar bed. PTS: 1 DIF: Cognitive Level: Applying REF: p. 684 OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
16. The nurse is caring for a patient after an esophagectomy. In the immediate postoperative period, which nursing intervention would have the highest priority? a. Preventing atelectasis b. Managing pain c. Promoting ambulation d. Preventing infection
*ANS:* B It is imperative to appropriately manage the patient's pain after gastrointestinal (GI) surgery. Adequate analgesia is necessary to promote the mobility of the patient and decrease pulmonary complications. Initial pain management may be accomplished by intravenous opioid (morphine, hydromorphone) administration by means of a patient-controlled analgesia (PCA) pump or through continuous epidural infusion of an opioid and local anesthetic (bupivacaine). PTS: 1 DIF: Cognitive Level: Applying REF: p. 698|Box 29-18 OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
19. A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The patient has been started on a vasopressin drip. The nurse would monitor the patient for which side effect of the medication? a. Constipation b. Diarrhea c. Chest pain d. Bleeding
*ANS:* C A major side effect of the medication is systemic vasoconstriction, which can result in cardiac ischemia, chest pain, hypertension, acute heart failure, dysrhythmias, phlebitis, bowel ischemia, and cerebrovascular accident. These side effects can be offset with concurrent administration of nitroglycerin. Other complications include bradycardia and fluid retention. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 701 OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
1. Which disorders or conditions are potential causes of acute liver failure? (Select all that apply.) a. Ischemia b. Hepatitis A, B, C, D, E, non-A, non-B, non-C c. Acetaminophen toxicity d. Wilson disease e. Reye syndrome f. Diabetes
*ANS:* A, B, C, D, E Diabetes is not a primary cause of acute liver failure but is associated with pancreatitis. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 693|Box 29-14 OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
8. A patient with a history of chronic alcoholism was admitted with acute pancreatitis. What intervention would the nurse include in the patient's plan of care? a. Monitor the patient for hypovolemic shock from plasma volume depletion. b. Observe the patient for hypoglycemia and hypercalcemia. c. Initiate enteral feedings after the nasogastric tube is placed. d. Place the patient on a fluid restriction to avoid the fluid sequestration.
*ANS:* A Because pancreatitis is often associated with massive fluid shifts, intravenous crystalloids and colloids are administered immediately to prevent hypovolemic shock and maintain hemodynamic stability. Electrolytes are monitored closely, and abnormalities such as hypocalcemia, hypokalemia, and hypomagnesemia are corrected. If hyperglycemia develops, exogenous insulin may be required. PTS: 1 DIF: Cognitive Level: Applying REF: p. 688 OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
3. A patient has been admitted with pancreatitis. Which clinical manifestations would the nurse expect to observe in support of this diagnosis? (Select all that apply.) a. Epigastric and abdominal pain b. Nausea and vomiting c. Diaphoresis d. Jaundice e. Hyperactive bowel sounds f. Fever
*ANS:* A, B, D, F Clinical manifestations of acute pancreatitis include pain, vomiting, nausea, fever, abdominal distention, abdominal guarding, abdominal tympany, hypoactive or absent bowel sounds, severe disease, peritoneal signs, ascites, jaundice, palpable abdominal mass, Grey-Turner sign, Cullen sign, and signs of hypovolemic shock. There may be peritonitis involved with pancreatitis and percussion will reveal a tympanic abdomen; bowel sounds will be decreased or absent. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 687|Box 29-7 OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiologic Integrity
10. A patient with a history of chronic alcoholism was admitted with acute pancreatitis. The nurse is developing a patient education plan. Which topic would the nurse include in the plan? a. Diabetes management b. Alcohol cessation c. Occult blood testing d. Anticoagulation management
*ANS:* B As the patient moves toward discharge, teaching should focus on the interventions necessary for preventing the recurrence of the precipitating disorder. If an alcohol abuser, the patient should be encouraged to stop drinking and be referred to an alcohol cessation program. PTS: 1 DIF: Cognitive Level: Applying REF: p. 692 OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
13. A patient was admitted with severe epigastric pain and has been diagnosed with cancer. The patient is scheduled for an esophagectomy. The patient asks about the procedure. What would be an appropriate response from the nurse? a. "This procedure is usually performed for cancer of the proximal esophagus and gastroesophageal junction." b. "This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction." c. "This procedure is usually performed for cancer of the pancreatic head." d. "The procedure is usually performed for varices of the distal esophagus and gastroesophageal junction."
*ANS:* B Esophagectomy is usually performed for cancer of the distal esophagus and gastroesophageal junction. PTS: 1 DIF: Cognitive Level: Applying REF: p. 695 OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
9. A patient with acute pancreatitis is complaining of a pain in the left upper quadrant. Using a 1- to 10-point pain scale, the patient states the current level is at an 8. What intervention would the nurse include in the patient's plan of care to facilitate pain control? a. Administer analgesics only as needed. b. Administer analgesics around the clock. c. Educate the patient and family on lifestyle changes. d. Teach relaxation and distraction techniques.
*ANS:* B Pain management is a major priority in acute pancreatitis. Administration of around-the-clock analgesics to achieve pain relief is essential. Morphine, fentanyl, and hydromorphone are the commonly used narcotics for pain control. Relaxation techniques and the knee-chest position can also assist in pain control. However, the patient's pain needs to be addressed first. PTS: 1 DIF: Cognitive Level: Applying REF: p. 691|Box 29-9 OBJ: Nursing Process Step: Evaluation TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
1. A patient is admitted with an upper gastrointestinal bleed. Which disorder is the leading cause of upper gastrointestinal (GI) hemorrhage? a. Stress ulcers b. Peptic ulcers c. Nonspecific erosive gastritis d. Esophageal varices
*ANS:* B Peptic ulcer disease (gastric and duodenal ulcers), resulting from the breakdown of the gastro mucosal lining, is the leading cause of upper gastrointestinal (GI) hemorrhage, accounting for approximately 21% of cases. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 681 OBJ: Nursing Process Step: Diagnosis TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
5. Which nursing intervention is a priority for a patient with gastrointestinal hemorrhage? a. Positioning the patient in a high-Fowler position b. Ensuring the patient has a patent airway c. Irrigating the nasogastric tube with iced saline d. Maintaining venous access so that fluids and blood can be administered
*ANS:* B Priorities in the medical management of a patient with gastrointestinal hemorrhage include airway protection, fluid resuscitation to achieve hemodynamic stability, correction of comorbid conditions (eg, coagulopathy), therapeutic procedures to control or stop bleeding, and diagnostic procedures to determine the exact cause of the bleeding. PTS: 1 DIF: Cognitive Level: Applying REF: p. 682 OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
20. How would the nurse administer sucralfate through a gastric tube? a. Crushed and mixed with 10 mL of water b. Dissolved in 10 mL of water to form a slurry c. Mixed in 15 mL of water to form a solution d. Administered as a whole pill with a 35-mL water flush
*ANS:* B Sucralfate should not be crushed but may be dissolved in 10 mL of water to form a slurry. It is also available as a suspension. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 700 OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
15. The nurse is caring for a patient after an esophagectomy. The nurse knows the patient is at risk for an anastomotic leak. Which finding would indicate this occurrence? a. Crackles in the lung bases b. Subcutaneous emphysema c. Incisional bleeding d. Absent of bowel sounds
*ANS:* B The clinical signs and symptoms include tachycardia, tachypnea, fever, abdominal pain, anxiety, and restlessness. In a patient who had an esophagectomy, a leak of the esophageal anastomosis may manifest as subcutaneous emphysema in the chest and neck. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 698 OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
18. A patient was admitted with acute liver failure. The patient is lethargic, confused, and has marked asterixis. The nurse suspects the patient is in what stage of hepatic encephalopathy. a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4
*ANS:* B The patient is in Stage 2 hepatic encephalopathy as evidenced by lethargy, moderate confusion, marked asterixis, and abnormal electroencephalography (EEG). PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 694|Box 29-15 OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
2. A patient is admitted with the diagnosis of acute pancreatitis. The nurse expects which laboratory values to be elevated? (Select all that apply.) a. Calcium b. Serum amylase c. Serum glucose d. Potassium e. White blood cells f. Serum triglycerides
*ANS:* B, C, E, F Calcium and potassium decrease with acute pancreatitis. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 688|Table 29-2 OBJ: Nursing Process Step: Diagnosis TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
4. A patient has been admitted with acute liver failure. Which interventions would the nurse expect as part of the interprofessional collaborative management plan? (Select all that apply.) a. Benzodiazepines for agitation b. Pulse oximetry and serial arterial blood gas measurements c. Insulin drip for hyperglycemia and hyperkalemia d. Monitoring electrolyte blood levels e. Assessing for signs of cerebral edema
*ANS:* B, D, E The patient may experience a variety of other complications, including cerebral edema, cardiac dysrhythmias, acute respiratory failure, sepsis, and acute kidney injury. Cerebral edema and increased intracranial pressure develop as a result of breakdown of the blood-brain barrier and astrocyte swelling. Circulatory failure that mimics sepsis is common in acute liver failure and may exacerbate low cerebral perfusion pressure. Hypoxemia, acidosis, electrolyte imbalances, and cerebral edema can precipitate the development of cardiac dysrhythmias. Acute respiratory failure, progressing to acute respiratory distress syndrome, intrapulmonary shunting, ventilation-perfusion mismatch, sepsis, and aspiration may be attributed to the universal arterial hypoxemia. PTS: 1 DIF: Cognitive Level: Analyzing REF: pp. 693-694 OBJ: Nursing Process Step: Planning TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiologic Integrity
14. A patient was admitted after a Roux-en-Y gastric bypass (RYGBP). A nursing student asks the nurse what type of surgery an RYGBP is. What would be an appropriate response from the nurse? a. "It is an esophagectomy performed using the transthoracic approach." b. "It is an esophagectomy performed using a transhiatal approach." c. "It is a combination of restrictive and malabsorption types of bariatric surgery." d. "It is a standard operation for pancreatic cancer."
*ANS:* C Bariatric procedures are divided into three broad types: (1) restrictive, (2) malabsorptive, and (3) combined restrictive and malabsorptive. The Roux-en-Y gastric bypass combines both strategies by creating a small gastric pouch and anastomosing the jejunum to the pouch. Food then bypasses the lower stomach and duodenum, resulting in decreased absorption of digestive materials. The standard operation for pancreatic cancer is a pancreaticoduodenectomy, also called the Whipple procedure. PTS: 1 DIF: Cognitive Level: Understanding REF: pp. 695-696 OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
7. A patient was admitted with acute pancreatitis. The nurse understands that pancreatitis occurs as a result of what pathophysiologic mechanism? a. Uncontrolled hypoglycemia caused by an increased release of insulin b. Loss of storage capacity for senescent red blood cells c. Premature activation of inactive digestive enzymes, resulting in autodigestion d. Release of glycogen into the serum, resulting in hyperglycemia
*ANS:* C In acute pancreatitis, the normally inactive digestive enzymes become prematurely activated within the pancreas itself, creating the central pathophysiologic mechanism of acute pancreatitis, namely autodigestion. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 687 OBJ: Nursing Process Step: General TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
12. The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the nurse expect the practitioner to order for this patient? a. Insulin b. Vitamin K c. Lactulose d. Lorazepam
*ANS:* C Lactulose, a synthetic ketoanalogue of lactose split into lactic acid and acetic acid in the intestine, is given orally through a nasogastric tube or as a retention enema. The result is the creation of an acidic environment that results in ammonia being drawn out of the portal circulation. Lactulose has a laxative effect that promotes expulsion. Vitamin K is used to help control bleeding. Insulin would be given to control hyperglycemia. Use of benzodiazepines and other sedatives is discouraged in a patient with acute liver failure because pertinent neurologic changes may be masked, and hepatic encephalopathy may be exacerbated. PTS: 1 DIF: Cognitive Level: Applying REF: p. 694 OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
17. An older patient reports taking cimetidine for several years. The nurse knows that this medication can cause central nervous system side effects. For what side effect would the nurse monitor the patient? a. Tremors b. Dizziness c. Confusion d. Hallucinations
*ANS:* C Side effects of histamine antagonists include central nervous system (CNS) toxicity (confusion or delirium) and thrombocytopenia. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 702|Table 29-3 OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
11. A Salem sump nasogastric tube has two lumens. The first lumen is for suction and drainage. What is the purpose of the second lumen? a. Allows for administration of tube feeding b. Allows for testing of gastric secretions c. Prevents the tube from adhering to the gastric wall d. Prevents the tube from advancing
*ANS:* C The Salem sump has one lumen that is used for suction and drainage and another that allows air to enter the patient's stomach and prevents the tube from adhering to the gastric wall and damaging the mucosa. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 698 OBJ: Nursing Process Step: Evaluation TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
6. The nurse is caring for a patient with acute liver failure. The practitioner asks the nurse to assess the patient for asterixis. How should the nurse assess for this symptom? a. Inflate a blood pressure cuff on the patient's arm. b. Have the patient bring the knees to the chest. c. Have the patient extend the arms and dorsiflex the wrists. d. Dorsiflex the patient's foot.
*ANS:* C The patient should be evaluated for the presence of asterixis, or "liver flap," best described as the inability to voluntarily sustain a fixed position of the extremities. Asterixis is best recognized by downward flapping of the hands when the patient extends the arms and dorsiflexes the wrists. PTS: 1 DIF: Cognitive Level: Applying REF: p. 693 OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
3. A patient is admitted with a severe head injury. The nurse knows that critically ill patients are at risk for gastrointestinal hemorrhage due to stress-related mucosal disease. The nurse would monitor the patient for which signs and symptoms? a. Metabolic acidosis and hypovolemia b. Decreasing hemoglobin and hematocrit c. Hyperkalemia and hypernatremia d. Hematemesis and melena
*ANS:* D The initial clinical presentation of the patient with acute gastrointestinal (GI) hemorrhage is that of a patient in hypovolemic shock; the clinical presentation depends on the amount of blood lost. Hematemesis (bright red or brown, coffee grounds emesis), hematochezia (bright red stools), and melena (black, tarry, or dark red stools) are the hallmarks of GI hemorrhage. PTS: 1 DIF: Cognitive Level: Applying REF: p. 682 OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
21. A patient has been admitted with severe abdominal pain. When examining the patient, the nurse notes hypoactive bowel sounds, abdominal guarding, distention, and a discoloration around the umbilicus. The nurse suspects the patient may have which condition? a. Peptic ulcer disease b. Esophageal varices c. Acute liver failure d. Acute pancreatitis
*ANS:* D The results of physical assessment of a patient with pancreatitis usually reveal hypoactive bowel sounds and abdominal tenderness, guarding, distention, and tympany. Findings that may indicate pancreatic hemorrhage include Grey Turner sign (gray-blue discoloration of the flanks) and Cullen sign (discoloration of the umbilical region); however, they are rare and usually seen several days into the illness. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 688 OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal MSC: NCLEX: Physiologic Integrity
