Chapter 41: Gastrointestinal Dysfunction

An infant with short bowel syndrome will be discharged home on total parenteral nutrition (TPN) and gastrostomy feedings. Nursing care should include: a. Preparing the family for impending death. b. Teaching the family signs of central venous catheter infection. c. Teaching the family how to calculate caloric needs. d. Securing TPN and gastrostomy tubing under diaper to lessen risk of dislodgment.

ANS: B During TPN therapy, care must be taken to minimize the risk of complications related to the central venous access device, such as catheter infections, occlusions, or accidental removal. This is an important part of family teaching. The prognosis for patients with short bowel syndrome depends in part on the length of residual small intestine. It has improved with advances in TPN. Although parents need to be taught about nutritional needs, the caloric needs and prescribed TPN and rate are the responsibility of the health care team. The tubes should not be placed under the diapers because of risk of infection.

When caring for a child with probable appendicitis, the nurse should be alert to recognize that a sign of perforation is: a. Bradycardia. b. Anorexia. 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. Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical manifestation of appendicitis. Abdominal distention usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen).

Which type of dehydration results from water loss in excess of electrolyte loss? a. Isotonic dehydration b. Isosmotic dehydration c. Hypotonic dehydration d. Hypertonic dehydration

ANS: D Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion. Isosmotic dehydration is another term for isotonic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic.

An infant with pyloric stenosis experiences excessive vomiting that can result in: a. Hyperchloremia. b. Hypernatremia. c. Metabolic acidosis. d. Metabolic alkalosis.

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

Therapeutic management of most children with Hirschsprungs disease is primarily: a.Daily enemas. b.Low-fiber diet. c. Permanent colostomy. d. Surgical removal of affected section of bowel.

ANS: D Most children with Hirschsprungs disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter. Preoperative management may include enemas and low-fiber, high- calorie, high-protein diet until the child is physically ready for surgery. The colostomy that is created in Hirschsprungs disease is usually temporary.

Which clinical manifestation would most suggest acute appendicitis? a. Rebound tenderness b. Bright red or dark red rectal bleeding c. Abdominal pain that is relieved by eating d. Abdominal pain that is most intense at McBurneys point

ANS: D Pain is the cardinal feature. It is initially generalized and usually periumbilical. The pain localizes to the right lower quadrant at McBurneys point. Rebound tenderness is not a reliable sign and is extremely painful to the child. Abdominal pain that is relieved by eating and bright or dark red rectal bleeding are not signs of acute appendicitis.

A nurse is conducting dietary teaching on high-fiber foods for parents of a child with constipation. Which foods should the nurse include as being high in fiber (Select all that apply)? a. White rice b. Avocados c. Whole grain breads d. Bran pancakes e. Raw carrots

ANS: C, D, E High-fiber foods include whole grain breads, bran pancakes, and raw carrots. Unrefined (brown) rice is high in fiber but white rice is not. Raw fruits, especially those with skins or seeds, other than ripe banana or avocados are high in fiber.

An infant is brought to the emergency department with poor skin turgor, weight loss, lethargy, and tachycardia. This is suggestive of: a. Overhydration. b. Dehydration. c. Sodium excess. d. Calcium excess.

ANS: B These clinical manifestations indicate dehydration. Symptoms of overhydration are edema and weight gain. Regardless of extracellular sodium levels, total body sodium is usually depleted in dehydration. Symptoms of hypocalcemia are a result of neuromuscular irritability and manifest as jitteriness, tetany, tremors, and muscle twitching.

Therapeutic management of the child with acute diarrhea and dehydration usually begins with: a. Clear liquids. b. Adsorbents such as kaolin and pectin. c. Oral rehydration solution (ORS). d. Antidiarrheal medications such as paregoric.

ANS: C ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they contain too much sugar, which may contribute to diarrhea. Adsorbents are not recommended and neither are antidiarrheals because they do not get rid of pathogens.

A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child will begin with: a. Intravenous fluids. b. Oral rehydration solution (ORS). c. Clear liquids, 1 to 2 ounces at a time. d. Administration of antidiarrheal medication.

ANS: A Intravenous fluids are initiated in children with severe dehydration. ORS is acceptable therapy if the dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth. These fluids have a high carbohydrate content, low electrolyte content, and high osmolality. Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea.

Acute diarrhea is often caused by: a. Hirschsprungs disease. b. Antibiotic therapy. c. Hypothyroidism. d. Meconium ileus.

ANS: B Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy. Hirschsprungs disease, hypothyroidism, and meconium ileus are usually manifested with constipation rather than diarrhea.

Constipation has recently become a problem for a school-age girl. She is healthy except for seasonal allergies, which are now being successfully treated with antihistamines. The nurse should suspect that the constipation is most likely caused by: a. Diet. b. Allergies. c. Antihistamines. d. Emotional factors.

ANS: C Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids, antiepileptics, and iron. Because this is the only known recent change in her habits, the addition of antihistamines is most likely the etiology of the diarrhea, rather than diet, allergies, or emotional factors. With a change in bowel habits, the presence and role of any recently prescribed medications should be assessed.

A child has a nasogastric (NG) tube to continuous low intermittent suction. The physicians prescription is to replace the previous 4-hour NG output with a normal saline piggyback over a 2-hour period. The NG output for the previous 4 hours totaled 50 mL. What milliliter/hour rate should the nurse administer to replace with a normal saline piggyback?

ANS: 25 The previous total 4-hour output was 50 mL. To run the 50 mL over a 2-hour period, the nurse would divide 50 by 2 = 25. The normal saline replacement fluid would be run at 25 mL/hr.

Nurses must be alert for increased fluid requirements when a child has: a. Fever. b. Mechanical ventilation. c. Congestive heart failure. d. Increased intracranial pressure (ICP).

ANS: A Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid overload in children. ICP does not lead to increased fluid requirements in children.

A high-fiber food that the nurse could recommend for a child with chronic constipation is: a. Popcorn. b. Pancakes. c. Muffins. d. Ripe bananas.

ANS: A Popcorn is a high-fiber food. Pancakes and muffins do not have significant fiber unless made with fruit or bran. Raw fruits, especially those with skins and seeds, other than ripe bananas and avocados are high in fiber.

What is used to treat moderate-to-severe inflammatory bowel disease? a. Antacids. b. Antibiotics. c. Corticosteroids. d. Antidiarrheal medications.

ANS: C Corticosteroids such as prednisone and prednisolone are used in short bursts to suppress the inflammatory response in inflammatory bowel disease. Antacids and antidiarrheals are not drugs of choice to treat the inflammatory process of inflammatory bowel disease. Antibiotics may be used as adjunctive therapy to treat complications.

The nurse is explaining to a parent how to care for a child with vomiting associated with a viral illness. The nurse should include: a. Avoiding carbohydrate-containing liquids. b. Giving nothing by mouth for 24 hours. c. Brushing teeth or rinsing mouth after vomiting. d. Giving plain water until vomiting ceases for at least 24 hours.

ANS: C It is important to emphasize the need for the child to brush the teeth or rinse the mouth after vomiting to dilute the hydrochloric acid that comes in contact with the teeth. Administration of a glucose-electrolyte solution to an alert child will help restore water and electrolytes satisfactorily. It is important to include carbohydrates to spare body protein and avoid ketosis.

The viral pathogen that frequently causes acute diarrhea in young children is: a. Giardia organisms. b. Shigella organisms. c. Rotavirus. d. Salmonella organisms.

ANS: C Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial pathogen that is uncommon in the United States.

The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis? a. Abdominal rigidity and pain on palpation b. Rounded abdomen and hypoactive bowel sounds c. Visible peristalsis and weight loss d. Distention of lower abdomen and constipation

ANS: C Visible gastric peristaltic waves that move from left to right across the epigastrium are observed in pyloric stenosis, as is weight loss. Abdominal rigidity and pain on palpation, and rounded abdomen and hypoactive bowel sounds, are usually not present. The upper abdomen is distended, not the lower abdomen.

Which description of a stool is characteristic of intussusception? a. Ribbon-like stools b. Hard stools positive for guaiac c. Currant jelly stools d. Loose, foul-smelling stools

ANS: CPressure on the bowel from obstruction leads to passage of currant jelly stools. Ribbon-like stools are characteristic of Hirschsprungs disease. With intussusception, passage of bloody mucus-coated stools occurs. Stools will not be hard. Loose, foul-smelling stools may indicate infectious gastroenteritis.

Which type of hernia has an impaired blood supply to the herniated organ? a. Hiatal hernia. b. Incarcerated hernia. c. Omphalocele. d. Strangulated hernia.

ANS: D A strangulated hernia is one in which the blood supply to the herniated organ is impaired. A hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the esophageal hiatus. An incarcerated hernia is a hernia that cannot be reduced easily. Omphalocele is the protrusion of intraabdominal viscera into the base of the umbilical cord. The sac is covered with peritoneum and not skin.

Caring for the newborn with a cleft lip and palate before surgical repair includes: a. Gastrostomy feedings. b. Keeping the infant in near-horizontal position during feedings. c. Allowing little or no sucking. d. Providing satisfaction of sucking needs.

ANS: D Using special or modified nipples for feeding techniques helps to meet the infants sucking needs. Gastrostomy feedings are usually not indicated. Feeding is best accomplished with the infants head in an upright position. The child requires both nutritive and nonnutritive sucking.

A mother who intended to breastfeed has given birth to an infant with a cleft palate. Nursing interventions should include (Select all that apply): a. Giving medication to suppress lactation. b. Encouraging and helping mother to breastfeed. c. Teaching mother to feed breast milk by gavage. d. Recommending use of a breast pump to maintain lactation until infant can suck.

ANS: B, D The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues. The nipple must be positioned and stabilized well back in the infants oral cavity so that the tongue action facilitates milk expression. The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex. Because breastfeeding is an option, if the mother wishes to breastfeed, medications should not be given to suppress lactation. Because breastfeeding can usually be accomplished, gavage feedings are not indicated.

The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. The most appropriate nursing action is to: a. Notify the practitioner. b. Measure abdominal girth. c. Auscultate for bowel sounds. d. Take vital signs, including blood pressure.

ANS: A Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic/therapeutic plan of care.

What is characterized by a chronic inflammatory process that may involve any part of the gastrointestinal (GI) tract from mouth to anus? a. Crohns disease. b. Ulcerative colitis. c. Meckels diverticulum. d. Irritable bowel syndrome.

ANS: A The chronic inflammatory process of Crohns disease involves any part of the GI tract from the mouth to the anus but most often affects the terminal ileum. Ulcerative colitis, Meckels diverticulum, and irritable bowel syndrome do not affect the entire GI tract.

Bismuth subsalicylate, clarithromycin, and metronidazole are prescribed for a child with a peptic ulcer to: a. Eradicate Helicobacter pylori. b. Coat gastric mucosa. c. Treat epigastric pain. d. Reduce gastric acid production.

ANS: A This combination of drug therapy is effective in the treatment and eradication of H. pylori.

A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. Initialtherapeutic approach to the mother should be to: a. Restate what the physician has told her about plastic surgery. b. Encourage her to express her feelings. c. Emphasize the normalcy of her baby and the babys need for mothering. d. Recognize that negative feelings toward the child continue throughout childhood.

ANS: B For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must place emphasis not only on the infants physical needs but also on the parents emotional needs. The mother needs to be able to express her feelings before the acceptance of her child can occur. Although discussing plastic surgery will be addressed, it is not part of the initial therapeutic approach. As the mother expresses her feelings, the nurses actions should convey to the parents that the infant is a precious human being. The childs normalcy is emphasized, and the mother is assisted to recognize the childs uniqueness. A focus on abnormal maternal- infant attachment would be inappropriate at this time.

A 4-month-old infant has gastroesophageal reflux disease (GERD) but is thriving without other complications. What should the nurse suggest to minimize reflux? a. Place in Trendelenburg position after eating. b. Thicken formula with rice cereal. c. Give continuous nasogastric tube feedings. d. Give larger, less frequent feedings.

ANS: B Giving small frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula has been recommended. Milk thickening agents have been shown to decrease the number of episodes of vomiting and increase the caloric density of the formula. This may benefit infants who are underweight as a result of GERD. Placing the child in Trendelenburg position would increase the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive. Smaller, more frequent feedings are recommended in reflux.

What should the nurse stress in a teaching plan for the mother of an 11-year-old boy with ulcerative colitis? a. Preventing the spread of illness to others b. Nutritional guidance and preventing constipation c. Teaching daily use of enemas d. Coping with stress and avoiding triggers

ANS: D Coping with the stress of chronic illness and the clinical manifestations associated with ulcerative colitis (diarrhea, pain) are important teaching foci. Avoidance of triggers can help minimize the impact of the disease and its effect on the child. Ulcerative colitis is not infectious. Although nutritional guidance is a priority teaching focus, diarrhea is a problem with ulcerative colitis, not constipation. Daily enemas are not part of the therapeutic plan of care.

The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infants postoperative care include: a. Arm restraints, postural drainage, and mouth irrigations. b. Cleansing of suture line, supine and side-lying positions, and arm restraints. c. Mouth irrigations, prone position, and cleansing of suture line. d. Supine and side-lying positions, postural drainage, and arm restraints.

ANS: B The suture line should be cleansed gently after feeding. The child should be positioned on back or side or in an infant seat. Elbows are restrained to prevent the child from accessing the operative site. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. Mouth irrigations would not be indicated.

A parasite that causes acute diarrhea is: a. Shigella organisms. b. Salmonella organisms. c. Giardia lamblia. d. Escherichia coli.

ANS: C Giardia is a parasite that represents 15% of nondysenteric illness in the United States. Shigella, Salmonella, and E. coli are bacterial pathogens.

What is the most important information to be included in the discharge planning for an infant with gastroesophageal reflux? a. Teach parents to position the infant on the left side. b. Reinforce the parents knowledge of the infants developmental needs. c. Teach the parents how to do infant cardiopulmonary resuscitation (CPR). d. Have the parents keep an accurate record of intake and output.

ANS: C Risk of aspiration is a priority nursing diagnosis for the infant with gastroesophageal reflux. The parents must be taught infant CPR. Correct positioning minimizes the risk for aspiration. The correct position for the infant is on the right side after feeding and supine for sleeping. Knowledge of developmental needs should be included in discharge planning for all hospitalized infants, but it is not the most important in this case. Keeping a record of intake and output is not a priority and may not be necessary.

A 3-year-old child with Hirschsprungs disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child psychologically is: a. Not necessary because of childs age. b. Not necessary because the colostomy is temporary. c. Necessary because it will be an adjustment. d. Necessary because the child must deal with a negative body image.

ANS: C The childs age dictates the type and extent of psychologic preparation. When a colostomy is performed, the child who is at least preschool age is told about the procedure and what to expect in concrete terms with the use of visual aids. It is necessary to prepare this age child for procedures. The preschooler is not yet concerned with body image.

A histamine receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is ordered for an infant with gastroesophageal reflux. The purpose of this is to: a. Prevent reflux. b. Prevent hematemesis. c. Reduce gastric acid production. d. Increase gastric acid production.

ANS: C The mechanism of action of histamine receptor antagonists is to reduce the amount of acid present in gastric contents and may prevent esophagitis. Preventing reflux and hematemesis and increasing gastric acid production are not the modes of action of histamine receptor antagonists.

During the first few days after surgery for cleft lip, which intervention should the nurse do? a. Leave infant in crib at all times to prevent suture strain. b. Keep infant heavily sedated to prevent suture strain. c. Remove restraints periodically to cuddle infant. d. Alternate position from prone to side-lying to supine.

ANS: C The nurse should remove restraints periodically, while supervising the infant, to allow him or her to exercise arms and to provide cuddling and tactile stimulation. The infant should not be left in the crib, but should be removed for appropriate holding and stimulation. Analgesia and sedation are administered for pain. Heavy sedation is not indicated. The child should not be placed in the prone position.

A stool specimen from a child with diarrhea shows the presence of neutrophils and red blood cells. This is most suggestive of which condition? a. Protein intolerance. b. Parasitic infection c. Fat malabsorption. d. Bacterial gastroenteritis.

ANS: D Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance is suspected in the presence of eosinophils. Parasitic infection is indicated by eosinophils. Fat malabsorption is indicated by foul- smelling, greasy, bulky stools.

Which intervention should be included in the nurses plan of care for a 7-year-old child with encopresis who has cleared the initial impaction? a. Have the child sit on the toilet for 30 minutes when he gets up in the morning and at bedtime. b. Increase sugar in the childs diet to promote bowel elimination. c. Use a Fleet enema daily. d. Give the child a choice of beverage to mix with a laxative.

ANS: D Offering realistic choices is helpful in meeting the school-age childs sense of control. To facilitate bowel elimination, the child should sit on the toilet for 5 to 10 minutes after breakfast and dinner. Decreasing the amount of sugar in the diet will help keep stools soft. Daily Fleet enemas can result in hypernatremia and hyperphosphatemia, and are used only during periods of fecal impaction.