Chapter 43: Assessment of Digestive and Gastrointestinal Function

The nurse is providing instructions to a patient scheduled for a gastroscopy. What should the nurse be sure to include in the instructions? (Select all that apply.)

The patient must fast for 8 hours before the examination. The throat will be sprayed with a local anesthetic. After gastroscopy, the patient cannot eat or drink until the gag reflex returns (1 to 2 hours).

The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon return to the nursing unit, what does the nurse identify as the client goal?

Increase the amount of fluids

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are

normal

A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?

Permit the client to drink only clear liquids.

Which diagnostic produces images of the body by detecting the radiation emitted from radioactive substances?

Positron emission tomography (PET)

The nurse is caring for a client who is scheduled for a percutaneous liver biopsy. Which diagnostic test is obtained prior?

Prothrombin time (PT)

A client is scheduled for magnetic resonance imaging (MRI). During the client teaching, the nurse will discuss which of the following?

"Do you experience any claustrophobia?"

The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following?

"Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact."

The nurse provides client education to a client about to undergo hydrogen breath testing. The nurse evaluates that the client understands the test when the client makes which statement?

"I should avoid antibiotics for 1 month before the test."

A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers:

"It indicates if a cancer is present."

The nurse asks a client to point to where she feels pain. The client asks why this is important. The nurse's best response would be which of the following?

"Often the area of pain is referred from another area."

Which of the following is the primary function of the small intestine?

Absorption

Which of the following digestive enzymes aids in the digesting of starch?

Amylase

A client, age 82, is admitted to an acute care facility for treatment of an acute flare-up of a chronic GI condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the GI tract. Which age-related change increases the risk of anemia?

Atrophy of the gastric mucosa

The nurse is performing a focused abdominal assessment of a client with a history of bowel obstruction. The nurse has positioned the client appropriately and inspected the client's abdomen carefully. What action should the nurse perform next?

Auscultate the client's abdomen

When assisting with preparing a client scheduled for a barium swallow, which of the following would be appropriate to include?

Avoid smoking for at least a day before the procedure.

Which of the following is considered the gold standard for the diagnosis of liver disease?

Biopsy

During a colonoscopy with moderate sedation, the patient groans with obvious discomfort and begins bleeding from the rectum. The patient is diaphoretic and has an increase in abdominal girth from distention. What complication of this procedure is the nurse aware may be occurring?

Bowel perforation

A patient is scheduled for a fiberoptic colonoscopy. What does the nurse know that fiberoptic colonoscopy is most frequently used to diagnose?

Cancer

When examining the skin of a client who is dehydrated due to fluid losses from the gastrointestinal tract, which of the following would be most important?

Checking if the mucous membranes are dry

The nurse is investigating a patient's complaint of pain in the duodenal area. Where should the nurse perform the assessment?

Epigastric area and consider possible radiation of pain to the right subscapular region

The nurse teaches a client scheduled for a colonoscopy. Which instruction should be included as part of the preparation for the procedure?

Follow the dietary and fluid restrictions and bowel preparation procedures.

Which of the following is a function of the stomach? Select all that apply.

Food storage Secretion of digestive fluids Propels partially digested food into small intestine

A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first?

Further investigate the initial complaint.

A client reports having red stools lately. What will the nurse ask during assessment questioning?

Have you been eating beets?

The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds?

Hyperactive

When examining the abdomen of a client with complaints of nausea and vomiting, which of the following would the nurse do first?

Inspection

The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? Use all options.

Inspection Auscultation Percussion Palpation

A nurse is assessing a client who complains of abdominal pain, nausea, and diarrhea. When examining the client's abdomen, which sequence should the nurse use?

Inspection, auscultation, percussion, and palpation

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?

Intrinsic factor

While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure?

Liver

Swallowing is regulated by which area of the central nervous system (CNS)?

Medulla oblongata

Which of the following would be most important to ensure that a client does not retain any barium after a barium swallow?

Monitoring the stool passage and its color.

What part of the GI tract begins the digestion of food?

Mouth

The nurse is working with clients with digestive tract disorders. Which of the following organs does the nurse realize has effects as an exocrine gland and an endocrine gland?

Pancreas

The nurse is assisting the physician with a gastric acid stimulation test for a patient. What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions?

Pentagastrin

Which of the following is an enzyme secreted by the gastric mucosa?

Pepsin

A client is scheduled for bowel resection with anastomosis involving the large intestine. Because of the surgical site, the nurse formulates the nursing diagnosis of Risk for infection. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Related to the presence of bacteria at the surgical site

The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?

Serum antibodies for H. pylori

It is important for a nurse to have an understanding of the major digestive enzymes and their actions. Choose the gastric mucosa secretion that plays an important role in the digestion of triglycerides.

Steapsin

When evaluating the function of the GI tract, the nurse needs to understand the role of hormones. Secretin, stimulated by the pH of chyme in the duodenum, is a major GI hormone that does which of the following?

Stimulates the production of bicarbonate in pancreatic juice

After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected?

Stomach

The nurse is preparing to examine the abdomen of a client complaining of a change in his bowel pattern. The nurse would place the client in which position?

Supine with knees flexed

Specific disease processes and ingestion of certain foods and medications may change the appearance of the stool. If blood is shed in sufficient quantities into the upper gastrointestinal (GI) tract, it produces which change in the stool appearance?

Tarry black

The nurse is caring for a geriatric client experiencing diarrhea. When teaching about the site in the body where water and electrolytes are absorbed, the nurse is most correct to instruct on which location?

The small bowel

Which nursing instruction is correct to provide the client following a barium enema?

The stools may be a white or clay colored.

A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor?

The ultrasonography should be scheduled before the GI procedure. Both an upper GI procedure with barium ingestion and an ultrasonography may be completed on the same day. The ultrasonography test should be completed first, because the barium solution could interfere with the transmission of the sound waves. The ultrasonography test uses sound waves that are passed into internal body structures, and the echoes are recorded as they strike tissues. Fluid in the abdomen prevents transmission of ultrasound.

The nurse is assisting the physician with a colonoscopy for a patient with rectal bleeding. The physician requests the nurse to administer glucagon during the procedure. Why is the nurse administering this medication during the procedure?

To relax colonic musculature and reduce spasm.

When describing the role of the pancreas to a client with a pancreatic dysfunction, the nurse would identify which substance as being acted on by pancreatic lipase?

Triglycerides

The nurse determines one or two bowel sounds in 2 minutes should be documented as

hypoactive

A physician plans to send a client home with supplies to complete a hemoccult test on all stools for 3 days. During the client education, the nurse informs the client to avoid which of the following medications while collecting stool for the test?

ibuprofen (Advil)

The nurse prepares to administer the lavage solution to a client having a colostomy completed. The nurse stops and notifies the physician when noting that the client has which condition?

inflammatory bowel disease

An enzyme that begins the digestion of starches is

ptyalin

The nurse is scheduling gastrointestinal (GI) diagnostic testing for a client. Which GI test should be scheduled first?

Radiography of the gallbladder

The nurse prepares a client for a barium enema. The nurse should place the client on which diet prior to the procedure?

clear liquids day before

A client is scheduled to have an endoscopic retrograde cholangiopancreatography. Which structures are visualized during this procedure?

common bile duct, pancreatic duct, and biliary tree

The nurse cares for a client after a gastroscopy for which the client received sedation. The nurse should report which finding to the physician?

difficulty swallowing

When gastric analysis testing reveals excess secretion of gastric acid, the nurse recognizes which medical diagnoses is supported?

duodenal ulcer

The major carbohydrate that tissue cells use as fuel is

glucose

Which procedure is performed to examine and visualize the lumen of the small bowel?

small bowel enteroscopy

Which enzyme aids in the digestion of protein?

trypsin

The nurse recognizes which change of the GI system is an age-related change?

weakened gag reflex

The nurse recognizes which change of the gastrointestinal system is an age-related change?

weakened gag reflex

While completing an abdominal assessment, the nurse will use which landmark as the upper boundary for auscultating bowel sounds?

Xiphoid process

A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure?

You will need to swallow a capsule

Cystic fibrosis, a genetic disorder characterized by pulmonary and pancreatic dysfunction, usually appears in young children but can also affect adults. If the pancreas was functioning correctly, where would the bile and pancreatic enzymes enter the GI system?

duodenum

The nurse is performing an assessment of a patient. During the assessment the patient informs the nurse of some recent "stomach trouble." What does the nurse know is the most common symptom of patients with GI dysfunction?

dyspepsia

A focused GI assessment begins with a complete history and physical examination. Identify the quadrant of the abdomen to be palpated or percussed for a patient with pancreatitis.

left upper

Lisa Bentley, a 32-year-old teacher, presents to the gastroenterology office where you work. She is known to have a history of Crohn's disease, and you have met with her several times to discuss the various health concerns that she has related to her diagnosis. When talking with the client, the nurse explains that having a GI disorder doesn't mean her problems are limited to the one area that is diseased but might also involve all of the following except ________.

metabolism

A client tells the nurse that the stool was colored yellow. The nurse assesses the client for

recent foods ingested

Blood flow to the GI tract is approximately what percentage of the total cardiac output?

20%

When completing a nutritional assessment of a patient who is admitted for a GI disorder, the nurse notes a recent history of dietary intake. This is based on the knowledge that a portion of digested waste products can remain in the rectum for how many days after a meal is digested?

3 days

The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment?

Abdominal distention

The nurse is teaching the client about the upcoming endoscopic retrograde cholangiopancreatography (ERCP). Although the nurse instructs on several pertinent points of care, which is emphasized?

The client will change positions frequently throughout the procedure.

A client is scheduled for several diagnostic tests to evaluate her gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when she identifies which test as not requiring the use of a contrast medium?

Colonoscopy

A client receives a local anesthetic to suppress the gag reflex for a diagnostic procedure of the upper GI tract. Which nursing intervention is advised for this client?

Do not give any food and fluids until the gag reflex returns.

During a nursing assessment, the nurse knows that the most common symptom in patients with GI dysfunction is which of the following?

Dyspepsia

A client with diabetes begins to have digestive problems and is told by the physician that they are a complication of the diabetes. Which of the following explanations from the nurse is most accurate?

The pancreas secretes digestive enzymes.