Chapter 45, Assessment of the Gastrointestinal System

NCLEX Examination Challenge 48.1 Physiological Integrity Which daily behavior of a client with GI problems requires further nursing assessment? Select all that apply. A. Smokes a pack of cigarettes B. Uses Fleet enemas frequently to assist with bowel movements C. Practices intentional relaxation D. Eats multiple servings of fruits E. Takes 325 mg of aspirin at night for arthritic pain F. Exercises for 30 minutes three times weekly G. Travels extensively across the world

1. A, B, E, G

Mastery Questions 1. Immediately following a colonoscopy, which client behavior will the nurse report to the health care provider? Select all that apply. A. Passing of flatus B. Blood pressure 128/80 mm Hg C. Abdominal guarding D. Change in mental status E. Report of mild abdominal cramping

1. C, D

2. Which teaching will the nurse include when educating a client who is scheduled to have an esophagogastroduodenoscopy (EGD)? Select all that apply. A. "Anesthesia will be used for sedation." B. "The procedure takes about 20 to 30 minutes to complete." C. "Informed consent will be needed prior to the procedure." D. "A separate test will be required to obtain any needed biopsies." E. "You will need to refrain from eating for at least 6 to 8 hours before the EGD."

2. A, B, D, E

Health Promotion and Maintenance Which teaching will the nurse provide to a community group about early detection of colorectal cancer? Select all that apply. A. Home testing kits are available with a prescription. B. Sigmoidoscopy should be performed every 10 years. C. People over 40 years old should be tested for colon cancer. D. Bowel preparation is necessary prior to performance of a colonoscopy. E. Virtual colonoscopies (CT colonography) can be performed every 5 years.

3. A, D, E

6. An older adult has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? a. "Changes in your liver cause drugs to be metabolized differently." b. "Perhaps you don't need as high a dose of the drug as before." c. "Stomach muscles atrophy with age and you digest more slowly." d. "Your body probably can't tolerate as much medication anymore."

ANS: A Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugs—possibly to toxic levels. The other options do not accurately explain this age-related change.

7. To promote comfort and the passage of flatus after a colonoscopy, in what position does the nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine

ANS: A After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.

4. A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? a. "It's a good thing I love orange and cherry gelatin." b. "My spouse will be here to drive me home." c. "I'll avoid ibuprofen for several days before the test." d. "I'll buy a case of clear Gatorade before the prep."

ANS: A The client would be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show an understanding of the preparation for the procedure.

2. A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse teaches the client and family about the signs of potential complications which include what problems? (Select all that apply.) a. Cholangitis b. Pancreatitis c. Perforation d. Renal lithiasis e. Sepsis

ANS: A, B, C, E Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.

3. The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.) a. Decreased hydrochloric acid production b. Diminished sensation that can lead to constipation c. Fat not digested as well in older adults d. Increased peristalsis in the large intestine e. Pancreatic vessels become calcified

ANS: A, B, C, E Several age-related changes occur in the gastrointestinal system. These include decreased hydrochloric acid production, diminished nerve function that leads to decreased sensation of the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and calcification of pancreatic vessels.

1. The nurse is aware of the most recent American Cancer Society Screening Guidelines for colon cancer, which include which accepted testing modalities for people over the age of 50? (Select all that apply.) a. Colonoscopy every 10 years b. Endoscopy every 5 years c. Computed tomography (CT) colonography every 5 years d. Double-contrast barium enema every 10 years e. Flexible sigmoidoscopy every 5 years

ANS: A, C, E The options for colon cancer screening for people over the age of 50 include colonoscopy every 10 years and CT colonography, double-contrast barium enema, or flexible sigmoidoscopy every 5 years.

11. The assistive personnel note that a client had a dark stool. What stool test would the nurse obtain for this client? a. Culture and sensitivity b. Parasites and ova c. Occult blood test d. Total fat content

ANS: C Dark stools are typical in clients who have lower GI bleeding. Therefore, an fecal occult blood test would be the most appropriate test as a follow-up.

2. The primary health care provider documents that a client has a bruit over the abdominal aorta. What teaching will the nurse provide for assistive personnel (AP) based on this assessment finding? a. "Use warm compresses on the client's abdomen continuously." b. "Avoid washing the client's abdomen too aggressively." c. "Apply ice to the client's abdomen every 4 hours." d. "Massage the client's abdomen to help reduce pain."

ANS: B A bruit heard over the abdominal aorta possible indicates stenosis or an aneurysm which should not be palpated or percussed. Therefore, the AP should wash the client's abdomen very gently.

9. The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ? a. Kidneys b. Liver c. Spleen d. Stomach

ANS: B Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting proteins. The other organs are not related to this issue.

10. A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is appropriate? a. Allow the client cool liquids only. b. Assess the client's gag reflex. c. Remind the client to remain NPO. d. Tell the client to wait 4 hours.

ANS: B The local anesthetic used during this procedure depresses the client's gag reflex. After the procedure, the nurse would ensure that the gag reflex is intact before offering food or fluids. The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the client's readiness for them.

4. The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to which organ functions or dysfunctions? (Select all that apply.) a. Alanine aminotransferase: biliary system b. Ammonia: liver c. Amylase: liver d. Lipase: pancreas e. Urine urobilinogen: stomach

ANS: B, D Alanine aminotransferase and ammonia are related to the liver. Amylase and lipase are related to the pancreas. Urobilinogen evaluates both hepatic and biliary function.

5. A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is appropriate? a. Ask the client to call back if this happens again today. b. Instruct the client to go to the emergency department. c. Remind the client that a small amount of bleeding is possible. d. Tell the client to come to the clinic this afternoon.

ANS: C After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse would remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.

8. A nurse is assessing a client reporting right upper quadrant (RUQ) abdominal pain. What technique would the nurse use to assess this client's abdomen? a. Auscultate after palpating. b. Avoid any type of palpation. c. Lightly palpate the RUQ first. d. Lightly palpate the RUQ last.

ANS: D If pain is present in a certain area of the abdomen, that area would be palpated last to keep the client from tensing which could possibly affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation

1. The nurse is interviewing a client who reports having abdominal cramping, bloating, and diarrhea after drinking milk or ingesting other dairy products. What health problem does the client most likely have? a. Steatorrhea b. Ulcerative colitis c. Crohn disease d. Lactose intolerance

ANS: D The client is demonstrating signs and symptoms of lactose intolerance because they occur after the client eats or drinks dairy products which contain lactose

Physiological Integrity While performing an abdominal assessment on a client, the nurse notes a bruit over the aorta. What is the appropriate nursing action? A. Consult another nurse to verify the bruit. B. Auscultate each quadrant for 5 minutes each. C. Notify the health care provider of the findings. D. Perform light palpation to further assess the pulsation.

C

3. A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride. The client's respiratory rate is 8 breaths/min. What action by the nurse is appropriate? a. Administer naloxone. b. Call the Rapid Response Team. c. Provide physical stimulation. d. Ventilate with a bag-valve-mask.

C For an EGD, clients are given mild sedation but would still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse's most appropriate action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for midazolam HCl. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.

5. A nurse cares for a client who is recovering from a colonoscopy. Which actions would the nurse take? (Select all that apply.) a. Obtain vital signs every 15 to 30 minutes until alert. b. Assess the client for rectal bleeding and severe pain. c. Administer prescribed pain medications as needed. d. Monitor the client's serum and urine glucose levels. e. Confirm the client has a ride home and plans to rest.

ANS: A, B, E During the recovery phase after a colonoscopy, the nurse would obtain vital signs every 15 to 30 minutes until the client is alert, assess for rectal bleeding or severe pain, and confirm the client has arranged for another person to drive home to get rest. Pain medications are not necessary after the procedure, and neither is glucose monitoring.