Chapter 52: Assessment of the GI System

The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.) a. Colon cancer b. Diverticulitis c. Inflammatory bowel disease d. Peptic ulcer disease e. Pernicious anemia

A, B, C, D. In adults, the most common cause of anemia is GI bleeding. This is commonly associated with colon cancer, diverticulitis, inflammatory bowel disease, and peptic ulcer disease. Pernicious anemia is not associated with GI bleeding.

A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse instructs 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

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

A client is admitted to the hospital with elevated serum amylase and lipase levels and a decreased calcium level. Which gastrointestinal health problem is indicated by these laboratory findings? A. Acute Pancreatitis B. Cirrhosis C. Crohn's Disease D. Diarrhea

A. Acute Pancreatitis. These laboratory values are commonly found in clients with acute pancreatitis. They are not indicative of cirrhosis of the liver or Crohn's disease. These laboratory values are not found in a client with diarrhea.

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

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.

A client has a routine sigmoidoscopy with a tissue biopsy. What complication is the nurse looking for in a postprocedure assessment? A. Excessive diarrhea B. Heavy bleeding C. Nausea and vomiting D. Severe rectal pain

B. Heavy bleeding Excessive or heavy bleeding is a possible complication following a sigmoidoscopy. It must be reported immediately to the health care provider. Excessive diarrhea, nausea, vomiting, and severe rectal pain are not common complications of sigmoidoscopy.

The nurse is assessing a client who has come to the emergency department with acute abdominal pain. The client is very thin and the nurse observes visible peristaltic movements when inspecting the abdomen. What does the nurse suspect? A.Acute diarrhea B. Aortic aneurysm C. Intestinal obstruction D. Pancreatitis

C. Intestinal obstruction Peristaltic movements are rarely seen except in thin clients and should be reported since the finding may indicate an intestinal obstruction. Acute diarrhea does not cause visible peristaltic movements. Aortic aneurysm may cause a bulging, pulsatile mass. Pancreatitis is characterized by severe pain.

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 best? 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 in to the clinic this afternoon.

C. After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse should 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.

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

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

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

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.

The nurse is aware of the 2014 American Cancer Society Screening Guidelines for colon cancer, which include which testing modalities for people over the age of 50? (Select all that apply.) a. Colonoscopy every 10 years b. Colonoscopy every 5 years c. Computed tomography (CT) colonography every 5 years d. Double-contrast barium enema every 10 years e. Flexible sigmoidoscopy every 10 years

A, C. 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.

A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority? a. Auscultate for bowel sounds. b. Notify the provider immediately. c. Order an abdominal flat-plate x-ray. d. Palpate the mass and measure its size.

B. This observation could indicate an abdominal aortic aneurysm, which could be life threatening and should never be palpated. The nurse notifies the provider at once. An x-ray may be indicated. Auscultation is part of assessment, but the nurse's priority action is to notify the provider.

A 49-year-old woman comes to the emergency department with reports of black tarry stools that started 2 weeks ago. In taking a gastrointestinal (GI) history, which questions does the nurse ask that pertain to Gordon's Functional Health Patterns? A. "Are you having any difficulty having sex? How frequently do you have sex?" B. "Do you have any difficulty chewing or swallowing?" C. "Do you have pain, diarrhea, gas, or any other problems? Do any specific foods cause these symptoms for you?" D. "What is your usual bowel elimination pattern? Frequency? Character?" E. "When was your last colonoscopy?"

B, C, D, E. Chewing or swallowing difficulties affect the client's ability to get food into her GI system. Pain, diarrhea, gas, and foods that cause these symptoms constitute very important data for collection in the GI history. The client needs to be questioned about usual bowel elimination patterns—frequency and character are two descriptors. Colonoscopy history is also elicited from the client. Sexual difficulties and frequency are not generally affected by GI problems; this would not be a routine question in a GI problem inquiry.

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

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.

A client who has been taking antibiotics reports severe, watery diarrhea. About which test does the nurse teach the client? a. Colonoscopy b. Enzyme-linked immunosorbent assay (ELISA) toxin A+B c. Ova and parasites d. Stool culture

B. Clients taking antibiotics are at risk for Clostridium difficile infection. The most common test for this disorder is a stool sample for ELISA toxin A+B. Colonoscopy, ova and parasites, and stool culture are not warranted at this time.

The nurse is educating a group of older adults about screening for colorectal cancer. Which statement by a group member indicates the need for further clarification about these guidelines? A. "A barium enema every 5 years is a screening option." B. "I will need to have a routine colonoscopy every 5 years." C. "My routine flexible sigmoidoscopy every 5 years is OK." D. "The 'virtual' colonoscopy every 5 years is acceptable."

B. "I will need to have a routine colonoscopy every 5 years." The 2010 guidelines indicate that routine screening with colonoscopy is performed every 10 years, not every 5 years. Other options are performed at 5-year intervals. A barium enema every 5 years is a screening option. A flexible sigmoidoscopy and a "virtual" colonoscopy every 5 years are also acceptable for screening.

Which substance, produced in the stomach, facilitates the absorption of vitamin B12? A. Glucagon B. Hydrochloric acid C. Intrinsic factor D. Pepsinogen

C. Intrinsic factor Parietal cells in the stomach produce intrinsic factor, a substance that facilitates the absorption of vitamin B12. Absence of intrinsic factor causes pernicious anemia. Glucagon, which is produced by the alpha cells in the pancreas, is essential for the regulation of metabolism. Parietal cells secrete hydrochloric acid, but this does not facilitate the absorption of vitamin B12. Pepsinogen is secreted by the chief cells; pepsinogen is a precursor to pepsin, a digestive enzyme.

A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this client's abdomen? a. Auscultate after palpating. b. Avoid any palpation. c. Palpate the RUQ first. d. Palpate the RUQ last.

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

An older client 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."

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.

A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best? a. Ask the client about shellfish allergies. b. Document this information on the chart. c. Ensure that the client has a ride home. d. Instruct the client on bowel preparation.

A. PTC uses iodinated dye, so the client should be asked about seafood allergies, specifically to shellfish. Documentation should occur, but this is not the priority. The client will need a ride home afterward if the procedure is done on an outpatient basis. There is no bowel preparation for PTC.

Which factors place a client at risk for gastrointestinal (GI) problems? A. Eating a high-fiber diet B. Smoking a half-pack of cigarettes per day C. Socioeconomic status D. Some herbal preparations E. Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

B, C, D, E. Smoking or any tobacco use places a client in a higher-risk category for GI problems. Socioeconomic status can also influence the risk for GI problems; clients may not be able to afford to seek care or treatment and may put off seeking help. Some herbal preparations contribute to GI problems, such as Ayurvedic herbs, which can affect appetite, absorption, and elimination. NSAIDs can predispose clients to peptic ulcer disease or GI bleeding. High-fiber diets are generally believed to be healthy for most clients.

The student nurse studying the gastrointestinal system understands that chyme refers to what? a. Hormones that reduce gastric acidity b. Liquefied food ready for digestion c. Nutrients after being absorbed d. Secretions that help digest food

B. Before being digested, food must be broken down into a liquid form. This liquid is called chyme. Secretin is the hormone that inhibits acid production and decreases gastric motility. Absorption is carried out as the nutrients produced by digestion move from the lumen of the GI tract into the body's circulatory system for uptake by individual cells. The secretions that help digest food include hydrochloric acid, bile, and digestive enzymes.

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best? 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.

B. The local anesthetic used during this procedure will depress the client's gag reflex. After the procedure, the nurse should 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.

A client with newly diagnosed irritable bowel syndrome (IBS) reports having five to six loose stools daily. What is the common psychological client response to this gastrointestinal health problem? A. Acceptance B. Embarrassment C. Euphoria D. Grief

B. Embarrassment The client who has a new onset of IBS with frequent stools most likely would be embarrassed. The client normally would not react to a new onset of IBS with acceptance or grief. It would be an abnormal reaction for the client to feel euphoria over a new onset of IBS.

A client arrives at the emergency department with acute abdominal pain in the left lower quadrant. In which order does the nurse examine and assess the client's left lower quadrant (LLQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and right upper quadrant (RUQ)? A. LLQ, RLQ, LUQ, RUQ B. LUQ, LLQ, RUQ, RLQ C. RLQ, LLQ, RUQ, LUQ D. RUQ, LUQ, RLQ, LLQ

D. RUQ, LUQ, RLQ, LLQ Abdominal examination usually begins at the client's right side and proceeds in a systematic fashion: RUQ, LUQ, LLQ, RLQ. However, if the client is experiencing pain in a specific quadrant, that area should be assessed last in the examination sequence to prevent the client from tensing abdominal muscles because of the pain, which would make the examination difficult. Therefore, the LLQ would be the last area assessed for this client.

A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important? a. Ask the client about recent exposure to illness. b. Assess the client's stool for obvious food particles. c. Include the date and time on the specimen container. d. Put on gloves prior to collecting the sample.

D. To avoid possible exposure to infectious agents, the nurse dons gloves prior to handling any bodily secretions. Recent exposure to illness is not related to collecting a stool sample. The nurse can visually inspect the stool for food particles, but it still needs analysis in the laboratory. The container should be dated and timed, but safety for the staff and other clients comes first.

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 should refrigerate the GoLYTELY before use." d. "I will buy a case of Gatorade before the prep."

A. The client should 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 a good understanding of the preparation for the procedure.

A client is scheduled for a colonoscopy. What does the nurse tell the client to do before the procedure is performed? A. "Begin a clear liquid diet 12 to 24 hours before the test." B. "Do not eat or drink anything for 12 hours before the test." C. "Give yourself tap water enemas until the fluid returns are clear." D. "You will have to drink a contrast liquid 2 hours before the test."

A. "Begin a clear liquid diet 12 to 24 hours before the test." The client is instructed to be on a liquid diet for 12 to 24 hours to cleanse the bowel before a colonoscopy. The client must be NPO (except for water) 4 to 6 hours before a colonoscopy. The client is instructed to drink a liquid preparation for cleaning the bowel (such as sodium phosphate) the evening before the colonoscopy, and may repeat that procedure on the morning of the test. In some cases, the client may require laxatives, suppositories, or one or more small-volume (i.e., Fleet) cleansing enemas. The client is not given an oral contrast liquid to swallow for a colonoscopy.

Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? A. A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis B. A 36-year-old who needs teaching about an endoscopic retrograde cholangiopancreatography. C. A 40-year-old who will need administration of IV midazolam hydrochloride (Versed) during an upper endoscopy. D. A 46-year-old who was recently admitted with abdominal cramping and diarrhea of unknown causes.

A. A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis Nasogastric tube insertion is included in LPN/LVN education and is an appropriate task for an experienced LPN/LVN. Assessment and client teaching should be done by an RN. IV hypnotic medications should be administered by an RN.

While working in the outpatient procedure unit, the RN is assigned to these clients. Which client does the nurse assess first? CORRECT A. A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) B. A 54-year-old who is ready for discharge following a colonoscopy C. A 58-year-old who has just arrived for basal gastric secretion and gastric acid stimulation testing D. A 60-year-old with questions about an endoscopic ultrasound examination.

A. A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) ERCP requires conscious sedation, so the client needs immediate assessment of respiratory and cardiovascular status. The other clients are not at risk for depressed respiratory status.

The nurse is assessing a client who had abdominal surgery yesterday. What method provides the most accurate data about resumption of peristalsis in the client? A. Asking the client whether he or she has passed flatus (gas) B. Auscultating bowel sounds in all abdominal quadrants C. Counting the number of bowel sounds in each abdominal quadrant D. Observing the abdomen for symmetry and distention.

A. Asking the client whether he or she has passed flatus (gas). The best and most reliable method for assessing the return of peristalsis following abdominal surgery is the client's report of passing flatus within the past 8 hours or stool within the past 12 hours. Although auscultation and counting the number of sounds was once a method of assessing for bowel activity, it is no longer considered the most effective method. Observing the abdomen is one method of examining a client's abdomen, but it is not a reliable way to assess for resumption of activity after surgery.

What is a common gastrointestinal problem that older adults experience more frequently as they age? A. Decreased hydrochloric acid B.Excess lipase production C. Increased liver enzymes D. Increased peristalsis

A. Decreased hydrochloric acid. Atrophy of the gastric mucosa causes a decreased ratio of gastrin-secreting cells to somatostatin-secreting cells. This results in a decrease in hydrochloric acid, causing decreased absorption of iron and vitamin B12. In the pancreas, calcification of pancreatic vessels occurs, with a decrease in lipase production. The decrease in lipase results in decreased fat absorption and digestion. Steatorrhea and diarrhea can subsequently occur. The number and size of hepatic cells are decreased, which results in decreased enzyme activity; decreased liver enzyme activity depresses drug metabolism, and therefore may cause accumulation of drugs to toxic levels. In the large intestine, peristalsis is decreased and nerve impulses are dulled, which can result in postponement of bowel movements in older adults.

Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) unit? A. A 38-year-old who needs discharge instructions after having an endoscopic retrograde cholangiopancreatography (ERCP) B. A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy C. A 43-year-old recently admitted with nausea, abdominal pain, and abdominal distention D. A 50-year-old with epigastric pain who needs conscious sedation during a scheduled endoscopy procedure.

B. A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy. A nurse who has experience with chronic GI problems will have experience and training in instructing clients on colonoscopy preparation. Discharge instructions following an ERCP, assessment of an admitted acutely ill client, and monitoring a client who is receiving conscious sedation would be accomplished best by nurses with experience in caring for adults with acute GI problems.

A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? A. Assesses the abdomen in the following sequence: inspection, palpation, percussion, auscultation. B. Examines the RUQ of the abdomen last C. Has the client lie in a supine position with legs straight and arms at the sides D. Views the abdomen by looking directly down while standing over the client's abdominal area

B. Examines the RUQ of the abdomen last If the client reports pain in the RUQ, the nurse would examine this area last in the examination sequence. This sequence prevents the client from tensing abdominal muscles because of the pain, which would make the examination difficult. The sequence for examining the abdomen is inspection, auscultation, percussion, and then palpation. This sequence prevents the increase in intestinal activity and bowel sounds caused by palpation and percussion. The client would be positioned supine with the knees bent, while keeping the arms at the sides to prevent tensing of the abdominal muscles. It is best to inspect the abdomen by standing at the side of the bed and then looking down on the abdomen, and also from the side at eye level.

The nurse practitioner is performing an abdominal assessment on a newly admitted client. In which order should the nurse proceed with assessment technique? A. Auscultation, percussion, palpation, inspection B. Inspection, auscultation, percussion, palpation C. Palpation, percussion, inspection, auscultation D. Percussion, auscultation, palpation, inspection

B. Inspection, auscultation, percussion, palpation The abdomen is assessed by using the four techniques of examination, but in a sequence different from that used for other body systems: inspection, auscultation, percussion, and then palpation. This sequence is preferred so that palpation and percussion do not increase intestinal activity and bowel sounds. Nurse generalists may perform inspection, auscultation, and light palpation; percussion and deep palpation may be done by advanced practice nurses.

The nurse is assessing a client who comes to the emergency department with acute abdominal pain. The nurse notes a bulging, pulsating mass when inspecting the abdomen. Which action by the nurse is correct? A. Auscultate the abdomen to determine the presence of bowel sounds. B. Notify the provider about this finding immediately. C. Palpate the client's abdomen to determine the outlines of the mass. D. Question the client about recent stool habits.

B. Notify the provider about this finding immediately. A bulging, pulsating mass may indicate an abdominal aortic aneurysm, and the nurse should notify the provider immediately. Palpating the abdomen or even touching the abdomen with a stethoscope may cause this to rupture, which would be a life-threatening emergency. Because this is a potential life-threatening situation, questioning the client about stool habits is not appropriate.

A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The client's respiratory rate is 8 breaths/min. What action by the nurse is best? a. Administer naloxone (Narcan). 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 should still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse's first action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for Versed. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.

The outpatient clinic nurse is caring for a recovering client who had a colonoscopy. The client asks for a drink. How does the nurse respond to this request? A. "After I hear bowel sounds, you can have a drink." B."Twenty minutes after the procedure was completed, you may have some liquids." C. "When you are able to pass flatus (gas), you can have a drink." D. "You can have fluids when you get home and are settled."

C. "When you are able to pass flatus (gas), you can have a drink." Fluids are permitted after the client's peristalsis has returned, which is validated by the client's passing flatus, not by auscultation of bowel sounds. There is no set time period after the procedure that is considered safe for the client to have something to drink. The client will not be discharged home without the nurse determining that peristalsis has returned. The client must report that he or she is passing flatus to go home; therefore, the client should be given a drink before being sent home.

After a colonoscopy, a client reports severe abdominal pain. The nurse obtains these data: temperature 100.2° F (37.9° C), pulse 122 beats/min, blood pressure 100/45 mm Hg, respirations 44 breaths/min, and O2 saturation 89%. Which request from the health care provider does the nurse implement first? A. Give cefazolin (Ancef) 500 mg IV. B. Infuse normal saline at 200 mL/hr. C. Give morphine sulfate 2 mg IV. D. Provide oxygen at 6 L/min per nasal cannula.

D. Provide oxygen at 6 L/min per nasal cannula. Based on the data given, the client may be experiencing complications of colonoscopy such as bleeding or perforation. The most immediate concern involves respiratory status, so the client should be placed on oxygen first. An antibiotic request is important, but is not the first priority. Fluid supplementation is important, but the client's oxygen saturation level places the client's respiratory status as the priority. The client's need for analgesia should be delayed until respiratory status is addressed. Morphine depresses respiratory status and therefore might not be the right choice for this client.