Hart Exam I GI, Hart exam I
Lower GI: Goals of IBD treatment - Bowel rest (IVF ____________) - Control inflammation (corticosteroids, 5-____) - Combat infection (IV _____) - Correct malnutrition (TPN)- when they can eat, put on a ____-_____, high __,___,__, and ____- free diet - Alleviate stress (rest) - Symptomatic relief - Improve quality of life
- Electrolytes - ASA - ABX - low-residue; vit, cal, PRO; lactose-free
Assessing for hepatitis: History - ________ - ________ __________ - _________ practices - __________/ toxic exposures ♣ Misuse of _________________, illicit drugs, chemical exposures, increases Hep risk ♣ Physical assessment depends on phase of infection
- Exposure - Foreign travel - Sexual - Medications Acetaminophen
Lower GI: Complications for Chron's - Scar ________ - Strictures - _________ - Impaired ________ (terminal ileum) - Fistulas (__________, ___________)
- tissue -Obstruction -absorption -rectovaginal, detrussor
A patient comes to the GI clinic and complains of N/V/diarrhea. What would you assess for in this patient? -History of _______ intake -Current __________ -Travel to a ___________ __________ -Interpersonal contacts (_________) -S/S of dehydration (_________)
-food -medications -foreign country -daycare, ill family members -decreased UO, dry skin, orthostatic BP changes, F/E abnormalities, BUN, Cr.
Lower GI: Complications for UC -intestinal _________ -___________ (peritonitis) -Toxic ______________ (super big) ->10 yrs ↑ risk of ________ CA
-hemorrhage -Perforation -Megacolon -COlon
Lower GI: Acute abdominal *pains* ○ __________ ○ _________ ○ _________ ○ _________ ___________
-inflammation -obstruction -peritonitis -internal bleeding
Low GI: Postoperative care acute abdominal pain 1. Manage N/V - Administer ________ - _____ to low suction 2. NPO - progress ____ ______ 3. Monitor FE 4. Administer IVF 5. Manage pain 6. I/O (monitors ______ function) 7. Early ambulation (↓_____risk)
1. - antiemetics; NG 2. diet slowly 6. renal 7. DVT
Low GI: Intestinal Obstruction 1. Mechanical (ASHT) 2. Non-mechanical (_______ _______ and vascular)
1. Adhesions, strictures, hernias, tumors 2. Paralytic ileus (lack of intestinal peristalsis and BS- usually occurs after abdominal sx)
What class of medications are used for IBD?
1. Aminosalicylates (5-ASA) 2. Antimicrobials 3. Corticosteroids (IV) 4. Immunosupressants 5. Biologic & Targeted therapies (Humira)
Major functions of the liver 1. Metabolizes: (____,____,_____) -> _____ = albumin, clotting factors 2. Detoxification of _____ into _____ 3. Produces _________ and excretes ________ If liver cells are destroyed, scar tissue forms, thus altering the blood flow in the liver = ↑BP in GI system
1. CHO, PRO, FAT PRO 2. NH3 into urea 3. bile/bilirubin
Lower GI: IBD - autoimmune d/o?
1. Ulcerative colitis 2. Chron's disease (skip lesions)
Lower GI: NANDAs- Acute abdominal pain 1. Acute _____ r/t inflammtion of the peritoneum and abdominal distention 2. Risk for _______ ______ ______ r/t collection of fluid in the peritoneal cavity 3. ________ r/t to pain and uncertainty of cause or outcome Nursing priorities?
1. pain 2. deficient fluid volume 3. Anxiety - Relief of pain, FE balance, reduce anxiety
Lower GI: Nursing assessment 1. VS - note for s/s of _______ (↓___/↑____) 2. LOC - altered LOC = poor _______ perfusion 3. Perfusion - look at skin _______, ________, _________ pulses 4. Focused GI - ______ ______, palpate, vomiting 5. Pain assessment - Note pt. _______, worsens with ______ or bed movement
1. shock (↓BP/↑HR) 2. cerebral 3. color, temp, peripheral 4. Bowel sounds' 5. position, cough (peritoneal pain = inflammation or appendicitis)
General physical Hepatitis findings: 1. Fever, lethargy, lymphadenopathy 2. Skin- __________, rash, spider angiomas ♦ ___________(from bilirubin diffusing into the tissues) ♦ __________ can accompany _________ r/t accumulation of bile salts beneath the skin 3. GU- urine become _________ because excess bilirubin is excreted 4. GI- hepatomegaly/spleenomegaly ♦ Liver is enlarged and tender ♦ Anorexia, N/V, stool can become light-clay colored if bilirubin __________ flow out of liver.
2. jaundice; pruritus 3. dark 4. CANNOT
Low GI: Initial NSG interventions - Acute abdominal pain 1. Maintain patent airway 2. Administer O2 3. Initiate IV access (_____ or _____) 4. Insert foley catheter (_______ function) 5. Insert NG tube (___________ stomach) 6. Obtain lab work (name 7) 7. Anticipate surgical intervention
3. NS or LR 4. Renal 5. decompress 6. CBC, electrolytes, UA, amylase (pancreatitis), preg test, clotting studies, and BLD type/cross match
Lower GI: Which inflammatory disorder? - Periumbilical pain ○___________ point ○ __________ ___________ ○ Constant ______ - Anorexia, N/V - Low-grade temp - ↑ WBC Diagnostics? Complications?
Appendicitis - Mcburney's point - rebound tenderness - pain Dx: CT scan, then prep for sx (give ABX and IVF before sx to prevent sepsis and dehydration) Complications: peritonitis, abscess
Lower GI: Type of IBD? -Non-specific (all over GI tract) -Skip lesions -Terminal ileum, jejunum, colon -Cobblestone appears -Fistula's are common (helps rule out ds) LRG intestine = diarrhea, dehydration Small intestine = ↓ nutrients, weakness, malabsorption, weight loss
Chron's disease
Which phase of Hepatitis infection? - S/s of jaundice resolve - LFTs return to normal
Convalescent phase
Type of hepatitis? - Fecal/oral transmission - Onset Acute-flu like s/s - Vaccine
Hep A
Type of hepatitis? - Blood and body fluid transmission - Onset slow-symptoms more severe - Vaccine
Hep B
Type of hepatitis? - Percutaneous transmission (through skin) - Asymptomatic or mild s/s - 20% will progress to cirrhosis 20-30 yrs - Liver damage 15-20 yrs after infection
Hep C
Which phase of Hepatitis infection? - Classic presentation of jaundice, dark urine, clay-colored stools, RUQ pain - Abnormal LFTs
Icteric phase
Which phase of Hepatitis infection? - Asymptomatic to vague s/s (anorexia, N/V, malaise, fatigue, pruritis, arthralgia) - May be dx as flu/virus gastro - Virus load can be detected
Incubation/prodromal
Lower GI: Type of IBD? - In colon and rectum - 15-40 yoa - either sex - involves mucosa and submucosa - begins distally and progresses upward Common s/s?
Ulcerative colitis common s/s: bloody diarrhea/abd pain
Assessment findings suggestive of peritonitis include (Select all that apply): a. Rebound tenderness b. a soft, distended abdomen c. shallow RR and bradypnea d. observing that the patient is lying still e. dull, intermittent abdominal pain
a, d With peritoneal irritation, the abdomen is hard, and the patient has severe continuous abdominal pain that is worse with any sudden movement. Palpating the abdomen and releasing the hands suddenly causes sudden movement within the abdomen and severe pain. This is called rebound tenderness. The patient lies very still and takes shallow breaths. Abdominal distention, tachypnea, fever, and tachycardia may occur.
The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which individual should the nurse refer for an immunoglobulin (IG) injection? a. A caregiver who lives in the same household with the patient b. A friend who delivers meals to the patient and family each week c. A relative with a history of hepatitis A who visits the patient daily d. A child living in the home who received the hepatitis A vaccine 3 months ago
a. A caregiver that lives in the same household as patient IG is recommended for persons who do not have anti-HAV antibodies and are exposed as a result of close contact with persons who have HAV or foodborne exposure. Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.
The nurse is caring for a patient who complains of abdominal pain and hematemesis. Which new assessment finding(s) would indicate the patient is experiencing a decline in condition? a. Pallor and diaphoresis b. Ecchymotic peripheral IV site c. Guaiac-positive diarrhea stools d. Heart rate 90, respiratory rate 20, BP 110/60
a. A patient with hematemesis has some degree of bleeding from an unknown source. When monitoring the patient for stability, the nurse observes for signs of hypovolemic shock such as tachycardia, tachypnea, hypotension, altered level of consciousness, pallor, and cool and clammy skin
A patient with a history of peptic ulcer disease has presented to the emergency department with severe abdominal pain and a rigid, boardlike abdomen. The health care provider suspects a perforated ulcer. Which interventions should the nurse anticipate? a. Providing IV fluids and inserting a nasogastric (NG) tube b. Administering oral bicarbonate and testing the patient's gastric pH level c. Performing a fecal occult blood test and administering IV calcium gluconate d. Starting parenteral nutrition and placing the patient in a high-Fowler's position
a. A perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube. Nothing is given by mouth, and gastric pH testing is not a priority. Calcium gluconate is not a medication directly relevant to the patient's suspected diagnosis, and parenteral nutrition is not a priority in the short term.
? a. "It would be beneficial for you to eliminate drinking alcohol." b. "You'll need to drink at least two to three glasses of milk daily." c. "Many people find that a minced or pureed diet eases their symptoms of PUD." d. "Taking medication will allow you to keep your present diet while minimizing symptoms."
a. Alcohol increases the amount of stomach acid produced. so it should be avoided. Although there is no specific recommended dietary modification for PUD, most patients find it necessary to make some sort of dietary modifications to minimize symptoms. Milk may exacerbate PUD.
A patient is scheduled for surgery with general anesthesia in 1 hour and is observed with a moist but empty water glass in his hand. Which assessment finding may indicate that the patient drank a glass of water? a. Easily heard, loud gurgling in abdomen b. High-pitched, hollow sounds in abdomen c. Tenderness in left upper quadrant upon palpation d. Flat abdomen without movement upon inspection
a. Easily heard, loud gurgling in abdomen If the patient drank water on an empty stomach, gurgling can be assessed without a stethoscope or assessed with auscultation. High-pitched, hollow sounds are tympanic and indicate an empty cavity. A flat abdomen and tenderness do not indicate that the patient drank a glass of water.
A nurse is assessing a client who has Chron's disease. Which of the following findings should the nurse expect? a. Fatty diarrheal stools b. Hyperkalemia c. Weight gain d. Sharp epigastric pain
a. Fatty diarrheal stools Steatorrhea, or fatty stool, is an expected finding in a client who has Crohn's disease.
A nurse is providing discharge teaching for a client who has peptic ulcer disease and a new prescription for famotidine. Which of the following statements by the client indicates an understanding of the teaching? a. I should take this medication at bedtime b. I should expect this medication to color my stools c. I will drink iced tea with my meals and snacks d. I will monitor my BG regularly while taking this medication
a. I should take this medication at bedtime The nurse should instruct the client to take the medication at bedtime to inhibit the action of histamine at the H2-receptor site in the stomach.
A patient with type 2 diabetes and cirrhosis asks the nurse if it would be acceptable to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge? a. Milk thistle may affect liver enzymes and thus alter drug metabolism. b. Milk thistle is generally safe in recommended doses for up to 10 years. c. There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. d. Milk thistle may elevate the serum glucose levels and is thus contraindicated in diabetes.
a. Milk thistle may affect liver enzymes and thus alter drug metabolism. Scientific evidence indicates there is no real benefit from milk thistle to protect liver cells from toxic damage in the treatment of cirrhosis. Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore, patients will need to be monitored for drug interactions. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels.
A patient with HAV is in the acute phase. The nurse plans care for the patient based on the knowledge that: a. pruritus is a common problem with jaundice in this phase b. the patient is most likely to transmit disease during this phase c. GI symptoms are not as severe in HAV as they are in HBV d. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase
a. The acute phase of jaundice may be icteric or anicteric. Jaundice results when bilirubin diffuses into the tissues. Pruritus sometimes accompanies jaundice. Pruritus is the result of an accumulation of bile salts beneath the skin.
A patient complaining of nausea receives a dose of metoclopramide. Which potential adverse effect should the nurse tell the patient to report? a. Tremors b. Constipation c. Double vision d. Numbness in fingers and toes
a. Tremors (Ataxia) Extrapyramidal side effects, including tremors and tardive dyskinesias, may occur with metoclopramide administration. Constipation, double vision, and numbness in fingers and toes are not adverse effects of metoclopramide.
A patient is jaundiced and her stools are clay colored (gray). This is most likely related to a. decreased bile flow into the intestine b. increased production of urobilinogen c. increased bile and bilirubin in the blood d. increased production of cholecystokinin
a. decreased bile flow into the intestine Bile is produced by the hepatocytes and is stored and concentrated in the gallbladder. When bile is released from the common bile duct, it enters the duodenum. In the intestines, bilirubin is reduced to stercobilinogen and urobilinogen by bacterial action. Stercobilinogen accounts for the brown color of stool. Stools may be clay-colored if bile is not released from the common bile duct into the duodenum. Jaundice may result if the bilirubin level in the blood is elevated.
Normal physical assessment findings of the GI system are (select all that apply) a. nonpalpable liver & spleen b. borborygmi in URQ c. tympany on percussion of the abdomen d. liver edge 2-4 cm below costal margin e. finding of a firm, nodular edge on the rectal examination
a. nonpalpable liver & spleen c. tympany on percussion of the abdomen Normal assessment findings of the gastrointestinal system include a nonpalpable liver and spleen and generalized tympany on percussion. Normally, bowel sounds are high pitched and gurgling; loud gurgles indicate hyperperistalsis and are called borborygmi (stomach growling). If the patient has chronic obstructive pulmonary disease, large lungs, or a low-set diaphragm, the liver may be palpated 0.4 to 0.8 inch (1 to 2 cm) below the right costal margin. On palpation, the rectal wall should be soft and smooth and should have no nodules.
The nurse perfoms a detailed assessment of the abdomen of a patient with possible bowel obstruction, knowing that manifestations of an obstruction in the large intestine are (select all that apply): a. persistent abdominal pain b. marked abdominal distention c. diarrhea that is loose or liquid d. colicky, severe, intermittent pain e. profuse vomiting that relieves abdominal pain
a. persistent abdominal pain b. marked abdominal distention With lower intestinal obstructions, abdominal distention is markedly increased and pain is persistent. Onset of a large intestine obstruction is gradual, vomiting is rare, and there is usually absolute constipation, not diarrhea.
The nurse is aware of potential complications related to cirrhosis. Which interventions would be included in a safe plan of care (select all that apply.)? a. Provide a high-protein, low-carbohydrate diet. b. Teach the patient to use soft-bristle toothbrush and electric razor. c. Teach the patient to avoid vigorous blowing of nose and coughing. d. Apply gentle pressure for the shortest possible time after venipuncture. e. Use the smallest gauge needle possible when giving injections or drawing blood. f. Instruct the patient to avoid aspirin and nonsteroidal antiinflammatory (NSAIDs).
b,c,e,f Using the smallest gauge needle for injections, using a soft bristle toothbrush and an electric razor will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding. A low-salt, low-protein, high-carbohydrate diet may be recommended.
The nurse is caring for a group of patients. Which patient has the highest risk for developing pancreatic cancer? a. A 38-yr-old Hispanic woman who is obese and has hyperinsulinemia b. A 72-yr-old African American man who has smoked cigarettes for 50 years c. A 23-yr-old man who has cystic fibrosis-related pancreatic enzyme insufficiency d. A 19-yr-old patient who has a 5-year history of uncontrolled type 1 diabetes mellitus
b. A 72-yr-old African American man who has smoked cigarettes for 50 years Risk factors for pancreatic cancer include chronic pancreatitis, diabetes mellitus, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine. African Americans have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are two or three times more likely to develop pancreatic cancer compared with nonsmokers. The risk is related to duration and number of cigarettes smoked.
When providing discharge teaching for a patient after a laparoscopic cholecystectomy, what information should the nurse include? a. Do not return to work or normal activities for 3 weeks. b. A lower-fat diet may be better tolerated for several weeks. c. Bile-colored drainage will probably drain from the incision. d. Keep the bandages on and the puncture site dry until it heals.
b. A lower-fat diet may be better tolerated for several weeks. Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks after surgery. Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.
A patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? a. 7:00 AM, 10:00 AM, and 1:00 PM b. 8:00 AM, 12:00 PM, and 4:00 PM c. 9:00 AM and 3:00 PM d. 9:00 AM, 12:00 PM, and 3:00 PM
b. A nasogastric tube should be checked for patency routinely at 4-hour intervals
The nurse is caring for a postoperative patient who has just vomited yellow green liquid and reports nausea. Which action would be an appropriate nursing intervention? a. Offer the patient an herbal supplement such as ginseng. b. Apply a cool washcloth to the forehead and provide mouth care. c. Take the patient for a walk in the hallway to promote peristalsis. d. Discontinue any medications that may cause nausea or vomiting.
b. Cleansing the face and hands with a cool washcloth and providing mouth care are appropriate comfort interventions for nausea and vomiting. - Ginseng is not used to treat postoperative nausea and vomiting. - Unnecessary activity should be avoided. The patient should rest in a quiet environment. - Medications may be temporarily withheld until the acute phase is over, but the medications should not be discontinued without consultation with the health care provider.
A nurse is providing teaching for a client who has cirrhosis and a new prescription for lactulose. The nurse should include which of the following instructions in the teaching? a. Notify the provider if bloating occurs b. Expect to have 2-3 soft stools/day c. Restrict CHOs in the diet d. Limit oral fluid intake to 1,000 ml per day of clear liquids
b. Expect to have 2-3 soft stools/ day The purpose of administering lactulose is to promote the excretion of ammonia in the stool. The nurse should instruct the client to take the medication every day and inform the client that two to three bowel movements every day is the treatment goal.
A patient with acute HBV is being discharged in 2 days. The discharge teaching plan should include instructions to a. avoid alcohol for the first 3 weeks b. use a condom during sexual intercourse c. have family members get an injection of immunoglobulin d. follow a low protein, moderate carb, moderate fat diet
b. Hepatitis B virus may be transmitted by mucosal exposure to infected blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B.
A patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. Which intervention should the nurse include in the patient's plan of care? a. Immediately start enteral feeding to prevent malnutrition. b. Insert an NG and maintain NPO status to allow pancreas to rest. c. Initiate early prophylactic antibiotic therapy to prevent infection. d. Administer acetaminophen (Tylenol) every 4 hours for pain relief.
b. Insert an NG and maintain NPO status to allow pancreas to rest. Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.
A 54-yr-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. Which diagnosis does the nurse expect? a. Starvation b. Pancreatitis c. Systemic sepsis d. Diabetic ketoacidosis
b. Pancreatitis The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal, 30-122 U/L) and serum lipase (normal, 31-186 U/L) levels as shown.
A colectomy is scheduled for a patient with ulcerative colitis. The nurse should plan to include which prescribed measure in the preoperative preparation of this patient? a. Instruction on irrigating a colostomy b. Administration of a cleansing enema c. A high-fiber diet the day before surgery d. Administration of IV antibiotics for bowel preparation
b. Preoperative preparation for bowel surgery typically includes bowel cleansing with antibiotics, such as oral neomycin and cleansing enemas, including Fleet enemas. Instructions to irrigate the colostomy will be done postoperatively. Oral antibiotics are given preoperatively and an IV antibiotic may be used in the operating room. A clear liquid diet will be used the day before surgery with the bowel cleansing.
A nurse is reviewing the lab results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? a. Blood glucose 110 mg/dL. b. Increased serum amylase c. WBC 9,000/mm3A WBC of 9,000/mm3 d. Decreased bilirubin
b. Serum amylase levels are increased in a client who as acute pancreatitis due to pancreatic cell injury
During an examination of the abdomen, the nurse should a. position the patient in the supine position with the bed flat and the knees straight b. listen to bowel sounds in the epigastrium and all four quadrants for 2 min. c. describe bowel sounds as absent if no sound is heard in a quadrant after 2 min d. use the following order of techniques: inspection, palpation, percussion, auscultation
b. listen to bowel sounds in the epigastrium and all four quadrants for 2 min. The nurse should listen in the epigastrium and all four quadrants for bowel sounds for at least 2 minutes The patient should be in the supine position with slightly flexed knees; HOB raised slightly. Bowel sounds cannot be described as absent until no sound is heard for 5 minutes in each quadrant
In preparing a patient for a colonoscopy, the nurse explains that a. a signed permit is not necessary. b. sedation may be used during the procedure. c. only one cleansing enema is necessary for preparation. d. a light meal should be eaten the day before the procedure.
b. sedation may be used during the procedure. Sedation is induced during a colonoscopy. A signed consent form is necessary for a colonoscopy. The patient should follow either a low-residue or a full liquid diet the day before the procedure until bowel cleansing begins. Bowel cleansing should follow a split-dose regimen. The evening before the procedure the patient should drink 2 L of oral polyethylene glycol (PEG) lavage solution. The second 2 L dose should begin 4 to 6 hours before the procedure. Some patients may receive less solution and a cleansing enema, but this does not occur in all patient situations.
When the nurse is assessing the health perception-health maintenance pattern as related to GI function, an appropriate question to ask is a. "What is your usual bowel elimination pattern?" b. "What percentage of your income is spent on food?" c. "Have you traveled to a foreign country in the last year?" d. "Do you have diarrhea when you are under a lot of stress?"
c. "Have you traveled to a foreign country in the last year?" When assessing gastrointestinal function in relation to the health perception-health management pattern, the nurse should ask the patient about recent foreign travel with possible exposure to hepatitis, parasitic infestation, or bacterial infection.
When caring for the patient with heart failure, the nurse knows that which gastrointestinal process is most dependent on cardiac output and may affect the patient's nutritional status? a. Ingestion b. Digestion c. Absorption d. Elimination
c. Absorption Substances that interface with the absorptive surfaces of the gastrointestinal tract (primarily in the small intestine) diffuse across the intestinal membranes into intestinal capillaries and are then carried to other parts of the body for use in energy production. The cardiac output provides the blood flow for this absorption of nutrients to occur.
A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report to the provider? a. spider angiomas b. peripheral edema c. bloody stools d. jaundice
c. Bloody stools The greatest risk to the client who has cirrhosis of the liver is hemorrhagic shock due to bleeding in the esophageal varices. Therefore, bloody stools is the priority finding to report to the provider.
A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report to the HCP? a. Spider angiomas b. Peripheral edema c. Bloody stools d. Jaundice
c. Bloody stools The greatest risk to the client who has cirrhosis of the liver is hemorrhagic shock due to bleeding in the esophageal varices. Therefore, bloody stools is the priority finding to report to the provider. --> all the other possible answers are expected findings for someone with cirrhosis
A patient is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority? a. Nausea and vomiting b. Hyperactive bowel sounds c. Firmly distended abdomen d. Abrasions on all extremities
c. Firmly distended abdomen Clinical manifestations of abdominal trauma are guarding and splinting of the abdominal wall; a hard, distended abdomen (indicating possible intraabdominal bleeding); decreased or absent bowel sounds; contusions, abrasions, or bruising over the abdomen; abdominal pain; pain over the scapula; hematemesis or hematuria; and signs of hypovolemic shock (tachycardia and decreased blood pressure).
A nurse is assessing a client who has an upper GI bleed. Which of the following findings should the nurse expect? a. bradycardia b. bounding peripheral pulses c. hypotension d. increased Hct. levels
c. Hypotension A client who has upper gastrointestinal bleeding is at risk for hemorrhagic shock. Hypotension is a manifestation of hemorrhagic shock.
A nurse admitting a client who has acute pancreatitis. Which of the following nursing actions should the nurse take first? a. Insert an NG tube b. Administer cefttazidime c. Identify the client's pain level d. Instruct the client to remain NPO
c. Identify pain level FIRST The first action the nurse should take when using the nursing process is to assess the client. Clients who have acute pancreatitis often have severe abdominal pain. By assessing the client's level of pain, the nurse can identify the need for and implement interventions to alleviate the client's pain.
A patient with an intestinal obstruction has a nasogastric (NG) tube to suction but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse? a. Notify the physician. b. Auscultate for bowel sounds. c. Reposition the tube and check for placement. d. Remove the tube and replace it with a new one.
c. Reposition the tube and check for placement. The tube may be resting against the stomach wall. The first action by the nurse is to reposition the tube and check it again for placement. The physician does not need to be notified unless the nurse cannot restore the tube function. The patient does not have bowel sounds, which is why the NG tube is in place. The NG tube would not be removed and replaced unless it was no longer in the stomach or the obstruction of the tube could not be relieved.
A nurse is teaching a client how to prepare for a colonoscopy. Which of the following instructions should the nurse include in the teaching? a. Begin drinking the oral liquid preparation for bowel cleansing on the morning of the procedure. b. Drink full liquids for breakfast the day of the procedure, and then take nothing by mouth for 2 hr prior to the procedure. c. Drink clear liquids for 24 hr prior to the procedure, and then take nothing by mouth for 6 hr before the procedure. d. Drink the oral liquid preparation for bowel cleansing slowly.
c. The nurse should instruct the client to drink clear liquids for 24 hr prior to the colonoscopy to promote adequate bowel cleansing. Maintaining NPO status for 4 to 6 hr prior to the colonoscopy preserves the bowel's cleansed state.
The patient is having an esophagoenterostomy with anastomosis of a segment of the colon to replace the resected portion. What initial postoperative care should the nurse expect when this patient returns to the nursing unit? a. Turn, deep breathe, cough, and use spirometer every 4 hours. b. Maintain an upright position for at least 2 hours after eating. c. NG will have bloody drainage and it should not be repositioned. d. Keep in a supine position to prevent movement of the anastomosis.
c. The patient will have bloody drainage from the nasogastric (NG) tube for 8 to 12 hours, and it should *not be repositioned* or reinserted without contacting the surgeon. Turning and deep breathing will be done every 2 hours, and the spirometer will be used more often than every 4 hours. Coughing would put too much pressure in the area and should not be done. Because the patient will have the NG tube, the patient will not be eating yet. The patient should be kept in a semi-Fowler's or Fowler's position, not supine, to prevent reflux and aspiration of secretions.
The patient with chronic gastritis is being put on a combination of medications to eradicate Helicobacter pylori. Which drugs does the nurse know will probably be used? a. Antibiotic(s), antacid, and corticosteroid b. Antibiotic(s), aspirin, and antiulcer/protectant c. Antibiotic(s), proton pump inhibitor, and bismuth d. Antibiotic(s) and nonsteroidal antiinflammatory drugs (NSAIDs)
c. To eradicate H. pylori, a combination of antibiotics, a proton pump inhibitor, and possibly bismuth (for quadruple therapy) will be used. Corticosteroids, aspirin, and NSAIDs are drugs that can cause gastritis and do not affect H. pylori.
The discharge teaching plan for the patient being discharged after an acute episode of an upper GI bleed includes information concerning the importance of (Select all that apply) a. limit alcohol intake to one serving per day b. only taking aspirin with milk or bread products c. avoiding taking aspirin and drugs containing aspirin d. only taking drugs prescribed by the HCP e. taking all drugs 1 hr. before meal time to prevent further bleeding
c. avoiding taking aspirin and drugs containing aspirin d. only taking drugs prescribed by the HCP Before discharge, the patient with upper gastrointestinal (GI) bleeding and the caregiver should be taught how to avoid future bleeding episodes. Ulcer disease and drug or alcohol abuse can cause upper GI bleeding. Help make the patient and caregiver aware of the consequences of noncompliance with drug therapy. Emphasize that no drugs (especially aspirin and nonsteroidal antiinflammatory drugs [NSAIDs]) other than those prescribed by the HCP should be taken. Alcohol should be eliminated because it is a source of irritation and interfere with tissue repair.
The nurse is assessing a patient admitted with a possible bowel obstruction. Which assessment finding would be expected in this patient? a. tympany to abdominal percussion b. aortic pulsation visible in epigastric region c. high-pitched sounds on abdominal auscultation d. liver border palpable 1 cm below the right costal margin
c. high-pitched sounds on abdominal auscultation The bowel sounds are higher pitched (rushes and tinkling) when the intestines are under tension, as in intestinal obstruction. Bowel sounds may also be diminished or absent with an intestinal obstruction. Normal findings include aortic pulsations on inspection and tympany with percussion, and the liver may be palpable 1 to 2 cm along the right costal margin.
In planning care for a client with Chron's disease, the nurse recognizes that a major difference between UC and Chron's disease is that Chron's disease: a. frequently results in toxic megacolon b. causes fewer nutritional deficiencies than UC c. often reoccurs after surgery, whereas UC is curable after a colectomy d. is manifested by rectal bleeding and anemia more often than UC
c. often reoccurs after surgery, whereas UC is curable after a colectomy UC affects only the colon and rectum = toxic megacolon and rectal bleeding, but not nutrient malabsorption. Surgical removal of the colon and rectum cures it. Crohn's disease usually involves the ileum, where bile salts and vitamin cobalamin are absorbed. After surgical treatment, disease recurrence at the site is common.
The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill. Which response by the nurse is most appropriate? a. "You will need to be tested first; then treatment can be determined." b. "The hepatitis vaccine will provide immunity from this and future exposures." c. "There is nothing you can do since the patient was infectious before admission." d. "An immunoglobulin injection will be given to prevent infection or limit symptoms."
d. "An immunoglobulin injection will be given to prevent infection or limit symptoms." Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.
When teaching the patient with acute hepatitis C (HCV), which statement demonstrates understanding of the disease process? a. "I will use care when kissing my wife to prevent giving it to her." b. "I will need to take adefovir (Hepsera) to prevent chronic HCV." c. "Now that I have had HCV, I will have immunity and not get it again." d. "I will need to be monitored for chronic HCV and other liver problems."
d. "I will need to be monitored for chronic HCV and other liver problems." The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva but by blood exposures such as sharing needles and high-risk sexual activity. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adefovir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.
A patient was involved in a motor vehicle crash and reports an inability to have a bowel movement. What is the best response by the nurse? a. "You are just too nervous to eat or drink, so there is no stool." b. "Your parasympathetic nervous system is now working to slow the GI tract." c. "The circulation in the GI system has been increased, so less waste is removed." d. "Your sympathetic nervous system was activated, so there is slowing of the GI tract".
d. "Your sympathetic nervous system was activated, so there is slowing of the GI tract". The constipation is most likely related to the sympathetic nervous system activation from the stress related to the accident. Sympathetic nervous system activation can decrease peristalsis. Even without oral intake for a short time, stool will be formed. The parasympathetic system stimulates peristalsis. The circulation to the gastrointestinal system is decreased with stress.
The nurse is caring for a patient admitted with a suspected bowel obstruction. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? a. Low-pitched and rumbling above the area of obstruction b. High-pitched and hypoactive below the area of obstruction c. Low-pitched and hyperactive below the area of obstruction d High-pitched and hyperactive above the area of obstruction
d. Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high pitched, sometimes referred to as "tinkling," above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.
A patient is admitted to the hospital with a diagnosis of diarrhea and dehydration. The nurse recognizes that increased peristalsis resulting in diarrhea can be related to a. sympathetic inhibition b. mixing and propulsion c. sympathetic simulation d. parasympathetic simulation
d. parasympathetic simulation Think rest and digest (Peristalsis is increased by parasympathetic stimulation)
A patient reports severe pain when the nurse assesses for *rebound tenderness*. What may this assessment finding indicate? a. hepatic cirrhosis b. hypersplenomegaly c. gallbladder distention d. peritoneal inflammation
d. peritoneal inflammation When palpating for rebound tenderness, the problem area of the abdomen will produce pain and severe muscle spasm when there is peritoneal inflammation. Hepatic cirrhosis, hypersplenomegaly, and gallbladder distention do not manifest with rebound tenderness.
The nurse is teaching the pt. and family that peptic ulcers are a. caused by stressful lifestyle and other acid producing factors such as H. pylori b. inherited within families and reinforced by bacterial spread of S. aureus in childhood c. promoted by factors that tend to cause an oversecretion of acid, such as excess dietary fats, smoking, and H. pylori d. promoted by a combination of factors that may result in erosion of the gastric mucosa, including certain drugs and alcohol
d. promoted by a combination of factors that may result in erosion of the gastric mucosa, including certain drugs and alcohol Peptic ulcers develop only in the presence of an acidic environment. However, an excess of hydrochloric acid (HCl) may not be necessary for ulcer development. The back diffusion of HCl into the gastric mucosa results in cellular destruction and inflammation. Histamine is released from the damaged mucosa, which results in vasodilation and increased capillary permeability and further secretion of acid and pepsin. A variety of agents (certain infections, medications, and lifestyle factors) can damage the mucosal barrier. Helicobacter pylori can alter gastric secretion and produce tissue damage, which leads to peptic ulcer disease. Ulcerogenic drugs, such as aspirin and NSAIDs, inhibit synthesis of prostaglandins, increase gastric acid secretion, and reduce the integrity of the mucosal barrier. Patients taking corticosteroids, anticoagulants, and SSRIs are at increased risk for ulcers. High alcohol intake stimulates acid secretion and is associated with acute mucosal lesions. Coffee (caffeinated and uncaffeinated) is a strong stimulant of gastric acid secretion.
The nurse is performing a *focused abdominal assessment* of a patient who has been recently admitted. In order to *palpate the patient's liver*, where should the nurse palpate the patient's abdomen? a. Left lower quadrant b. Left upper quadrant c. Right lower quadrant d. Right upper quadrant
d. right upper quadrant.
What is the primary cause of diarrhea?
infectious organisms (C. diff, E. coli, parasites, viruses)
Types of diarrhea are:
osmotic, malabsorptive, inflammatory, immunocompromised
Expected lab values for hepatitis virus: ___ Liver enzymes (AST/ALT) ___ Bilirubin ___________ PT/PTT ___ Albumin, anemia
↑ liver enzymes ↑ bilirubin Prolonged ↓ albumin