Unit 1 GI
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?" MRI is a noninvasive technique that uses magnetic fields and radio waves to produce images of the area being studied. Clients must be NPO for 6 to 8 hours before the study and remove all jewelry and other metals. The examination takes 60 to 90 minutes and can induce feelings of claustrophobia, because the scanner is close fitting.
When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the physician?
"I really don't like to be in small, enclosed spaces." An MRI scanner is a narrow, tunnel-like machine that will enclose the client during the test. Clients who are claustrophobic (fear enclosed spaces) may need sedation because it is imperative that they lie still and not panic during the test. Therefore, the nurse should notify the physician about the client's statement. Typically, the client is NPO for 6 to 8 hours before the test, and he or she must remove any metal objects, credit cards, jewelry, and watch before the test. The machine makes loud repetitive noises while the test is in progress, so earphones may be helpful.
A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?
"I'll avoid eating or drinking anything 6 to 8 hours before the test." The client demonstrates understanding of a barium swallow when he states that he must refrain from eating or drinking for 6 to 8 hours before the test. No other preparation is needed. Before a lower GI series, the client should eat a low-residue or clear liquid diet for 2 days and take a potent laxative and an oral liquid preparation.
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 carcinoembryonic antigen (CEA) blood test detects the presence of cancer by identifying the presence of a protein not normally detected in the blood of a healthy person. However, it does not indicate what type of cancer is present nor does it detect the functionality of the liver.
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." Pain can be a major symptom of disease. The location and distribution of pain can be referred from a different area. If a client points to an area of pain and has other symptoms associated with a certain disease, this is valuable information for treatment.
The nurse is instructing a client prior to a colonoscopy. The client states, "Why do I have to drink this disgusting liquid?" The nurse is most correct to verbalize the goal of the oral preparation as which of the following?
"To cleanse the bowel to promote clear visualization of structures" The goal of the oral preparation is to eliminate fecal matter to visualize the colon structures. Having a clean colon free of fecal matter does allow for easy of passage of the scope and eliminates gas. The client is sedated throughout the procedure so does not experience pain.
Upon hearing that his small intestine lining has thinned, an elderly client asks, "What can this lead to?" The nurse would most likely respond with which of the following comments?
"You may frequently experience constipation." As a person ages, the epithelial cells and villi thin in the small intestine. Implications of this consequence include decreased intestinal motility and transit time, which can lead to constipation. This would lead the nurse to discuss and advise the client on ways to prevent constipation.
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." A capsule endoscopy allows for noninvasive visualization of the small intestinal mucosa. The technique consists of the client swallowing a capsule that is embedded with a wireless miniature camera, which is propelled through the intestine by peristalsis. The capsule passes from the rectum in 1 to 2 days.
A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours?
80 to 120 mL Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours
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 correct to fully assess the client experiencing abdominal distention following an esophagogastroduodenoscopy (EGD). Abdominal distention could indicate complications such as perforation and bleeding. The client experiences drowsiness from the sedative during the early recovery process and a sore throat from passage of the scope. The client may also experience thirst because the client has not had liquids for a period of time.
Which of the following is the primary function of the small intestine?
Absorption Absorption is the primary function of the small intestine. Digestion occurs in the stomach. Peristalsis occurs in the colon. The duodenum secretes enzymes.
Which of the following digestive enzymes aids in the digesting of starch?
Amylase Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein; amylase, which aids in digesting starch; and lipase, which aids in digesting fats. Bile is secreted by the liver and is not considered a digestive enzyme.
A nurse caring for a patient who has had radical neck surgery notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. An expected normal amount of drainage is:
Approximately 80 to 120 mL. Between 80 to 120 mL may drain over the first 24 hours. Drainage of greater than 120 mL may be indicative of a chyle fistula or hemorrhage.
Which of the following is considered the gold standard for the diagnosis of liver disease?
Biopsy Liver biopsy is considered the gold standard for the diagnosis of liver disease. Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions. Cholecystography and ultrasonography may be used to detect gallstones.
The nurse is creating a plan of care for a client who is not able to tolerate brushing his teeth. The nurse includes which mouth irrigation in the plan of care?
Baking soda and water When a client is unable to tolerate teeth brushing, the following irrigating solutions are recommended: 1 tsp baking soda in 8 oz warm water, half-strength hydrogen peroxide, or normal saline solution.
Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis?
Chancre A chancre is a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis. Lichen planus is a white papule at the intersection of a network of interlacing lesions. Actinic cheilitis is an irritation of the lips associated with a scaling, crusting fissure. Leukoplakias are white patches usually found in the buccal mucosa.
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 Mucous membranes may be dry, and skin turgor may be poor in clients suffering from dehydration as a result of fluid losses from the GI tract. Checking the skin for discoloration and inspecting the sclera if it is yellow is taken into consideration when the client could have symptoms of jaundice, not fluid losses. Distended abdominal veins are not associated with dehydration.
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 colonoscopy is a direct visual examination of the entire large intestine. It does not involve the use of a contrast agent. Contrast medium may be used with a small bowel series, computed tomography, and upper GI series.
Which is the primary symptom of achalasia?
Difficulty swallowing The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The client may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.
The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease?
Dysphagia Dysphagia (difficulty swallowing), the most common symptom of esophageal disease, may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute odynophagia (pain on swallowing).
An elderly client states, "I don't understand why I have so many caries in my teeth." The nurse assesses the following as placing the client at risk:
Exhibiting hemoglobin A1C 8.2 Measures used to prevent and control dental caries include controlling diabetes. A hemoglobin A1C of 8.2 is not controlled. It is recommended for hemoglobin A1C to be less than 7 for people with diabetes. Other measures to prevent and control dental caries include drinking fluoridated water; eating foods that are less cariogenic, which include fruits, vegetables, nuts, cheese, or plain yogurt; and brushing teeth evenly with a soft-bristled toothbrush.
Postoperatively, a client with a radical neck dissection should be placed in which position?
Fowler The client should be placed in the Fowler position to facilitate breathing and promote comfort. This position expands the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs. The other positions are not the position of choice postoperatively.
Swallowing is regulated by which area of the central nervous system (CNS)?
Medulla oblongata Swallowing begins as a voluntary act that is regulated by the swallowing center in the medulla oblongata of the CNS. The act of swallowing requires the innervations of five cranial nerves (CNs), especially CN V, VII, IX, X, and XII. Swallowing is not regulated by the pons, cerebellum, or hypothalamus.
The nurse working in the recovery room is caring for a client who had a radical neck dissection. The nurse notices that the client makes a coarse, high-pitched sound upon inspiration. Which intervention by the nurse is appropriate?
Notify the physician The presence of stridor, a coarse, high-pitched sound upon inspiration, in the immediate postoperative period following radical neck dissection, indicates obstruction of the airway, and the nurse must report it immediately to the physician.
The nurse is creating a discharge teaching plan for a client after surgery for oral cancer. Which should be included in the teaching plan? Select all that apply.
Oral hygiene Follow-up dental appointment Follow-up medical appointment Use of humidification Discharge teaching for a client after oral surgery includes oral hygiene, follow-up dental and medical appointments, and the use of humidification to keep secretions moist.
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 pancreas is both an exocrine gland, one that releases secretions into a duct or channel, and an endocrine gland, one that releases substances directly into the bloodstream. The other organs have a variety of functions but do not have a combination function such as the pancreas.
Which of the following is an enzyme secreted by the gastric mucosa?
Pepsin Pepsin is secreted by the gastric mucosa. Trypsin is secreted by the pancreas. The salivary glands secrete ptyalin. The liver and gallbladder secrete bile.
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. After polyethylene glycol/electrolyte solution is administered, the client should have clear liquids because this ensures watery stools, which are necessary for procedures like a barium enema. Allowing the client to ingest a fat-free meal is used in preparation for oral cholecystography. Instructing the client to have low-residue meals is a pretest procedure for barium enema. A client is offered saline gargles after esophagogastroduodenoscopy.
The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. It is most important for the nurse to
Place the client in the Fowler's position. All the options are activities the nurse may do; however, the nurse has to prioritize according to Maslow's hierarchy of needs. Physiological needs are addressed first. Under physiological needs, ABCs (airway, breathing, circulation) take priority. Placing the client in the Fowler's position facilitates breathing and promotes comfort.
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 Helicobacter pylori, a bacterium, is believed to be responsible for the majority of peptic ulcers. Blood tests are used to determine whether there are antibodies to H. pylori in the blood. A complete blood count with differential can indicate bleeding and infection associated with a bleeding ulcer. A sigmoidoscopy assesses the lower gastrointestinal tract. Gastric analysis is more common in analyzing gastric fluid in determining problems with the secretory activity of the gastric mucosa.
The nurse is collecting a stool specimen from a patient. What characteristic of the stool indicates to the nurse that the patient may have an upper GI bleed?
Tarry and black Blood in the stool can present in various ways and must be investigated. If blood is shed in sufficient quantities into the upper GI tract, it produces a tarry-black color (melena).
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. Glucagon may be administered, if needed, to relax the colonic musculature and to reduce spasm during the colonoscopy.
Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?
Weakness, diaphoresis, diarrhea 90 minutes after eating Dumping syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramping, and diarrhea from the rapid emptying of the chyme after eating. Elevated temperature and chills can be a significant finding for infection and should be reported. Constipation with rectal bleeding is not indicative of dumping syndrome.
When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as:
a canker sore of the oral soft tissues. Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. Aphthous stomatitis isn't an acute stomach infection, acid indigestion, or early sign of peptic ulcer disease.
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 duodenum, which is approximately 10 inches long, is the first region of the small intestine and the site where bile and pancreatic enzymes enter.
The most common symptom of esophageal disease is
dysphagia. This symptom may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain upon swallowing. Nausea is the most common symptom of gastrointestinal problems in general. Vomiting is a nonspecific symptom that may have a variety of causes. Odynophagia refers specifically to acute pain upon swallowing.
The major carbohydrate that tissue cells use as fuel is
glucose. Glucose is the major carbohydrate that tissue cells use as fuel. Proteins are a source of energy after they are broken down into amino acids and peptides. Chyme stays in the small intestine for 3 to 6 hours, allowing for continued breakdown and absorption of nutrients. Ingested fats become monoglycerides and fatty acids by the process of emulsification.
When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are
normal. Normal bowel sounds are heard every 5 to 20 seconds. Hypoactive bowel sound is the description given to auscultation of one to two bowel sounds in 2 minutes. Sluggish is not a term a nurse would use to accurately describe bowel sounds. The nurse records that bowel sounds are absent when no sound is heard in 3 to 5 minutes.
A client tells the nurse that the stool was colored yellow. The nurse assesses the client for
recent foods ingested. The nurse should assess for recent foods that the client ingested, as ingestion of senna can cause the stool to turn yellow. Ingestion of bismuth can turn the stool black and, when occult blood is present, the stool can appear to be tarry black.
The nurse is caring for client scheduled to undergo radical neck dissection. During preoperative teaching, the nurse states that an associated complication is
shoulder drop. The nurse should include shoulder drop as an associated complication of radical neck dissection. Another associated complication is poor cosmesis, which is a visible depression in the neck. Clavicle fracture, venous engorgement, and neck distension are not complications associated with radical neck dissection.
Which procedure is performed to examine and visualize the lumen of the small bowel?
small bowel enteroscopy Small bowel enteroscopy is the endoscopic examination and visualization of the lumen of the small bowel. Colonoscopy is the examination of the entire large intestine with a flexible fiberoptic colonoscope. Panendoscopy is the examination of both the upper and lower GI tracts. Peritoneoscopy is the examination of GI structures through an endoscope inserted percutaneously through a small incision in the abdominal wall.
A client has received a diagnosis of oral cancer. During client education, the client expresses dismay at not having recognized any early signs or symptoms of the disease. The nurse tells the client that in early stages of this disease:
there are usually no symptoms. The early stage of oral cancer is characteristically asymptomatic.
The nurse recognizes which change of the gastrointestinal system is an age-related change?
weakened gag reflex A weakened gag reflex is an age-related change of the GI system. There is decreased motility, atrophy of the small intestine, and decreased mucus secretion.
The nurse assesses bowel sounds and hears one to two bowel sounds in 2 minutes. How should the nurse document the bowel sounds?
hypoactive Hypoactive bowel sound is the description given to auscultation of one to two bowel sounds in 2 minutes. Normal bowel sounds are heard every 5 to 20 seconds. Hyperactive bowel sounds occur when five or six sounds are heard in less than 30 seconds. The nurse records that bowel sounds are absent when no sound is heard in 3 to 5 minutes.
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 The nurse stops administering the lavage solution and notifies the physician when the nurse notes that the client has inflammatory bowel disease. Another contraindication for use of lavage solution is intestinal obstruction. Chronic obstructive pulmonary disease (COPD), congestive heart failure, and pulmonary hypertension are not contraindications to administration of lavage solution in preparation for a colonoscopy.
The client describes a test previously completed to detect a small bowel obstruction prior to admission to the hospital. The client states that the test involved insertion of a tube through the nose and lasted over 6 hours. The nurse determines which test name should be documented?
upper GI enteroclysis Enteroclysis is a double contrast study where a duodenal tube is inserted and 500 to 1000 mL of thin barium sulfate suspension and then methylcellulose is infused. Fluoroscopy is used to visualize the filling of the intestinal loops over a period of up to 6 hours. The test is used for detection of small bowel obstruction and diverticuli. Abdominal ultrasound, magnetic resonance imaging, and positron emission tomography do not involve insertion of a duodenal tube.
The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is a(n)
chancre. A chancre is a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis. Lichen planus are white papules at the intersection of a network of interlacing lesions. Actinic cheilitis is an irritation of the lips associated with a scaling, crusting fissure. Leukoplakias are white patches usually found in the buccal mucosa.
The healthcare provider of a client with oral cancer has ordered the placement of a GI tube to provide nutrition and to deliver medications. What would be the preferred route?
nasogastric intubation The nasal route is the preferred route for passing a tube when the client's nose is intact and free from injury.
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 The nurse should place the client on clear liquids the evening before the procedure, a low-residue diet 1 to 2 days before the test, and NPO at midnight in preparation for the barium enema.
For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone?
Lithotripsy Lithotripsy uses shock waves to disintegrate stones. It may be used instead of surgical extraction for parotid stones and smaller submandibular stones. Radiation, chemotherapy, and biopsy do not use shock waves to disintegrate a stone.
Which of the following should the nurse complete prior to assessing the abdomen of a 35-year-old man?
Ask the client to empty his bladder. The physical examination of the gastrointestinal system includes assessment of the mouth, abdomen, and rectum. It requires good light, full exposure of the abdomen, warm hands with short nails, and a relaxed client with an empty bladder. A full bladder will interfere with inspection and may elicit discomfort with palpation and percussion, thereby altering results.
A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. The first activity of the nurse is to:
Assess lung sounds bilaterally. All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment.
The client is postoperative following a graft reconstruction of the neck. It is most important for the nurse to
Assess the graft for color and temperature. The nurse may do all these activities related to the neck wound and dressing. Airway, breathing, circulation (ABCs) take priority. Assessing the graft for color and temperature addresses circulation.
The nurse is to obtain a stool specimen from a client who reported that he is taking iron supplements. The nurse would expect the stool to be which color?
Black Ingestion of iron can cause the stool to turn black. Meat protein causes stool to appear dark brown. Ingestion of large amounts of spinach may turn stool green while ingestion of carrots and beets may cause stool to turn red.
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 Immediately after the test, the patient is monitored for signs and symptoms of bowel perforation (e.g., rectal bleeding, abdominal pain or distention, fever, focal peritoneal signs).
A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. The nurse instructs the client to
Brush and floss daily. The description of erythema, edema, and pain of the mouth following radiation treatment describes stomatitis. Nursing considerations include prophylactic mouth care such as brushing and flossing daily. A soft-bristled toothbrush is recommended. The client is to avoid alcohol-based mouth rinses and hot or spicy foods that may be part of the client's usual diet.
A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?
Encourage plenty of fluids. The nurse should encourage plenty of fluids because adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Because dairy products leave a residue, they aren't allowed the evening before the test. Clear liquids only are allowed the evening before the test.
An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom?
Esophageal tumor Esophageal tumor is most significant and can result in advancing cancer. Esophageal cancer is a serious condition that presents with a symptom of difficulty swallowing as the tumor grows. Hiatal hernia, gastritis, and GERD can lead to serious associated complications but less likely to be as significant as esophageal tumor/cancer.
The nurse is working in a diagnostic testing unit focusing on gastrointestinal studies. For which testing procedure is the nurse correct to assess the gag reflex before offering fluids?
Esophagogastroduodenoscopy The nurse is correct to assess the gag reflex prior to offering fluids for a client having an esophagogastroduodenoscopy (EGD). The other options are lower gastrointestinal studies typically requiring a bowel preparation.
A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate?
Gastroesophageal reflux disease Symptoms may include pyrosis (burning sensation in the esophagus), dyspepsia (indigestion), regurgitation, dysphagia or odynophagia (pain on swallowing), hypersalivation, and esophagitis.
The nurse is assessing a client who is stating gastrointestinal upset and a feeling of bloating. Which type of meal would the nurse anticipate causing these types of symptoms?
Hamburger and French fries Fatty foods delay stomach emptying (bloating) and can cause symptoms of gastrointestinal upset. Fried and deep fried foods contain elevated amounts of fat. The other options have a lower fat content.
A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as
Ineffective airway clearance related to obstruction by mucus All the nursing diagnoses are appropriate for a client who has a radical neck dissection. According to Maslow's hierarchy of needs, physiological needs take priority. Under physiological needs, airway, breathing, circulation (ABCs) take highest priority. Thus, ineffective airway clearance is the highest priority nursing diagnosis.
he 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 Bowel sounds are assessed using the diaphragm of the stethoscope for high-pitched and gurgling sounds (Gu, Lim, & Moser, 2010). The frequency and character of the sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation, but these assessments are highly subjective (Li, Wang, & Ma, 2012).
Gastrin has which of the following effects on gastrointestinal (GI) motility?
Increased motility of the stomach Gastrin has the following effects on GI motility: increased motility of the stomach, excitation of the colon, relaxation of ileocecal sphincter, and contraction of the gastroesophageal sphincter.
Which of the following is one of the first clinical manifestations of esophageal cancer
Increasing difficulty in swallowing The patient first becomes aware of intermittent and increasing difficulty in swallowing. As the tumor grows and the obstruction becomes nearly complete, even liquids cannot pass into the stomach. Other clinical manifestations may include sensation of a mass in the throat, foul breath, and hiccups.
Which of the following is one of the first clinical manifestations of esophageal cancer?
Increasing difficulty in swallowing The patient first becomes aware of intermittent and increasing difficulty in swallowing. As the tumor grows and the obstruction becomes nearly complete, even liquids cannot pass into the stomach. Other clinical manifestations may include sensation of a mass in the throat, foul breath, and hiccups.
When examining the abdomen of a client with complaints of nausea and vomiting, which of the following would the nurse do first?
Inspection When assessing the abdomen, the nurse would first inspect or observe the abdomen. This would be followed by auscultation, percussion, and lastly, palpation.
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 The nurse is correct to assess the abdomen in a specific order to be able to judge the undisturbed status of the abdominal region. Begin with inspection of the abdomen using the nurse's assessment skills. Next, auscultate the abdomen before percussing and finally palpating.
A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. The best nursing intervention is to
Instruct the client to swish prescribed nystatin (Mycostatin) solution for 1 minute. A cheesy white plaque in the mouth that looks like milk curds and can be rubbed off is candidiasis. The most effective treatment is anitfungal medication such as nystatin (Mycostatin). When used as a suspension, the client is to swish vigorously for at least 1 minute and then swallow. Other measures such as providing saline rinses or ingesting a soft or bland diet are comfort measures. The nurse does not remove the plaques; doing so will cause erythema and potential bleeding.
The nurse is caring for a client receiving chemotherapy. For which mouth conditions associated with HIV infection should the nurse assess? Select all that apply.
Kaposi sarcoma Stomatitis Kaposi sarcoma appears first on the oral mucosa as a red, purple, or blue lesion that is associated with HIV infection. Stomatitis is associated with chemotherapy and radiation therapy, as well as HIV infection. Krythoplakia is caused by a nonspecific inflammation, and candidiasis is caused by fungus.
After 20 seconds of auscultating for bowel sounds on a client recovering from abdominal surgery, the nurse hears nothing. Which of the following should the nurse do based on the assessment findings?
Listen longer for the sounds. Auscultation is used to determine the character, location, and frequency of bowel sounds. The frequency and character of sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minutes. Normal sounds are heard about every 5 to 20 seconds, whereas hypoactive sounds can be one or two sounds in 2 minutes. Postoperatively, it is common for sounds to be reduced; therefore, the nurse needs to listen at least 3 to 5 minutes to verify absent or no bowel sounds.
While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure?
Liver The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in the left upper quadrant.
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. Monitoring stool passage and its color will ensure that the client remains barium free following a barium swallow test. The white or clay color of the stool would indicate barium retention. The stool should be placed in a special preservative if the client undergoes a stool analysis. Observing the color and volume of urine will not ensure that the client is barium free because barium is not eliminated through urine but through stool.
What part of the GI tract begins the digestion of food?
Mouth Food that contains starch undergoes partial digestion in the mouth when it mixes with the enzyme salivary amylase, which the salivary glands secrete. Food that contains starch undergoes partial digestion in the mouth.
A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an):
Protrusion of the upper stomach into the lower portion of the thorax. It is important for the patient and his family to understand the altered association between the esophagus and the stomach. The diaphragm opening, through which the esophagus passes, becomes enlarged and part of the upper stomach moves up into the lower portion of the thorax. The abnormality is not an involuntary, protruding, or twisted segment.
A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which of the following strategies can the nurse employ to assist this client?
Provide the client with an irrigating solution of baking soda and warm water. If a client cannot tolerate brushing or flossing, an irrigating solution of 1 tsp of baking soda to 8 oz of warm water, half strength hydrogen peroxide, or normal saline solution is recommended.
A group of students are studying for an examination on the gastrointestinal (GI) system and are reviewing the structures of the esophagus and stomach. The students demonstrate understanding of the material when they identify which of the following as the opening between the stomach and duodenum?
Pyloric sphincter The pyloric sphincter is the opening between the stomach and duodenum. The cardiac sphincter is the opening between the esophagus and the stomach. The hypopharyngeal sphincter or upper esophageal sphincter prevents food or fluids from re-entering the pharynx. The ileocecal valve is located at the distal end of the small intestine and regulates flow of intestinal contents into the large intestine.
The nurse determines a client scheduled to undergo an abdominal ultrasonography should receive which instruction?
Restrict eating of solid food for 6 to 8 hours before the test. A client scheduled to undergo an abdominal ultrasonography should restrict eating of all solid food for 6 to 8 hours to avoid having images of the test obscured with gas and intestinal contents. Ultrasonography records the reflection of sound waves. Strenuous exercises, the consumption of sweets, and exposure to sunlight do not affect the results of the test in any way.
Which term is used to describe stone formation in a salivary gland, usually the submandibular gland?
Sialolithiasis Salivary stones are formed mainly from calcium phosphate. Parotitis refers to inflammation of the parotid gland. Sialadenitis refers to inflammation of the salivary glands. Stomatitis refers to inflammation of the oral mucosa.
An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis?
Staphylococcus aureus People who are older, acutely ill, or debilitated with decreased salivary flow from general dehydration or medications are at high risk for parotitis. The infecting organisms travel from the mouth through the salivary duct. The organism is usually Staphylococcus aureus (except in mumps).
An elderly patient is diagnosed with parotitis. The nurse is aware that this bacterial infection is most likely caused by:
Staphylococcus aureus. The elderly and debilitated experience decreased salivary flow from general dehydration or medications. The bacterial infection is usually caused by Staphylococcus aureus. The infecting organism travels from the mouth through the salivary gland.
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 upper gastrointestinal (GI) tract begins at the mouth and ends at the jejunum. Therefore, the stomach would be a component of the upper GI tract. The lower GI tract begins at the ileum and ends at the anus. The liver is considered an accessory structure.
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 When examining the abdomen, the client lies supine with his knees flexed. This position assists in relaxing the abdominal muscles. The lithotomy position commonly is used for a female pelvic examination and to examine the rectum. The knee-chest position can be used for a variety of examinations, most commonly the anus and rectum. The left Sim's lateral position may be used to assess the rectum or vagina and to administer an enema.
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 If the blood is shed in sufficient quantities into the upper GI tract, it produces a tarry-black color, whereas blood entering the lower portion of the GI tract or passing rapidly though will cause the stool to appear bright or dark red. Lower rectal or anal bleeding is suspected if there is streaking of the blood on the surface of the stool or if blood is noted on toilet tissue. Stool is normally light or dark brown.
A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge?
The client is free from esophagitis and achalasia. Dysphagia may be the reason why a client with esophagitis or achalasia seeks treatment. Therefore, when the client is free of esophagitis or achalasia, he is ready for discharge. Dysphagia isn't associated with rectal tenesmus, duodenal inflammation, or abnormal gastric structures.
A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?
The client lying in a lateral position, with the head of bed flat A client who has had neck surgery is at risk for neck swelling. To prevent respiratory complications, the head of the bed should be at least at a 30-degree angle. This position gives the lungs room to expand and decreases swelling by promoting venous and lymphatic drainage. This position also minimizes the risk of aspiration. Serosanguineous drainage on the dressing, a Foley bag containing amber urine, and levofloxacin infusing aren't causes for concern.
What is the recommended order for performing an abdominal examination?
inspection, auscultation, percussion, palpation Examination should take an ordered and logical sequence to ensure that everything is done, and that each step is guided by the last. These steps follow simply through inspection, auscultation, percussion, and finally palpation. Abdominal auscultation is done before palpation, because palpation disrupts normal bowel sounds.
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
maintaining a patent airway. Rapid growth of cancer cells in the esophagus may put pressure on the adjacent trachea, jeopardizing the airway. Therefore, maintaining a patent airway is the highest care priority for a client with esophageal cancer. Helping the client cope with body image changes, ensuring adequate nutrition, and preventing injury are appropriate for a client with this disease, but are less crucial than maintaining airway patency.