Chapter 46: Gastrointestinal Dysfunction (QUESTIONS)

What is the earliest clinical manifestation of biliary atresia? a. Jaundice b. Vomiting c. Hepatomegaly d. Absence of stooling

ANS: A Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in the sclera, may be present at birth, but is usually not apparent until ages 2 to 3 weeks. Vomiting is not associated with biliary atresia. Hepatomegaly and abdominal distention are common, but usually occur later. Stools are large and lighter in colour than normal because of the lack of bile.

When a child has which symptom would the nurse be alert for increased fluid requirements? a. Fever b. Mechanical ventilation c. Heart failure d. Increased intracranial pressure (ICP)

ANS: A Fever may cause dehydration to develop quickly. The respiratory rate influences insensible fluid loss and should be monitored in a mechanically ventilated child. Heart failure is a case of fluid overload in children. ICP does not lead to increased fluid requirements in children.

A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. What is the first step in therapeutic management for this child? a. Intravenous fluids b. Oral rehydration solution (ORS) c. Clear liquids, 1 to 2 ounces at a time d. Administration of antidiarrheal medication

ANS: A Intravenous fluids are initiated in children with severe dehydration. ORS is an acceptable therapy if the dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth because they have a high carbohydrate content, low electrolyte content, and high osmolality. Antidiarrheal medications are not recommended for the treatment of acute, infectious diarrhea.

The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. What is the most appropriate nursing action? a. Notify the health provider. b. Measure abdominal girth. c. Auscultate for bowel sounds. d. Take vital signs, including blood pressure.

ANS: A Passage of a normal brown stool indicates that the intussusception has reduced itself. This should immediately be reported to the practitioner, who may choose to alter the diagnostic/therapeutic plan of care.

Which high-fibre food can the nurse recommend for a 10-year-old child with chronic constipation? a. Popcorn b. Pancakes c. Muffins d. Ripe bananas

ANS: A Popcorn is a high-fibre food. Pancakes and muffins do not have significant fibre unless made with fruit or bran. Raw fruits, especially those with skins and seeds (other than ripe bananas and avocado), are high in fibre.

What is the most important nursing consideration when caring for a child with celiac disease? a. Refer to a nutritionist for detailed dietary instructions and education. b. Help the child and family understand that diet restrictions are usually only temporary. c. Teach proper hand hygiene and standard precautions/routine practices to prevent disease transmission. d. Suggest ways to cope more effectively with stress to minimize symptoms.

ANS: A The main consideration is helping the child adhere to dietary management. Considerable time should be spent explaining to the child and parents the disease process, the specific role of gluten in aggravating the condition, and those foods that must be restricted. Referral to a nutritionist would help in this process. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not transmissible or stress related.

What is the best chance of survival for a child with cirrhosis? a. Liver transplantation b. Treatment with corticosteroids c. Treatment with immune globulin d. Provision of nutritional support

ANS: A The only successful treatment for end-stage liver disease and liver failure is currently liver transplantation, which has improved the prognosis for many children with cirrhosis. It has revolutionized the approach to cirrhosis. Liver transplantation reflects the failure of other medical and surgical measures to treat cirrhosis.

What should the nurse do when caring for a newborn with a suspected tracheoesophageal fistula? a. Elevate the head but give nothing by mouth. b. Elevate the head for feedings. c. Feed glucose water only. d. Avoid suctioning unless the infant is cyanotic.

ANS: A When a newborn is suspected of having tracheoesophageal fistula, the most desirable position is supine, with the head elevated on an incline plane, 30 to 45 degrees. It is imperative that any source of aspiration be removed immediately. Oral feedings should not be given to infants suspected of having tracheoesophageal fistulas. The oral pharynx should be kept clear of secretions with suctioning, in order to avoid the cyanosis that is usually the result of laryngospasm caused by the overflow of saliva into the larynx.

What is often the cause of acute diarrhea? a. Irritable bowel syndrome b. Antibiotic therapy c. Hypothyroidism d. Hirschsprung's disease

ANS: B Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy, upper respiratory or urinary infections, or laxative use. Hirschsprung's disease and hypothyroidism are usually manifested with constipation rather than diarrhea. Irritable bowel disease is the cause of chronic diarrhea rather than acute diarrhea.

A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician has explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. What should the nurse's initial therapeutic approach be to the mother? a. Restate what the physician has told her about plastic surgery. b. Encourage her to express her feelings. c. Emphasize the normalcy of her baby and the baby's need for mothering. d. Recognize that negative feelings toward the child continue throughout childhood.

ANS: B For parents, cleft lip and cleft palate deformities can be upsetting. The nurse must place emphasis not only on the infant's physical needs but also on the parents' emotional needs. The mother needs to be able to express her feelings before she can accept her child. Although plastic surgery will need to be discussed, it is not part of the initial therapeutic approach. As the mother expresses her feelings, the nurse's actions should convey to the parents that the infant is a precious human being. The child's normalcy should be emphasized and the mother assisted to recognize the child's uniqueness. A focus on abnormal maternal-infant attachment would be inappropriate at this time.

A 4-month-old infant has gastroesophageal reflux (GER) but is thriving without other complications. What should the nurse suggest to minimize reflux? a. Place the child in Trendelenburg position after eating. b. Thicken formula with rice cereal. c. Give continuous nasogastric tube feedings. d. Give larger, less frequent feedings.

ANS: B Small, frequent feedings of formula combined with 5 to 15 mL of rice cereal per 30 mL of formula has been recommended. Milk thickening agents have been shown to decrease the number of episodes of vomiting and increase the caloric density of the formula. This may benefit infants who are underweight as a result of GER. Placing the child in a Trendelenburg position increases the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive.

An infant is brought to the emergency department with poor skin turgor, weight loss, lethargy, and tachycardia. What are these signs suggestive of? a. Overhydration b. Dehydration c. Sodium excess d. Potassium excess

ANS: B These clinical manifestations indicate dehydration. Symptoms of overhydration are edema and weight gain. Regardless of extracellular sodium levels, total body sodium is usually depleted in dehydration. Symptoms of hypocalcemia are a result of neuromuscular irritability and manifest as jitteriness, tetany, tremors, and muscle twitching. These symptoms do not indicate hyperkalemia.

When providing patient education to parents of a child who has just been diagnosed with Crohn's disease, which clinical manifestations will the nurse include in the discussion? Select all that apply. Express answer in small letters followed by a comma and a space—e.g., a, b, c. a. Rectal bleeding is common. b. Diarrhea is usually moderate to severe. c. Pain is usually not a symptom. d. Anal and perianal lesions are common. e. Fistulas and strictures are rare. f. Growth delay may be severe.

ANS: B, D, F Clinical manifestations of Crohn's disease include diarrhea that is moderate to severe and pain; anal and perianal lesions are common, as well as fistulas and strictures, and growth delay may be severe. Rectal bleeding is uncommon in Crohn's disease but is common with ulcerative colitis.

Which statement best describes Meckel's diverticulum? a. It is more common in females than in males. b. It is acquired during childhood. c. Intestinal bleeding may be mild or profuse. d. Medical interventions are usually sufficient to treat the problem.

ANS: C Blood in stools is often a presenting sign of Meckel's diverticulum, because it is associated with mild-to-profuse intestinal bleeding. It is twice as common in males as in females, and complications are more frequent in males. Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract and is present in 1 to 4% of the general population. The standard therapy is surgical removal of the diverticulum.

Constipation has recently become a problem for a school-age girl. She is healthy except for seasonal allergies, which are now being successfully treated with antihistamines. What is the most likely cause of her constipation? a. Diet b. Allergies c. Antihistamines d. Emotional factors

ANS: C Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids, antiepileptics, and iron. Because this is the only known recent change in her habits, the addition of antihistamines is most likely the etiology of the diarrhea. With a change in bowel habits, the presence and role of any recently prescribed medications should be assessed.

What is used to treat moderate to severe ulcerative colitis? a. Antacids b. Antibiotics c. Corticosteroids d. Antidiarrheal medications

ANS: C Corticosteroids such as prednisone and prednisolone are used to treat severe ulcerative colitis in children. Antacids and antidiarrheals are not drugs of choice to treat this disease. Antibiotics may be used as adjunctive therapy to treat complications.

Which statement best describes hepatitis A? a. The incubation period is 6 weeks to 6 months. b. The principal mode of transmission is through the parenteral route. c. The onset is usually rapid and acute. d. There is a persistent carrier state.

ANS: C Hepatitis A is the most common form of acute hepatitis in most parts of the world. It is characterized by a rapid, acute onset. The incubation period is approximately 3 weeks, and the principal mode of transmission is the fecal-oral route. Hepatitis A does not have a carrier state.

Which statement is true about hepatitis B? a. Hepatitis B cannot exist in a carrier state. b. Immunity to hepatitis B does not occur after one attack. c. Hepatitis B can be transferred to an infant from a breastfeeding mother. d. The principal mode of transmission for hepatitis B is the fecal-oral route.

ANS: C Hepatitis B can be transferred to an infant from a breastfeeding mother, especially if the mother's nipples are cracked. The onset of hepatitis B is insidious. Immunity develops after one exposure to hepatitis B. Hepatitis B is not transferred by the fecal-oral route.

Which is a parasite that causes acute diarrhea? a. Shigella organisms b. Salmonella organisms c. Giardia lamblia d. Escherichia coli

ANS: C In Canada, the incidence of intestinal parasitic disease, especially giardiasis, has increased among young children and causes acute diarrhea. Shigella, Salmonella, and E. coli are bacterial pathogens, not parasites.

What is the first treatment a nurse provides in the therapeutic management of a child with acute diarrhea and dehydration? a. Clear liquids b. Adsorbents such as kaolin and pectin c. Oral rehydration solution (ORS) d. Antidiarrheal medications such as paregoric

ANS: C ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they contain too much sugar, which may contribute to the diarrhea. Adsorbents are not recommended and neither are antidiarrheal medications because they do not get rid of pathogens.

What is the viral pathogen that frequently causes acute diarrhea in young children? a. Giardia organisms b. Shigella organisms c. Rotavirus d. Salmonella organisms

ANS: C Rotavirus is the most common viral pathogen that causes diarrhea in young children. Giardia and Salmonella are bacterial pathogens that also cause diarrhea. Shigella is a bacterial pathogen that is uncommon in Canada.

When caring for a child with probable appendicitis, which should the nurse watch for as a sign of perforation? a. Bradycardia b. Anorexia c. Sudden relief from pain d. Decreased abdominal distension

ANS: C Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical manifestation of appendicitis. Abdominal distension usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen).

A 3-year-old child with Hirschsprung's disease is hospitalized for surgery. A temporary colostomy will be necessary. What should the nurse recognize about preparing this child psychologically for surgery? a. It is not necessary because of child's age. b. It is not necessary because the colostomy is temporary. c. It is necessary because it will require the child's adjustment. d. It is necessary because the child must deal with a negative body image.

ANS: C The child's age dictates the type and extent of psychological preparation. Before a colostomy is performed, a child who is at least preschool age must be told about the procedure and what to expect in concrete terms with the use of visual aids. It is necessary to prepare a child this age for procedures. The preschooler is not yet concerned with body image.

A histamine-receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is ordered for an infant with gastroesophageal reflux disease. What is the purpose of this drug? a. It prevents reflux. b. It prevents hematemesis. c. It reduces gastric acid production. d. It increases gastric acid production.

ANS: C The mechanism of action of histamine-receptor antagonists is to reduce the amount of acid present in gastric contents and may prevent esophagitis. Preventing reflux and hematemesis and increasing gastric acid production are not the modes of action for histamine-receptor antagonists.

The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation indicates this condition? a. Abdominal rigidity and pain on palpation b. Rounded abdomen and hypoactive bowel sounds c. Visible peristalsis and weight loss d. Distension of lower abdomen and constipation

ANS: C Visible gastric peristaltic waves that move from left to right across the epigastrium are observed in pyloric stenosis. Abdominal rigidity and pain on palpation, and rounded abdomen and hypoactive bowel sounds are usually not present. The upper abdomen is distended, not the lower abdomen.

What type of hernia has an impaired blood supply to the herniated organ? a. Hiatal hernia b. Incarcerated hernia c. Omphalocele d. Strangulated hernia

ANS: D A strangulated hernia is one in which the blood supply to the herniated organ is impaired. A hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the esophageal hiatus. An incarcerated hernia is a hernia that cannot be reduced easily. Omphalocele is the protrusion of intra-abdominal viscera into the base of the umbilical cord. The sac is covered with peritoneum and not skin.

A school-age child with diarrhea has been rehydrated. The nurse is discussing the child's diet with the family. Which statement by the parent would indicate a correct understanding of the teaching? a. "I will keep my child on a clear liquid diet for the next 24 hours." b. "I should encourage my child to drink carbonated drinks but avoid food for the next 24 hours." c. "I will offer my child bananas, rice, applesauce, and toast for the next 48 hours." d. "I should have my child eat a normal diet with easily digested foods for the next 48 hours."

ANS: D Easily digested foods such as cereals, cooked vegetables, and meats should be provided to the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a regular diet has no adverse effects and actually lessens the severity and duration of the illness. Clear liquids and carbonated drinks have high carbohydrate contents and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic. A diet of bananas, applesauce, and toast is contraindicated because it has little nutritional value (low in energy and protein), is high in carbohydrates, and is low in electrolytes.

What type of dehydration results from water loss in excess of electrolyte loss? a. Isotonic dehydration b. Isosmotic dehydration c. Hypotonic dehydration d. Hypertonic dehydration

ANS: D Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration, caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs when electrolyte and water deficits are balanced in proportion. Isosmotic dehydration is another term for isotonic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic.

What is the primary therapeutic management for most children with Hirschsprung's disease? a. Daily enemas b. Low-fibre diet c. Permanent colostomy d. Surgical removal of affected section of bowel

ANS: D Most children with Hirschsprung's disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter. Preoperative management may include enemas and a low-fibre, high-calorie, high-protein diet until the child is physically ready for surgery. The colostomy that is created in Hirschsprung's disease is usually temporary.

A stool specimen from a child with diarrhea shows the presence of neutrophils and red blood cells. These results are most suggestive of what condition? a. Protein intolerance b. Parasitic infection c. Fat malabsorption d. Bacterial gastroenteritis

ANS: D Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance is suspected in the presence of eosinophils, as is parasitic infection. Fat malabsorption is indicated by foul-smelling, greasy, bulky stools.

Which clinical manifestation indicates acute appendicitis? a. Rebound tenderness b. Bright red or dark red rectal bleeding c. Abdominal pain that is relieved by eating d. Abdominal pain that is most intense at the McBurney point

ANS: D Pain is the cardinal feature. It is initially generalized and usually periumbilical. The pain localizes to the right lower quadrant at the McBurney point. Rebound tenderness is not a reliable sign and is extremely painful to the child. Abdominal pain that is relieved by eating and bright or dark red rectal bleeding are not signs of acute appendicitis.

Which should be included when caring for the newborn with a cleft lip and palate before surgical repair? a. Gastrostomy feedings b. Keeping the infant in near-horizontal position during feedings c. Allowing little or no sucking d. Providing satisfaction for the infant's sucking needs

ANS: D Using special or modified nipples for feeding techniques helps to meet the infant's sucking needs. Gastrostomy feedings are usually not indicated. Feeding is best accomplished with the infant's head in an upright position. The child requires both nutritive and non-nutritive sucking.

An infant with short bowel syndrome will be discharged home on total parenteral nutrition (TPN) and gastrostomy feedings. What should nursing care include? a. Prepare the family for impending death. b. Teach the family to watch for signs of central venous catheter infection. c. Teach the family how to calculate caloric needs. d. Secure TPN and gastrostomy tubing under the diaper, to lessen risk of dislodgment.

ANS: B During TPN therapy, care must be taken to minimize the risk of complications related to the central venous access device such as catheter infections, occlusions, or accidental removal. This is an important part of family teaching. The prognosis for patients with short bowel syndrome depends in part on the length of residual small intestine, and it has improved with advances in TPN. Although parents need to be taught about nutritional needs, the caloric needs, prescribed TPN, and rate are the responsibility of the health care team. The tubes should not be placed under the diapers because of risk of infection.

The nurse is explaining to a parent how to care for a child with vomiting associated with a viral illness. What should the nurse include in her discussion? a. Avoid carbohydrate-containing liquids. b. Give nothing by mouth for 24 hours. c. Brush teeth or rinse mouth after vomiting. d. Give plain water until vomiting ceases for at least 24 hours.

ANS: C It is important to emphasize that the child needs to brush his teeth or rinse his mouth after vomiting to dilute the hydrochloric acid that comes in contact with the teeth. Administration of a glucose-electrolyte solution to an alert child will help restore water and electrolytes satisfactorily. It is important to include carbohydrates to spare body protein and avoid ketosis.

What disorder is characterized by a chronic inflammatory process that may involve any part of the gastrointestinal (GI) tract from mouth to anus? a. Crohn's disease b. Ulcerative colitis c. Meckel's diverticulum d. Irritable bowel syndrome

ANS: A The chronic inflammatory process of Crohn's disease involves any part of the GI tract from the mouth to the anus, but most often affects the terminal ileum. Ulcerative colitis, Meckel's diverticulum, and irritable bowel syndrome do not affect the entire GI tract.

Bismuth subsalicylate, clarithromycin, and metronidazole are prescribed for a child with a peptic ulcer for which reason? a. It eradicates Helicobacter pylori. b. It coats gastric mucosa. c. It treats epigastric pain. d. It reduces gastric acid production.

ANS: A This combination drug therapy is effective for the treatment and eradication of H. pylori.