Honan-Chapter 21: Nursing Assessment: Digestive, Gastrointestinal, and Metabolic Function
The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following? "It is not going to happen. Your nerve cells are too damaged." "Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact." "Over time, the nerve fibers will regrow new tracts, and you can have bowel movements again." "Wearing an undergarment will become more comfortable over time."
"Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact." Explanation: The act of defecation is a spinal reflex involving the parasympathetic nerve fibers. Normally, the external anal sphincter is maintained in a state of tonic contraction. With a spinal cord injury, the client no longer has this nervous system control and is often incontinent.
A home care nurse is caring for a client with reports 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." "I'll drink full liquids the day before the test." "There is no need for special preparation before the test." "I'll take a laxative to clear my bowels before the test."
"I'll avoid eating or drinking anything 6 to 8 hours before the test." Explanation: The client demonstrates understanding of a barium swallow when stating he or she 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.
The nurse is instructing the client on frequent sensations experienced when a contrast agent is injected into the body during diagnostic studies. Which sensation is most common? Light-headedness A warm sensation Heart palpitations Chills
A warm sensation Explanation: The nurse informs the client that he or she may experience a warm sensation and nausea when the contrast agent is instilled. The client is instructed to take a couple of deep breaths, and, many times, the sensation will go away. The other options are not frequently encountered.
Which of the following foods could give a false-positive result on the fecal occult blood test (FOBT)? Select all that apply. A. Red meats B. Pasta C. Turnips D. Fish E. Whole-grain bread
A. Red meats C. Turnips D. Fish RATIONALE Fish, red meats, and turnips can produce false-positive results if consumed prior to the collection of stool for fecal occult blood testing (FOBT). Pasta and whole grain bread do not affect the results of the FOBT.
Which of the following is the primary function of the small intestine? Absorption Digestion Peristalsis Secretion
Absorption Explanation: 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 Lipase Trypsin Bile
Amylase Explanation: 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 56-year-old presented to her nurse practitioner because she had been experiencing unprecedented constipation and the passage of pencil-like stools despite her high fluid and fiber intake. The nurse recognized the need to assess the patient for colorectal cancer and ordered diagnostic evaluations. What component of the patient's blood work would be most indicative of the presence of cancer? C-reactive protein (CRP) Carcinoembryonic antigen (CEA) Ceruloplasmin Coproporphyrin
Carcinoembryonic antigen (CEA) Explanation: CEA is a protein that is normally not detected in the blood of a healthy person; therefore, when detected it indicates that cancer is present. The other cited blood analyses are not associated with cancer.
A client is scheduled for several diagnostic tests to evaluate gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when the client identifies which test as not requiring the use of a contrast medium? Small bowel series Computer tomography Colonoscopy Upper GI series
Colonoscopy Explanation: 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 assessment finding does the nurse expect as a normal consequence of aging? A. Increased salivation and drooling B. Hyperactive bowel sounds and loose stools C. Increased gastric production and heartburn D. Decreased sensation to defecate and constipation
D. Decreased sensation to defecate and constipation RATIONALE Older adults may lose the sensation to defecate, resulting in constipation. Salivation decreases with aging, along with peristalsis and gastric acid production.
When performing an abdominal assessment on a patient with suspected cholecystitis, how does the nurse palpate the patient's abdomen? A. Palpate the right lower quadrant only B. Palpate the upper quadrants only C. Defer palpation and use percussion only D. Palpate the right upper quadrant last
D. Palpate the right upper quadrant last RATIONALE The patient with cholecystitis will report pain in the right upper quadrant of the abdomen. Tender or painful areas should be palpated last to prevent the patient from tensing his or her abdominal muscles because of pain, thereby making the examination more difficult. Palpation is an important assessment tool that should not be deferred for this patient.
Gastrin has which of the following effects on gastrointestinal (GI) motility? Increased motility of the stomach Relaxation of the colon Contraction of the ileocecal sphincter Relaxation of gastroesophageal sphincter
Increased motility of the stomach Explanation: 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.
When examining the abdomen of a client with reports of nausea and vomiting, what would the nurse do first? Palpation Inspection Auscultation Percussion
Inspection Explanation: When assessing the abdomen, the nurse would first inspect or observe the abdomen. This would be followed by auscultation, percussion, and lastly, palpation.
A nurse is giving a client barium swallow test. What is the most important assessment a nurse would make to ensure that a client does not retain any barium after a barium swallow? Placing any stool passed in a specific preservative. Monitoring the stool passage and its color. Observing the color of urine. Monitoring the volume of urine.
Monitoring the stool passage and its color. Explanation: 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
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? A complete blood count including differential Serum antibodies for H. pylori A sigmoidoscopy Gastric analysis
Serum antibodies for H. pylori Explanation: 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.
An individual has had a snack consisting of half a bagel with cream cheese, lox (smoked salmon), red onions, and capers. Stimulation of the person's gastrointestinal tract has resulted in the secretion of numerous digestive enzymes into the small intestine, including trypsin. What component of this person's snack will be primarily digested by the action of trypsin? The bagel The lox The cream cheese The red onions and capers
The lox Explanation: Trypsin aids in digesting protein, such as fish. Amylase aids in digesting starch, such as the carbohydrates in a bagel. Lipase aids in digesting fats, such as those found in many dairy products.
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 jejunum ileum cecum
duodenum Explanation: 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 major carbohydrate that tissue cells use as fuel is chyme. proteins. glucose. fats
glucose. Explanation: 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. hypoactive. sluggish. absent.
normal. Explanation: 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 nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. What is the nurse's best response? stomach small intestine large intestine rectum
small intestine Explanation: The small intestine absorbs products of digestion, completes food digestion, and secretes hormones that help control the secretion of bile, pancreatic juice, and intestinal secretions. The stomach stores, mixes, and liquefies the food bolus into chyme and controls food passage into the duodenum; it doesn't absorb products of digestion. Although the large intestine completes the absorption of water, chloride, and sodium, it plays no part in absorbing food. The rectum is the portion of the large intestine that forms and expels feces from the body; its functions don't include absorption.
The nurse is assisting the physician in a percutaneous liver biopsy. In assisting with positioning, the nurse should assist the client into a: high Fowler's position. lithotomy position. dorsal recumbent position. supine position.
supine position. Explanation: The nurse is correct to instruct the client to assume the supine position. Also, the nurse places a rolled towel beneath the right lower ribs.
The nurse recognizes which change of the gastrointestinal system is an age-related change? increased motility hypertrophy of the small intestine weakened gag reflex increased mucus secretion
weakened gag reflex Explanation: 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.
A nurse practitioner examined a patient who had been diagnosed with hepatomegaly (enlarged liver) due to accumulated fat deposits in the liver, subsequent to obesity. The nurse would palpate the liver by placing: One hand under the left lower rib cage and pressing upward toward the midline. Both hands over the left lower quadrant and applying gentle pressure. The left hand at the level of the umbilicus and the right hand at the base of the diaphragm. One hand under the right lower rib cage and press downward with the other hand.
One hand under the right lower rib cage and press downward with the other hand. Explanation: Refer to Figure 21-8 in the text for an illustration of this procedure. The liver is located under the diaphragm on the right side of the abdominal cavity, extending slightly left from the midline.
Which of the following is an enzyme secreted by the gastric mucosa? Pepsin Trypsin Ptyalin Bile
Pepsin Explanation: 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? Instruct the client to have low-residue meals. Allow the client to ingest fat-free meal. Permit the client to drink only clear liquids. Provide saline gargles to the client.
Permit the client to drink only clear liquids. Explanation: 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.
Which of the following is considered the gold standard for the diagnosis of liver disease? Biopsy Paracentesis Cholecystography Ultrasonography
Biopsy Explanation: 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 recognizes that most nutrients and electrolytes are absorbed by which organ? A. Esophagus B. Stomach C. Colon D. Small intestine
D. Small intestine RATIONALE The small intestine absorbs most of the nutrients and electrolytes. The colon absorbs water, sodium, and chloride from the digested food that has passed from the small intestine. The esophagus moves food from the mouth to the stomach, which stores food during eating and secretes digestive fluids.
After 20 seconds of auscultating for bowel sounds on a client recovering from abdominal surgery, the nurse hears nothing. What should the nurse do based on the assessment findings? Listen longer for the sounds. Document that the client is constipated. Call the health care provider to report absent bowel sounds. Return in 1 hour and listen again to confirm findings.
Listen longer for the sounds. Explanation: 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.
The nurse is caring for a geriatric client and notices polypharmacy. Which diagnostic studies are anticipated? Complete blood count Urinalysis Liver function studies Blood chemistry
Liver function studies Explanation: The liver metabolizes and biotransforms the medications ingested. Geriatric clients who experience polypharmacy or multiple medications have an elevated risk of liver impairment. Routine liver function studies monitor the status of the liver and its ability to metabolize.
Following ingestion of carrots or beets, the nurse would expect which alteration in stool color? Red Black Yellow Milky white
Red Explanation: Carrots or beets will tend to change the stool color to red. Black stools are associated with iron, licorice, and charcoal. Senna is associated with yellow stools. A milky white stool is associated with administration of barium.
The nurse is providing care for a patient whose cancer has metastasized to her small intestine. What does the small intestine do? Select all that apply. Creation of human waste products Reabsorption of water to maintain blood pressure Secretion Absorption Movement of nutrients into the blood stream.
Secretion Absorption Movement of nutrients into the blood stream. Explanation: The small intestine is the longest segment of the gastrointestinal tract, accounting for about two-thirds of the total length. It folds back and forth on itself, providing approximately 7000 cm2 (70 m2) of surface area for secretion and absorption, the process by which nutrients enter the bloodstream through the intestinal walls. The colon makes the stool that is human waste. The small intestine does not reabsorb water to maintain blood pressure; this is a function of the kidneys.
A client receives a local anesthetic to suppress the gag reflex for a diagnostic procedure of the upper GI tract. Which nursing intervention is advised for this patient? The client should not be given any food and fluids until the gag reflex returns. The client should be monitored for any breathing-related disorder or discomforts. The client's fluid output should be measured for at least 24 hours after the procedure. The client should be monitored for cramping or abdominal distention.
The client should not be given any food and fluids until the gag reflex returns. Explanation: For a client receiving a local anesthetic that suppresses the gag reflex, the nurse is advised to withhold food and fluids until the reflex returns.
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? Both tests need to be done before breakfast. The ultrasonography should be scheduled before the GI procedure. The upper GI should be scheduled before the ultrasonography. The client may eat a light meal before either test.
The ultrasonography should be scheduled before the GI procedure. Explanation: 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.
A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers: "It tells the physician what type of cancer is present." "It indicates if a cancer is present." "It determines functionality of the liver." "It detects a protein normally found in the blood."
"It indicates if a cancer is present." Explanation: 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.
A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The health care provider has ordered a visualization of the small intestine via a capsule endoscopy. What will the nurse include in the client education about this procedure? "A capsule will be inserted into your rectum." "You will need to swallow a capsule." "The health care provider will use a scope called a capsule to view your intestine." "An x-ray machine will use a capsule ray to follow your intestinal tract."
"You will need to swallow a capsule." Explanation: 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.
Which question will best assist the nurse in the assessment of a patient with acute diarrhea? A. "Have you had a colonoscopy in the last 3 months?" B. "Have you traveled outside the country recently?" C. "Do you have any trouble swallowing?" D. "Do you have any allergies?"
B. "Have you traveled outside the country recently?" RATIONALE A history of recent travel may help pinpoint an infectious source for the patient's diarrhea. A colonoscopy will not cause acute diarrhea. Trouble swallowing is not related to diarrhea. Allergic reactions do not typically cause acute diarrhea.
The nurse cares for a client after a gastroscopy for which the client received sedation. The nurse should report which finding to the physician? loss of gag reflex minor throat pain drowsiness difficulty swallowing
difficulty swallowing Explanation: The nurse should report difficulty swallowing to the physician as this may be a sign of perforation. Loss of gag reflex, minor throat pain, and drowsiness are expected findings after a gastroscopy for which the client received sedation and therefore there is no need to report to the physician.
A client tells the nurse that the stool was colored yellow. The nurse assesses the client for recent foods ingested. occult blood. ingestion of bismuth. pilonidal cyst.
recent foods ingested. Explanation: 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 conducting an abdominal assessment of a patient who is postoperative day 1 following an open cholecystectomy. During auscultation of the patient's abdomen, the nurse has noted that clicks and gurgles are audible approximately every 10 seconds. How should the nurse follow up this assessment finding? The nurse should administer a p.r.n. stool softener. The nurse should contact the patient's care provider. The nurse should assess the patient for paralytic ileus. The nurse should document normoactive bowel sounds.
The nurse should document normoactive bowel sounds. Explanation: The frequency and character of bowel sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. Bowel sounds occurring every 10 seconds would be an expected assessment finding that does not indicate the need for intervention.
