Med Surg 2 Exam 3 GI
When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are a) normal b) hypoactive c) absent d) sluggish
a) 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.
Which mouth condition is associated with HIV infection? a) Krythoplakia b) Kaposi sarcoma c) stomatitis d) candidiasis
b) Kaposi sarcoma Kaposi sarcoma appears first on the oral mucosa as a red, purple, or blue lesion. It is associated with HIV infection. Stomatitis is associated with chemotherapy and radiation therapy. Krythoplakia is caused by a nonspecific inflammation. Candidiasis is caused by fungus.
Which term describes an inflammation of the salivary glands? a) parotitis b) sialadentitis c) stomatitis d) pyosis
b) Sialadenitis Sialadenitis is inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus.
The nurse recognizes that blood shed in sufficient quantities into the upper GI tract produces which color of stool? a) bright red b) milky white c) tarry black d) green
c) tarry black Blood shed in sufficient quantities into the upper GI tract produces a tarry-black stool. Blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red. A milky white stool is indicative of a client who received barium. A green stool is indicative of a client who has eaten spinach.
A client with an esophageal disorder comes to the hospital with symptoms that include halitosis and a sour taste in the mouth. These symptoms are associated most directly with which condition? a) gastroesophageal reflux b) esophageal diverticula c) hiatal hernia d) achalasia
b) Esophageal diverticula Because the diverticula may retain decomposed food, halitosis and a sour taste in the mouth are frequently reported. Achalasia presents as difficulty swallowing both liquids and solids. Gastroesophageal reflux presents as burning in the esophagus, indigestion, and difficulty or pain upon swallowing. Hiatal hernia presents as heartburn, regurgitation, and dysphagia in many clients, although at least 50% of clients are asymptomatic.
The most common symptom of esophageal disease is a) nausea b) vomiting c) dysphagia d) odynophagia
c) 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.
Which response is a parasympathetic response in the GI tract? a) increased peristalsis b) blood vessel constriction c) decreased motility d) decreased gastric secretion
a) increased peristalsis Increased peristalsis is a parasympathetic response in the GI tract. Decreased gastric secretion, blood vessel constriction, and decreased motility are sympathetic responses in the GI tract.
Postoperatively, a client with a radical neck dissection should be placed in which position? a) side-lying b) fowler c) supine d) prone
b) 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.
The nurse prepares a client for a barium enema. The nurse should place the client on which diet prior to the procedure? a) high-fiber diet 1 to 2 days prior b) nothing by mouth (NPO) 2 days prior c) clear liquids day before d) soft diet 1 day prior
c) 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.
Which term is used to describe stone formation in a salivary gland, usually the submandibular gland? a) sialadenitis b) Sialolithiasis c) Parotitis d) stomatitis
b) 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.
The nurse is conducting a health instruction program on oral cancer. The nurse determines that the participants understand the instructions when they state a) "A typical lesion is soft and crater like" b) "blood testing is used to diagnose oral cancer." c) "many oral cancers produce no symptoms in the early stages" d) "most oral cancer are painful at the outset"
c) "Many oral cancers produce no symptoms in the early stages." The most frequent symptom of oral cancer is a painless sore that does not heal. The client may complain of tenderness and difficulty chewing, swallowing, or speaking as the cancer progresses. Biopsy is used to diagnose oral cancer. A typical lesion in oral cancer is a painless, hardened ulcer with raised edges.
A client tells the nurse that the stool was colored yellow. The nurse assesses the client for a) pilonidal cyst b) occult blood c) recent foods ingested d) ingestion of bismuth
c) 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 cares for a client after a gastroscopy for which the client received sedation. The nurse should report which finding to the physician? a) drowsiness b) minor throat pain c) loss of gag reflex d) difficulty swallowing
d) difficulty swallowing 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.
The nurse performs an abdominal assessment. The nurse should peform the assessment in which order? a) auscultation, inspection, percussion, palpation b) inspection, auscultation, percussion, palpation c) auscultation, percussion, inspection, palpation d) inspection, palpation, percussion, auscultation
b) inspection, auscultation, percussion, palpation The correct order for the abdominal assessment is inspection, auscultation, percussion, and palpation.
The nurse recognizes which change of the GI system is an age-related change? a) increased motility b) weakened gag reflex c) increased mucus secretion d) hypertrophy of the small intestine
b) 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 provides client education to a client about to undergo hydrogen breath testing. The nurse evaluates that the client understands the test when the client makes which statement? a) "The test will detect the presence of staph." b) "first, I will drink a cherry flavored liquid." c) "I should avoid antibiotics for 1 month before the test." d) "The test will detect the presence of oral cancer."
c) "I should avoid antibiotics for 1 month before the test." The nurse evaluates that the client understands the education when the client states antibiotics should be avoided one month before the test. In addition, the client should avoid loperamide, sucralfate, and omeprazole for 1 week prior to the test, and cimetidine, famotidine, and ranitidine for 24 hours before the test. During the test, the client swallows a capsule of carbon-labeled urea and a breath sample is obtained 10 to 20 minutes later. The hydrogen breath test detects the presence of Helicobacter pylori, the bacteria that causes peptic ulcer disease.
The major carbohydrate that tissue cells use as fuel is a) glucose b) chyme c) fats d) proteins
a) 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.
Which term describes a gastric secretion that combines with vitamin B12 so that it can be absorbed? a) intrinsic factor b) amylase c) pepsin d) trypsin
a) intrinsic factor Intrinsic factor, secreted by the gastric mucosa, combines with dietary vitamin B12 so that the vitamin can be absorbed in the ileum. In the absence of intrinsic factor, vitamin B12cannot be absorbed and pernicious anemia results. Amylase is an enzyme that aids in the digestion of starch. Pepsin, an important enzyme for protein digestion, is the end product of the conversion of pepsinogen from the chief cells. Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein.
The nurse determines which is a true statement regarding older clients, considering the age-related effects on the gastrointestinal (GI) system? a) they usually have less control of the rectal sphincter b) they tend to have increased muscle tone and mass c) they tend to have higher physiologic reserves to compensate for fluid loss d) they have no awareness of the filling reflex
a) They usually have less control of the rectal sphincter. Older adults tend to have fewer physiologic reserves to compensate for fluid loss. The older adult usually has less control of the rectal sphincter than a younger adult because of age-related changes in innervations, a diminished awareness of the filling reflex, and decreased muscle tone.
A client receives a local anesthetic to suppress the gag reflex for a diagnostic procedure of the upper GI tract. The nurse determines which nursing intervention is advised for this client? a) do not give any food or fluids until the gag reflex returns b) monitor for cramping or abdominal distention c) monitor for any breathing-related disorder or discomforts d) measure fluid output for at least 24 hours after the procedure
a) do not give any food and fluids until the gag reflex returns 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. The client is monitored for other symptoms specifically related to the procedure but may not be monitored for cramping or abdominal distention or breathing related discomforts unless reporting these symptoms. It is also not essential to monitor the client's fluid output for 24 hours, since the client is advised to avoid fluid or food intake until the reflex returns. However, the client may be monitored for any dehydration related to not consuming any fluids or food before the procedure.
Halitosis and a sour taste in the mouth are clinical manifestations associated most directly with a) esophageal diverticula b) hiatal hernia c) gastroesophageal reflux d) achalasia
a) esophageal diverticula. Because the diverticula may retain decomposed food, halitosis and a sour taste in the mouth are frequently reported. Achalasia presents as difficulty swallowing both liquids and solids. Gastroesophageal reflux presents as burning in the esophagus, indigestion, and difficulty or pain upon swallowing. Hiatal hernia presents as heartburn, regurgitation, and dysphagia in many clients, although at least 50% of clients are asymptomatic.
The nurse assesses bowel sounds and hears one to two bowel sounds in 2 minutes. How should the nurse document the bowel sounds? a) hypoactive b) hyperactive c) normal d) absent
a) 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 determines one or two bowel sounds in 2 minutes should be documented as a) hypoactive b) normal c) hyperactive d) absent
a) 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 5 or 6 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? a) inflammatory bowel disease b) chronic obstructive pulmonary disease c) congestive heart failure d) pulmonary hypertension
a) 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.
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 client? a) measure fluid output for at least 24 hours after the procedure b) do not five any food and fluids until the gag reflex returns c) monitor for breathing-related disorder or discomforts d) monitor for cramping or abdominal distention
b) Do not give any food and fluids until the gag reflex returns. 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. The client is monitored for other symptoms specifically related to the procedure, but may not be monitored for cramping or abdominal distention or breathing-related discomforts unless reporting these symptoms. It is also not essential to monitor the client's fluid output for 24 hours, because the client is advised to avoid fluid or food intake until the reflex returns. However, the client may be monitored for any dehydration related to not consuming any fluids or food before the procedure.
The nurse teaches a client scheduled for a colonoscopy. Which instruction should be included as part of the preparation for the procedure? a) do not void for at least 30 minutes before the test b) follow the dietary and fluid restrictions and bowel preparation procedures c) consume at least 3 quarts of water 30 minutes before the test d) spray or gargle with a local anesthetic
b) Follow the dietary and fluid restrictions and bowel preparation procedures. For a client due to have a colonoscopy, it is essential that the client follow the dietary and fluid restrictions and bowel preparation procedures. For the client having an esophagogastroduodenoscopy (EGD), it is necessary for the client to spray or gargle with a local anesthetic. The client is not advised to consume 3 quarts of water nor to void before the test. These interventions may be essential for tests that involve ultrasonographic procedures.
The nurse conducts education related to test preparation for a client scheduled to undergo an abdominal ultrasonography. The nurse should give the client which instruction? a) do not consume anything sweet for 24 hours before the test b) restrict eating of solid food for 8 to 12 hours before the test c) avoid exposure to sunlight for at least 6 to 8 hours before the test d) do not undertake any strenuous exercise for 24 hours before the test
b) Restrict eating of solid food for 8 to 12 hours before the test. For a client who is scheduled to undergo an abdominal ultrasonography, the client should restrict 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.
The nurse cares for a client after an endoscopic examination and prepares the client for discharge. The nurse includes which instruction? a) increase fluid intake b) resume regular diet c) continue a clear liquid diet d) avoid driving for 24 hours
b) Resume regular diet. The nurse includes resumption of regular diet in the client's discharge instructions as the client is able to resume activities and diet after an endoscopic exam. There is no need to adhere to a clear liquid diet or to increase fluid intake. As sedation is not usually involved for endoscopic examinations, the client does not need to avoid driving.
Which neuroregulator increase gastric acid secretion? a) gastrin b) acetylcholine c) norepinephrine d) secretin
b) acetylcholine Acetylcholine causes increased gastric acid. Norepinephrine inhibits secretions of the GI tract. Gastrin increases secretion of gastric juice, which is rich in HCL. Secretin in the stomach inhibits gastric secretion somewhat.
When gastric analysis testing reveals excess secretion of gastric acid, the nurse recognizes which medical diagnoses is supported? a) chronic atrophic gastritis b) duodenal ulcer c) gastric cancer d) pernicious anemia
b) duodenal ulcer Clients with duodenal ulcers usually secrete an excess amount of hydrochloric acid. Clients with chronic atrophic gastritis secrete little or no acid. Clients with gastric cancer secrete little or no acid. Clients with pernicious anemia secrete no acid under basal conditions or after stimulation.
The nurse provides health teaching to inform the client with oral cancer that a) blood testing is used to diagnose oral cancer b) many oral cancers produce no symptoms in early stages c) a typical lesion is soft and craterlike d) most oral cancers are painful at the outset
b) many oral cancers produce no symptoms in the early stages. The most frequent symptom of oral cancer is a painless sore that does not heal. The client may complain of tenderness, and difficulty with chewing, swallowing, or speaking occur as the cancer progresses. Biopsy is used to diagnose oral cancer. A typical lesion in oral cancer is a painless, hardened ulcer with raised edges.
The nurse is conducting a community education session on the prevention of oral cancers. The nurse includes which cancer as being a type of premalignant squamous cell skin cancer?
Actinic cheilitis Actinic cheilitis is a type of premalignant squamous cell skin cancer that presents as scaling, crusty fissures or a white overgrowth of the horny layer of the epidermis. Herpes simplex 1 is an opportunistic infection frequently seen in immunosuppressed clients. Chancres are reddened circumscribed lesions that ulcerate and become crusted and are the primary lesions of syphilis. Krythoplakia is a red patch on the oral mucous membrane that is frequently seen in the elderly.
The nurse is planning care for a client with painful oral lesions. Which food should be included in the client's diet?
Jello The nurse should include Jello in the client's diet; spicy, hot, and/or hard foods or beverages (pretzels, hot tea, chili) should be avoided to reduce pain and discomfort in the client with painful oral lesions.
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.
The nurse is caring for a client with a history of bulimia. The client complains of retrosternal pain and dysphagia after forcibly causing herself to vomit after a large meal. The nurse suspects which condition?
Boerhaave syndrome Boerhaave syndrome, a spontaneous rupture of the esophagus after forceful vomiting (may occur after eating a large meal), is characterized by retrosternal pain, dysphagia, infection, fever, and severe hypotension. Halitosis (bad breath) is a symptom of pharyngoesophageal pulsion diverticulum, also known as Zenker diverticulum. A periapical abscess (an abscessed tooth) is characterized by dull, gnawing continuous pain, cellulitis, and edema and mobility of the involved tooth.
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.
The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication?
Diuretics Diuretics, frequently taken by older adults, can cause xerostomia (dry mouth). This is uncomfortable, impairs communication, and increases the client's risk for oral infection. Antibiotics, antiemetics, and steroids are not medications typically taken orally by adults that cause dry mouth.
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.
Follow-up dental appointment Follow-up medical appointment Oral hygieneUse 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 assessing the skin graft site of a client who has undergone a radical neck dissection. The skin graft site is pink. The nurse documents which result?
Healthy graft A healthy graft site is pink and warm to the touch. A pale graft indicates arterial thrombosis. A cyanotic, cool graft indicates possible necrosis. A purple graft indicates venous congestion.
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.
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 preparing to assess the donor site of a client who underwent a myocutaneous flap after a radical neck dissection. The nurse prepares to assess the most commonly used muscle for this surgery. Which muscle should the nurse assess?
Pectoralis major The most common donor site for a myocutaneous flap after radical neck dissection is the pectoralis major muscle, so the nurse should prepare to assess this site unless a different donor site is documented on the client's chart.
The nurse notes that a client has inflammation of the salivary glands. The nurse documents which finding?
Sialadenitis Sialadenitis is inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus.
Which are accurate clinical manifestations associated with hemorrhage? Select all that apply.
Tachycardia Hemorrhage may occur from carotid artery rupture as a result of necrosis of the graft or damage to the artery itself from tumor or infection. Tachycardia, tachypnea, and hypotension may indicate hemorrhage and impending hypovolemic shock.
The nurse determines a client scheduled to undergo an abdominal ultrasonography should receive which instruction? a) restrict eating of solid food for 6 to 8 hours before the test b) avoid exposure to sunlight for at least 6 to 8 hours before the test c) do not consume anything sweet for 24 hours before the test d) do not undertake any strenuous exercise for 24 hours before the test
a) 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.
The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is a(n) a) chancre b) leukoplakia c) actinic chelitis d) lichen planus
a) 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 nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? a) eat a low-carbohydrate diet b) elevate the foot of the bed on 6 to 8 inch blocks c) avoid eating or drinking 2 hours before bedtime d) minimize intake of caffeine, beer, milk and foods containing peppermint or spearmint
c) Avoid eating or drinking 2 hours before bedtime The client should not recline with a full stomach. The client should be instructed to avoid caffeine, beer, milk, and foods containing peppermint or spearmint, and to eat a low-fat diet. The client should be instructed to elevate the head of the bed on 6- to 8-inch blocks.
The nurse determines which is a true statement regarding older clients, considering the age-related effects on their GI system? a) They have no awareness of the filling reflex. b) They tend to have higher physiologic reserves to compensate for fluid loss. c) They tend to have increased muscle tone and mass. d) They tend to usually have less control of the rectal sphincter.
d) They tend usually to have less control of the rectal sphincter. Older adults tend to have fewer physiologic reserves to compensate for fluid loss. The older adult usually has less control of the rectal sphincter than a younger adult because of age-related changes in innervations, a diminished awareness of the filling reflex, and decreased muscle tone.
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.
An enzyme that begins the digestion of starches is a) pepsin b) ptyalin c) trypsin d) bile
b) ptyalin. Ptyalin, or salivary amylase, is an enzyme that begins digestion of starches. Pepsin, an important enzyme for protein digestion, is the end product of the conversion of pepsinogen from the chief cells. Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein. Bile is an enzyme secreted by the liver and gallbladder.
Which is the primary symptom of achalasia? a) chest pain b) pulmonary symptoms c) heartburn d) difficulty swallowing
d) 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.
A client with gastroesophageal reflux disease (GERD) comes to the physician's office reporting a burning sensation in the esophagus. The nurse documents that the client is experiencing
pyrosis. Pyrosis refers to a burning sensation in the esophagus and indicates GERD. Indigestion is termed dyspepsia. Difficulty swallowing is termed dysphagia. Pain upon swallowing is termed odynophagia.
The nurses assesses the client for blood in the stool due to an upper GI condition. The nurse understands that if there is blood in the stool, the stool will be which color? a) bright red b) tarry black c) milky white d) green
b) tarry black Blood that is shed in sufficient quantities from the upper GI tract produces a tarry-black stool. Blood from the lower portion of the GI tract will appear bright or dark red. A milky white stool is indicative of a client who received barium. A green stool is indicative of a client who has eaten spinach.
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? a) positron emission tomography b) abdominal ultrasound c) upper GI enteroclysis d) magnetic resonance imaging
c) 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 nurse recognizes which change of the gastrointestinal system is an age-related change? a) increased motility b) increased mucus secretion c) weakened gag reflex d) hypertrophy of the small intestine
c) 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.
A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers: a) "It determines functionality of the liver." b) "It detects a protein normally found in the blood." c) "It tells the physician what type of cancer is present." d) "It indicates if a cancer is present."
d) "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.
Blood flow to the GI tract is approximately what percentage of the total cardiac output? a) 10% b) 40% c) 30% d) 20%
d) 20% Blood flow to the GI tract is about 20% of the total cardiac output and increases significantly after eating.
The nurse inspects a client's tongue. Which finding would the nurse evaluate as an indication of potential oral cancer? a) V formation of dorsum of tongue b) large, vallate papillae on dorsum of tongue c) thin, white coating on dorsum of tongue d) red plaque on under surface of tongue
d) red plaque on undersurface of tongue Red or white plaque located on the undersurface of the tongue can be indicative of oral cancer. A thin, white coating on the dorsum of the tongue and large vallate papillae that form a V on the distal portion of the tongue are normal findings.
A client has undergone a radical neck dissection. His skin graft site is pale. This indicates which condition? a) infection b) venous congestion c) possible necrosis d) arterial thrombosis
d) Arterial thrombosis A pale graft indicates arterial thrombosis. A cyanotic, cool graft indicates possible necrosis. A purple graft indicates venous congestion.
For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone? a) chemotherapy b) biopsy c) radiation d) lithotripsy
d) 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.
The nurse is caring for a client during the postoperative period following radical neck dissection. Which finding should be reported to the physician?
High epigastric pain and/or discomfort The nurse should report high epigastric pain and/or discomfort because this can be a sign of impending rupture. Crackles that clear after coughing, serous drainage on the dressing, and a temperature of 99.0°F are normal findings in the immediate postoperative period and do not need to be reported to the physician.
Which term refers to the symptom of gastroesophageal reflux disease (GERD), which is characterized by a burning sensation in the esophagus? a) dyspepsia b) dysphagia c) odynophagia d) pyrosis
d) Pyrosis Pyrosis refers to a burning sensation in the esophagus and indicates GERD. Indigestion is termed dyspepsia. Difficulty swallowing is termed dysphagia. Pain on swallowing is termed odynophagia.
Which enzyme aids in the digestion of protein? a. Amylase b. Lipase c. Pepsin d. Trypsin
d) trypsin Trypsin, amylase, and lipase are digestive enzymes secreted by the pancreas. Trypsin aids in digesting protein; amylase aids in digesting starch; and lipase aids in digesting fats. Pepsin, an important enzyme for protein digestion, is the end product of the conversion of pepsinogen from the chief cells. Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein. Amylase is an enzyme that aids in the digestion of starch.
