Chapter 38: Assessment of Digestive and Gastrointestinal Function
A client is scheduled for magnetic resonance imaging (MRI). During the client teaching, what will the nurse discuss? "You must remove all jewelry but can wear your wedding ring." "You must be NPO for the day before the examination." "Do you experience any claustrophobia?" "The examination will take only 15 minutes."
"Do you experience any claustrophobia?" Explanation: 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 completing a nutritional assessment of a patient who is admitted for a GI disorder, the nurse notes a recent history of dietary intake. This is based on the knowledge that a portion of digested waste products can remain in the rectum for how many days after a meal is digested? 1 day 2 days 3 days 4 days
3 days Explanation: As much as 25% of the waste products from a meal may still be in the rectum 3 days after a meal is ingested.
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.
The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon returning to the nursing unit, what does the nurse identify as the client goal? Recovery from the general anesthesia Decrease in nausea and vomiting Increase in the amount of fluids Ambulates independently
Increase in the amount of fluids Explanation: The client, returning from an upper gastrointestinal series, needs to increase fluids in an effort to eliminate the barium from the body through a bowel movement. General anesthesia is not used. The client typically does not have nausea and vomiting following the procedure. If the client is able to ambulate independently prior to the procedure, the client will be able to ambulate independently following.
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? Cardiac sphincter Hypopharyngeal sphincter Ileocecal valve Pyloric sphincter
Pyloric sphincter Explanation: 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.
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.
When assisting with preparing a client scheduled for a barium swallow, which of the following would be appropriate to include? Avoid smoking for at least 12 to 24 hours before the procedure. Take vitamin K before the procedure. Take three cleansing enemas before the procedure. Avoid the intake of red meat before the procedure.
Avoid smoking for at least 12 to 24 hours before the procedure. Explanation: The nurse should instruct the client to avoid smoking for at least a day before the procedure of barium swallow because smoking stimulates gastric motility. The client is advised to take vitamin K before a liver biopsy and instructed to take three cleansing enemas before a barium enema. Instruction to avoid red meat would be appropriate for a client who is having a Hemoccult test.
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? Dark brown Green Red Black
Black Explanation: 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.
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.
Which enzyme aids in the digestion of protein? trypsin lipase steapsin ptyalin
trypsin Explanation: 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. Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein. Amylase is an enzyme that aids in the digestion of starch. Steapsin digests fats.
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.
When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the health care provider? "I haven't had anything to eat or drink since midnight last night." "I really don't like to be in small, enclosed spaces." "I left all my jewelry and my watch at home." "I brought earphones to shut out the loud noise."
"I really don't like to be in small, enclosed spaces." Explanation: 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 health care provider 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 client is scheduled for an ultrasound of the abdomen. Which statement indicates that teaching provided to the client to prepare for the test was effective? "I will take an over-the-counter enema before the test." "I will not eat or drink for 8 to 12 hours before the test." "I will ingest a clear liquid diet for 3 days before the test." "I will take medications to reduce gastric acid before the test."
"I will not eat or drink for 8 to 12 hours before the test." Explanation: Ultrasonography is a noninvasive diagnostic technique in which high-frequency sound waves are passed into internal body structures, and the ultrasonic echoes are recorded on an oscilloscope as they strike tissues of different densities. It is particularly useful in the detection of an enlarged gallbladder or pancreas, or the presence of gallstones, an enlarged ovary, an ectopic pregnancy, or appendicitis. The client should be instructed to fast for 8 to 12 hours before the test to decrease the amount of gas in the bowel. Enemas are not needed before an abdominal ultrasound. A clear liquid diet is not needed before the test. Medications to reduce gastric acid are not required before the test.
The nurse asks a client to point to where pain is felt. The client asks why this is important. What is the nurse's best response? "If the health care provider massages over the exact painful area, the pain will disappear." "The area may determine the severity of the pain." "This determines the pain medication to be ordered." "Often the area of pain is referred from another area."
"Often the area of pain is referred from another area." Explanation: 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 caring for a client recovering from a colonoscopy. Which assessment finding will the nurse expect in the client after the procedure? Fever Rectal bleeding Abdominal cramps Abdominal distention
Abdominal cramps Explanation: After the procedure, clients are maintained on bed rest until fully alert. Some clients have abdominal cramps caused by increased peristalsis stimulated by the air insufflated into the bowel during the procedure. Fever, rectal bleeding, and abdominal distention are symptoms of bowel perforation and should be immediately reported to the health care provider.
A client is scheduled for a flexible sigmoidoscopy. Which preparation will the nurse instruct the client to complete before the procedure? Administer tap water enemas until liquid from rectum is clear. Maintain liquid diet for 3 days before the procedure. Take oral laxatives for 2 days before the procedure. Avoid aspirin products a week before the procedure.
Administer tap water enemas until liquid from rectum is clear. Explanation: The flexible fiberoptic sigmoidoscope permits the colon to be examined up to 40 to 50 cm (16 to 20 inches) from the anus. It has many of the same capabilities as the scopes used for the upper GI study, including the use of still or video images to document findings. This examination requires only limited bowel preparation, including a warm tap water or Fleet enema until returns are clear. Dietary restrictions usually are not necessary. Oral laxatives before the procedure are not needed. There are no medication restrictions before the procedure.
A client reports a history of bleeding hemorrhoids to the nurse. Which observation supports the client's statement? Hard, dry stool Dark red stool Black tarry stool Blood streaks on stool
Blood streaks on stool Explanation: Blood in the stool can present in various ways and must be investigated. Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool or if blood is noted on toilet tissue. Hard, dry stool occurs in constipation. If blood is shed in sufficient quantities into the upper GI tract, it produces a dark red color, a tarry-black color, or melena.
A patient is scheduled for a fiberoptic colonoscopy. What does the nurse know that fiberoptic colonoscopy is most frequently used to diagnose? Bowel disease of unknown origin Cancer Inflammatory bowel disease Occult bleeding
Cancer Explanation: This procedure is used commonly as a diagnostic aid and screening device. It is most frequently used for cancer screening and for surveillance in patients with previous colon cancer or polyps. In addition, tissue biopsies can be obtained as needed, and polyps can be removed and evaluated. Other uses of colonoscopy include the evaluation of patients with diarrhea of unknown cause, occult bleeding, or anemia; further study of abnormalities detected on barium enema; and diagnosis, clarification, and determination of the extent of inflammatory or other bowel disease.
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 skin is discolored Checking if the mucous membranes are dry Examining the sclera if it is yellow Observing for distended abdominal veins
Checking if the mucous membranes are dry Explanation: 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 nurse is assessing a client for GI dysfunction. What is the most common symptom in a client with GI dysfunction? Diffuse pain Dyspepsia Constipation Abdominal bleeding
Dyspepsia Explanation: Dyspepsia is a condition that usually involves a combination of symptoms: abdominal pain, bloating, distention, nausea, and belching. Dyspepsia refers to altered digestion that is not associated with a pathologic condition.
Which of the following is a function of the stomach? Select all that apply. Food storage Secretion of digestive fluids Propels partially digested food into small intestine Secretion of digestive enzymes Secretion of bile
Food storage Secretion of digestive fluids Propels partially digested food into small intestine Explanation: The stomach stores food during eating, secretes digestive fluids, and propels the partially digested foods into the small intestine. Secretion of digestive enzymes is completed by the pancreas. The liver secretes bile.
A client with gastroesophageal reflux disease is scheduled for esophageal manometry. Which information about the test will the nurse review with the client? Select all that apply. Take laxatives for 2 days before the test. Withhold food and fluids until the gag reflex returns. Ingest no food or fluids for 8 to 12 hours before the test. Withhold taking calcium channel blocking medications for 24 to 48 hours. Expect to remain in the testing facility until fully awake from the anesthesia.
Ingest no food or fluids for 8 to 12 hours before the test. Withhold taking calcium channel blocking medications for 24 to 48 hours. Explanation: Esophageal manometry is used to detect motility disorders of the esophagus and the upper and lower esophageal sphincter. Evaluation of a client for gastroesophageal reflux disease typically includes esophageal manometry. The client must refrain from eating or drinking for 8 to 12 hours before the test. Medications that could have a direct effect on motility (e.g., calcium channel blockers) are withheld for 24 to 48 hours. Laxatives are not needed to prepare for the test. The gag reflex is not affected by this test. Anesthesia is not needed for this test.
A focused GI assessment begins with a complete history and physical examination. Identify the quadrant of the abdomen to be palpated or percussed for a patient with pancreatitis. Right upper Right lower Left upper Left lower
Left upper Explanation: The pancreas, which is about 6 inches long, is located behind the stomach in the upper left side of the body.
While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure? Sigmoid colon Appendix Spleen Liver
Liver Explanation: 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.
Swallowing is regulated by which area of the central nervous system (CNS)? Medulla oblongata Pons Cerebellum Hypothalamus
Medulla oblongata Explanation: 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.
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 assisting the health care provider with a gastric acid stimulation test for a client. What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions? Pentagastrin Atropine Glycopyrronium bromide Acetylcysteine
Pentagastrin Explanation: The gastric acid stimulation test usually is performed in conjunction with gastric analysis. Histamine or pentagastrin is administered subcutaneously to stimulate gastric secretions.
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.
Which diagnostic produces images of the body by detecting the radiation emitted from radioactive substances? Positron emission tomography (PET) Computed tomography (CT) Magnetic resonance imaging (MRI) Fibroscopy
Positron emission tomography (PET) Explanation: PET produces images of the body by detecting the radiation emitted from radioactive substances. CT provides cross-sectional images of abdominal organs and structures. MRI uses magnetic fields and radio waves to produce an image of the area being studied. Fibroscopy of the upper GI tract allows direct visualization of the esophageal, gastric, and duodenal mucosa through a lighted endoscope.
The nurse is caring for a client who is scheduled for a percutaneous liver biopsy. Which diagnostic test is obtained prior? Complete blood count (CBC) Prothrombin time (PT) Blood chemistry Erythrocyte sedimentation rate (ESR)
Prothrombin time (PT) Explanation: The client must have coagulation studies (PT, aPTT, INR, platelet count) before the procedure because a major complication after a liver biopsy is bleeding. Clients at risk for serious bleeding may receive precautionary vitamin K. A complete blood count and blood chemistry may be completed for baseline values. Typically, an ESR is not associated with the procedure.
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.
The nurse is preparing to examine the abdomen of a client who reports a change in bowel pattern. The nurse would place the client in which position? Supine with knees flexed Knee-chest Lithotomy Left Sim's lateral
Supine with knees flexed Explanation: When examining the abdomen, the client lies supine with 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.
What would the nurse recognize as preventing a client from being able to take a fecal occult blood test (FOBT)? The client has hemorrhoidal bleeding The client had a hamburger for dinner the night before The client took an ibuprofen tablet this morning The client regularly takes aspirin
The client has hemorrhoidal bleeding Explanation: FOBT should not be performed when there is hemorrhoidal bleeding. In the past, clients were taught to avoid aspirin, red meats, nonsteroidal anti-inflammatory agents, and horseradish for 72 hours prior to the examination. However, these restrictions are no longer advised as the actual effects on testing have not been established.
The nurse determines which is a true statement regarding older clients, considering the age-related effects on the gastrointestinal (GI) system? They tend to have higher physiologic reserves to compensate for fluid loss. They usually have less control of the rectal sphincter. They have no awareness of the filling reflex. They tend to have increased muscle tone and mass.
They usually have less control of the rectal sphincter. Explanation: 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.
When describing the role of the pancreas to a client with a pancreatic dysfunction, the nurse would identify which substance as being acted on by pancreatic lipase? Starch Protein Triglycerides Glucose
Triglycerides Explanation: Pancreatic lipase acts on lipids, especially triglycerides. Salivary amylase and pancreatic amylase act on starch. Pepsin and hydrochloric acid in the stomach and trypsin from the pancreas act on proteins. Insulin acts on glucose.
When gastric analysis testing reveals excess secretion of gastric acid, the nurse recognizes which medical diagnoses is supported? chronic atrophic gastritis duodenal ulcer gastric cancer pernicious anemia
duodenal ulcer Explanation: 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.
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.
Blood flow to the GI tract is approximately what percentage of the total cardiac output? 10% 20% 30% 40%
20% Explanation: Blood flow to the GI tract is about 20% of the total cardiac output and increases significantly after eating.
The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment? Drowsiness Abdominal distention Sore throat Thirst
Abdominal distention Explanation: 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.
The nurse is caring for a client who is scheduled for a urea breath test to detect for Helicobacter pylori as a reason for gastric distress. Which instruction(s) will the nurse provide to the client to prepare for this test? Select all that apply. Take antibiotics prior to the test. Take cimetidine 24 hours before the test. Avoid bismuth subsalicylate before the test. Do not take proton pump inhibitors before the test. Take famotidine for 1 week before the test.
Avoid bismuth subsalicylate before the test. Do not take proton pump inhibitors before the test. Explanation: Urea breath tests detect the presence of Helicobacter pylori, the bacteria that can live in the mucosal lining of the stomach and cause peptic ulcer disease. Prior to urea breath testing, the client should be instructed to avoid antibiotics and bismuth subsalicylate for 1 month. Proton pump inhibitors should be avoided for 2 weeks. Cimetidine and famotidine should be avoided for 24 hours before the test.
A client with abdominal pain is scheduled for a CT scan of the abdomen with contrast. Which assessment will the nurse complete before transporting the client for the diagnostic test? History of allergies Presence of a cochlear implant Last use of an oral laxative Current list of prescribed medications
History of allergies Explanation: A CT scan provides cross-sectional images of abdominal organs and structures. A CT scan may be performed with or without oral or intravenous (IV) contrast, but the enhancement of the study is greater with the use of a contrast agent. A common risk from IV contrast agents is allergic reactions; therefore, the client must be screened for this risk. Any allergies to contrast agents, iodine, or shellfish must be determined before administration of a contrast agent. Clients allergic to the contrast agent may be premedicated with a corticosteroid and antihistamine. Therefore, a history of allergies must be completed before the test. Assessing for the presence of a cochlear implant is recommended before magnetic resonance imaging (MRI), but not before a CT scan. The last use of an oral laxative and current list of prescribed medications are not required before a CT scan of the abdomen.
A client with gastroesophageal reflux disease is scheduled for esophageal manometry. Which information about the test will the nurse review with the client? Select all that apply. Take laxatives for 2 days before the test. Withhold food and fluids until the gag reflex returns. Ingest no food or fluids for 8 to 12 hours before the test. Withhold taking calcium channel blocking medications for 24 to 48 hours. Expect to remain in the testing facility until fully awake from the anesthesia.
Ingest no food or fluids for 8 to 12 hours before the test. Withhold taking calcium channel blocking medications for 24 to 48 hours. Explanation: Esophageal manometry is used to detect motility disorders of the esophagus and the upper and lower esophageal sphincter. Evaluation of a client for gastroesophageal reflux disease typically includes esophageal manometry. The client must refrain from eating or drinking for 8 to 12 hours before the test. Medications that could have a direct effect on motility (e.g., calcium channel blockers) are withheld for 24 to 48 hours. Laxatives are not needed to prepare for the test. The gag reflex is not affected by this test. Anesthesia is not needed for this test.
The nurse is preparing to examine the abdomen of a client with reports of nausea and vomiting. What action would the nurse perform 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 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.
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.
The nurse determines one or two bowel sounds in 2 minutes should be documented as normal. hyperactive. hypoactive. absent.
hypoactive. Explanation: 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.
Which response is a parasympathetic response in the GI tract? decreased gastric secretion blood vessel constriction increased peristalsis decreased motility
increased peristalsis Explanation: 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.
The nurse prepares to administer the lavage solution to a client having a colonoscopy completed. The nurse stops and notifies the physician when noting that the client has which condition? inflammatory bowel disease chronic obstructive pulmonary disease congestive heart failure pulmonary hypertension
inflammatory bowel disease Explanation: 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.
Which term describes a gastric secretion that combines with vitamin B12 so that it can be absorbed? amylase pepsin trypsin intrinsic factor
intrinsic factor Explanation: 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 B12 cannot 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.
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 recognizes which change of the GI 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.