GI Test One
A nurse is caring for a newly admitted patient with a suspected GI bleeding. The nurse assesses the patient's stool after a bowel movement and notes it to be a tarry-black color. The nurse recognizes that the bleeding is likely occurring where? a) The lower GI tract b) The upper GI tract c) The esophagus d) The anal area
ANSWER: B
The student nurses are studying diseases of the lower GI tract. Many of the diseases can be identified by the characteristics of the patient's stool. What would voluminous, greasy stools suggest? a) Intestinal malabsorption b) Inflammatory colitis c) Colon cancer d) Small bowel obstruction
A
The client being seen in a physician's office has just been scheduled for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test? a) Fast for 8 hours before the test b) Eat a regular supper and breakfast c) Continue to take all oral medications as scheduled d) Monitor own bowel movement pattern for constipation
A (Rationale: A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the GI tract. The client should fast for 8 to 12 hours before the test, depending on the physician instructions. Most oral medications also are withheld before the test. After the procedure the nurse must monitor for constipation, which can occur as a result of the presence of barium in the GI tract.)
A client with which of the following conditions may be likely to develop rectal cancer? a) Adenomatous polyps b) Diverticulitis c) Hemorrhoids d) Peptic ulcer disease
A (Rationale: A client with adenomatous polyps has a higher risk for developing rectal cancer than others do. Clients with diverticulitis are more likely to develop colon cancer. Hemorrhoids don't increase the chance of any type of cancer. Clients with peptic ulcer disease have a higher incidence of gastric cancer.)
A client has just had surgery for colon cancer. Which of the following disorders might the client develop? a) Peritonitis b) Diverticulosis c) Partial bowel obstruction d) Complete bowel obstruction
A (Rationale: Bowel spillage could occur during surgery, resulting in peritonitis. Complete or partial bowel obstruction may occur before bowel resection. Diverticulosis doesn't result from surgery or colon cancer.)
The nurse is caring for a patient in the emergency department with complaints of acute abdominal pain, nausea, and vomiting. When the nurse palpates the patient's left lower abdominal quadrant, the patient complains of pain in the right lower quadrant. The nurse will document this as which of the following diagnostic signs of appendicitis? a) Rovsing sign b) Referred pain c) Chvostek's sign d) Rebound tenderness
A (Rationale: In patients with suspected appendicitis, Rovsing sign may be elicited by palpation of the left lower quadrant, causing pain to be felt in the right lower quadrant.)
The nurse is caring for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST? a) "Take three deep breaths, hold your incision, and then cough." b) "That was good. Do that again and soon it won't hurt as much." c) "It won't hurt as much if you hold your incision when you cough." d) "Take another deep breath, hold it, and then cough deeply."
A (Rationale: It is the most effective way of deep breathing and coughing, dilates airway and expands lung surface area.)
A nurse is presenting an educational event to a local community group. The nurse is speaking about colorectal cancer. What would the nurse identify as a risk factor associated with colorectal cancer? a) Over 50 years of age b) History of bowel obstruction c) Family history of stomach caner d) Low-fat, low-protein, low-fiber diet
A (Rationale: Risk factors for colorectal cancer include age older than 50; history of rectal or colon polyps; presence of adenomatous polyps or villous adenomas; family history of colon cancer or familial polyposis; history of inflammatory bowel disease; and high-fat, high-protein (with high intake of beef), low-fiber diet.)
A client is admitted with right lower quadrant pain, anorexia, nausea, low-grade fever, and an elevated white blood cell count. Which complication is most likely the cause? a) A fecalith b) Bowel kinking c) Internal bowel occlusion d) Abdominal wall swelling
A (Rationale: The client is experiencing appendicitis. A fecalith is a fecal calculus, or stone, that occludes the lumen of the appendix and is the most common cause of appendicitis. Bowel wall swelling kinking of the appendix, and external occlusion, not internal occlusion, of the bowel by adhesions can also be causes of appendicitis.)
The client with a new colostomy is concerned about the odor from the stool in the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor? a) Yogurt b) Broccoli c) Cucumbers d) Eggs
A (Rationale: The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is gas forming food as well. Broccoli, cucumbers, and eggs are gas forming foods.)
The client with Crohn's disease has a nursing diagnosis of acute pain. The nurse would teach the client to avoid which of the following in managing this problem? a) Lying supine with the legs straight b) Massaging the abdomen c) Using antispasmodic medication d) Using relaxation techniques
A (Rationale: The pain associated with Crohn's disease is alleviated by the use of analgesics and antispasmodics and also is reduced by having the client practice relaxation techniques, applying local cold or heat to the abdomen, and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen, which could aggravate the inflamed intestinal tissue as the abdominal muscles are stretched.)
A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings. Before starting a continuous feeding, the nurse should place the client in which position? a) Semi-Fowlers b) Supine c) Reverse Trendelenburg d) High Fowler's
A (Rationale: To prevent aspiration of stomach contents, the nurse should place the client in semi-Fowler's position. High Fowler's position isn't necessary and may not be tolerated as well as semi-Fowler's.)
You are caring for a patient admitted with symptoms of an anorectal infection. Cultures obtained from a rectal swab indicate that the patient has a viral infection? What antibiotic will you anticipate the physician to order for this viral anorectal infection? a) Acyclovir (Zovirax) b) Doxyclycline (Vibramycin) c) Penicillin (penicillin G) d) Metronidazole (Flagyl)
A Rationale: Acyclovir (Zovirax) is given to patients with viral infections. Doxyclycline (Vibramycin) and penicillin (penicillin G) are drugs of choice for bacterial infections. Metronidazole (Flagyl) is appropriate for infections with E. histolytica and G. lamblia.
The nurse is caring for a patient who is scheduled for a colonoscopy. The nurse is preparing to instruct the patient on a colon preparation procedure that will include polyethylene glycol electrolyte lavage prior to the procedure. What is the nurse aware of about the use of lavage solutions and when they are contraindicated? a) In a patient with an inflammatory bowel disease. b) In a patient with polyps. c) In a patient with a colostomy. d) In a patient with colon cancer
ANSWER: A
The nursing instructor is discussing ulcerative colitis with her clinical group. What would she tell her students about the characteristics of the stools of these patients? a) Watery with blood and mucus b) Hard and black c) Long and cylindrical shaped d) Loose and fatty
ANSWER: A
You are caring for a patient in the ED who is waiting to have a CT scan because of a possible obstruction of the intestinal tract. You draw blood to send to the lab and the patient asks you why you are drawing his blood. What would be your best response? a) "One thing the physicians are looking at is what your level of CA 19-9 is. If the levels are high, it can indicate one of several diseases that might cause your bowel obstruction." b) "The physicians are checking the levels of a tumor marker in your blood." c) "You don't need to worry about that right now." d) "The doctor wants to know if you have pancreatitis."
ANSWER: A
The client diagnosed with appendicitis has undergone an appendectomy. At two hours postoperative, the nurse takes the vital signs and note T 102.6F, P 132, R 26, and BP 92/46. Which interventions should the nurse implement? List in order of priority. a) Increase the IV rate. b) Notify the health care provider. c) Elevate the foot of the bed. d) Check the abdominal dressing. e) Determine if the IV antibiotics have been administered.
ANSWER: A-C-D-E-B (Rationale: (A) The nurse should increase the IV rate to maintain the circulatory system function until further orders can be obtained. (C) The foot of the bed should be elevated to help treat shock, the symptoms of which include elevated 56 pulse and decreased BP. Those signs and an elevated temperature indicate an infection may be present and the client could be developing septicemia. (D) The dressing should be assessed to determine if bleeding is occurring. (E) The nurse should administer any IV antibiotics ordered after addressing hypovolemia. The nurse will need this information when reporting to the HCP. (B) The HCP should be notified when the nurse has the needed information.)
A patient has come to the clinic complaining of blood in the stool. A guaiac test is performed but is negative. The physician suggests a colonoscopy, but the patient refuses. What other test might the physician order to check for blood in the stool? a) A quantitative serum immunochemical test b) A quantitative fecal immunochemical test c) A CT scan d) An MRI
ANSWER: B (Rationale: Quantitative fecal immunochemical tests may be more accurate than guaiac testing and useful for patients who refuse invasive testing. )
A patient has come to the radiology department to undergo testing for possible polyps. What diagnostic test may be done to diagnose this type of lesion? a) Gastric analysis b) Barium enema c) Barium swallow d) Gastroscopy
ANSWER: B (Rationale: The purpose of the barium enema is to detect the presence of polyps, tumors, and other lesions of the large intestine and to demonstrate any abnormal anatomy or malfunction of the bowel.)
An adult patient is schedule for an upper GI series that will use a barium swallow. What teaching should the nurse include when the patient has completed the test? a) Stool will be yellow for the first 24 hours post-procedure. b) The barium may cause diarrhea. c) Fluids must be increased to facilitate the evacuation of the stool. d) This series includes analysis of gastric secretions.
ANSWER: C
A nurse is caring for a patient with Crohn's disease. The patient is scheduled for a barium enema. What is an appropriate nursing intervention the day before the test? a) Serve the patient his usual diet. b) Order a high-fiber diet. c) Encourage plenty of fluids. d) Serve dairy products
ANSWER: C (Rationale: Adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. Because dairy products leave a residue, they aren't allowed the evening before the test. Only clear liquids are allowed the evening before the test.)
You have assumed care of a patient who has returned after a barium enema study. When you assess the patient's bowel patterns and stools, what findings based upon the assessment of the stool would you report to the physician? a) Large, wide stools b) Milky white stools c) Three stools during an 8-hour period of time d) Stool has streaks of blood throughout the fecal material
ANSWER: D (Rationale: Barium has a high osmolarity and may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in great output (large stools). The barium will give the stools a milky white appearance, and it is not uncommon for the patient to experience an increase in the number of bowel movements. Blood in fecal matter is not an expected finding and the nurse should notify the physician.)
Probably the most widely used in-office or at-home occult blood test is the Hemoccult II. The patient has come to the clinic because he thinks there is blood in his stool. When you reviewed his medications, you noted he is on anti-hypertensive drugs and NSAIDs for early arthritic pain. You are sending the patient home with the supplies necessary to perform 2 hemoccult tests on his stool and mail the samples back to the clinic. What instruction would you give this patient? a) Take all your medications as usual. b) Take all your medications except the anti-hypertensive medications. c) Don't eat Jell-O for 72 hours before you start the test. d) Do not ingest vitamin C for 72 hours before you start the test.
ANSWER: D ( Can create a false negative)
A patient is scheduled to have a fecal occult blood test. Before the test, the nurse should instruct the patient to avoid: a) Non-steroidal anti-inflammatory drugs b) Acetaminophen c) Fish d) Carrots
Answer: A
Diarrhea Nursing Interventions:
Assess skin around anal area; clean with warm water and gentle soap; pat dry. Provide more rest period. Reduce anxiety. Give bland diet (low in fiber, e.g., white bread, fruits and vegetables without skin and seeds) or BRAT diet (extremely low in fiber, e.g., bananas, rice, applesauce, toast).
You are caring for a patient with constipation who has been prescribed bisacodyl (Dulcolax) for the management of this condition. You are providing teaching related to this medication and properly instruct the patient to follow which of the guidelines when taking this medication? a) Drink 8 ounces of water before and after taking the medication. b) Swallow the tablets without crushing or chewing. c) Take the medication with milk to avoid stomach upset. d) Avoid taking with meals due to impairment of fat-soluble vitamin absorption.
B
When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? a) Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. b) Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. c) The appendix may develop gangrene and rupture, especially in a middle-aged client. d) Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.
B (Rationale: A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing 57 venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Geriatric, not middle-aged, clients are especially susceptible to appendix rupture.)
The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate post-op period for which of the following most frequent complications of this type of surgery? a) Intestinal obstruction b) Fluid and electrolyte imbalance c) Malabsorption of fat d) Folate deficiency
B (Rationale: A major complication that occurs most frequent following an ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from happening. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.)
Case for the postoperative client after gastric resection should focus on which of the following problems? a) Body image b) Nutritional needs c) Skin care d) Spiritual needs
B (Rationale: After gastric resection, a client may require total parenteral nutrition or jejunostomy tube feedings to maintain adequate nutritional status.)
During the first few days of recovery from ostomy surgery for ulcerative colitis, which of the following aspects should be the first priority of client care? a) Body image b) Ostomy care c) Sexual concerns d) Skin care
B (Rationale: Although all of these are concerns the nurse should address, being able to safely manage the ostomy is crucial for the client before discharge.)
The client with severe abdominal pain is being evaluated for appendicitis. What is the most common cause of appendicitis? a) Rupture of the appendix b) Obstruction of the appendix c) A high-fat diet d) A duodenal ulcer
B (Rationale: Appendicitis most commonly results from obstruction of the appendix, which may lead to rupture. A high-fat diet or duodenal ulcer doesn't cause appendicitis; however, a client may require dietary restrictions after an appendectomy.)
A client with gastric cancer can expect to have surgery for resection. Which of the following should be the nursing management priority for the preoperative client with gastric cancer? a) Discharge planning b) Correction of nutritional deficits c) Prevention of DVT d) Instruction regarding radiation treatment
B (Rationale: Clients with gastric cancer commonly have nutritional deficits and may be cachectic. Discharge planning before surgery is important, but correcting the nutrition deficit is a higher priority. At present, radiation therapy hasn't been proven effective for gastric cancer, and teaching about it preoperatively wouldn't be appropriate. Prevention of DVT also isn't a high priority to surgery, though it assumes greater importance after surgery.)
Which of the following factors is believed to cause ulcerative colitis? a) Acidic diet b) Altered immunity c) Chronic constipation d) Emotional stress
B (Rationale: Several theories exist regarding the cause of ulcerative colitis. One suggests altered immunity as the cause based on the extraintestinal characteristics of the disease, such as peripheral arthritis and cholangitis. Diet and constipation have no effect on the development of ulcerative colitis. Emotional stress can exacerbate the attacks but isn't believed to be the primary cause.)
The nursing instructor is talking with their clinical group about constipation and the elderly. What should the instructor tell the students is the best recommendation a nurse can make about treating chronic constipation? a) Take a mild laxative, such as magnesium citrate, when necessary. b) Take a stool softener, such as docusate sodium (Colace), daily. c) Administer a tap-water enema weekly. d) Administer a phosphor-soda (Fleet) enema when necessary.
B (Rationale: Stool softeners taken daily promote absorption of liquid into the stool, creating a softer mass. They may be taken on a daily basis without developing dependence. Dependence is an adverse effect of daily laxative use. Enemas used daily or on a frequent basis can also lead to dependence of the bowel on an external source of stimulation.)
After a right hemicolectomy for treatment of colon cancer, a 57-year-old client is reluctant to turn while on bed rest. Which action by the nurse would be appropriate? a) Asking a co-worker to help turn the client. b) Explaining to the client why turning is important. c) Allowing the client to turn when he's ready to do so. d) Telling the client that the physician's order states he must turn every 2 hours.
B (Rationale: The appropriate action is to explain the importance of turning to avoid postoperative complications. Asking a coworker to help turn the client would infringe on his rights. Allowing him to turn when he's ready would increase his risk for postoperative complications. Telling him he must turn because of the physician's orders would put him on the defensive and exclude him from participating in care decision.)
A client with appendicitis is experiencing excruciating abdominal pain. An abdominal x-ray film reveals intraperitoneal air. The nurse should prepare the client for: a) Colonoscopy b) Surgery c) Nasogastric tube insertion d) Barium enema
B (Rationale: The client should be prepared for surgery because his signs and symptoms indicate bowel perforation. Appendicitis is the most common cause of bowel perforation in the United States. Because perforation can lead to peritonitis and sepsis, surgery wouldn't be delayed to perform other interventions, such as colonoscopy, NG tube insertion, or a barium enema. These procedures aren't necessary at this point.)
A client with irritable bowel syndrome is being prepared for discharge. Which of the following meal plans should the nurse give the client? should the nurse give the client? a) Low fiber, low-fat b) High fiber, low-fat c) Low fiber, high-fat d) High fiber, high-fat
B (Rationale: The client with irritable bowel syndrome needs to be on a diet that contains at least 25 grams of fiber per day. Fatty foods are to be avoided because they may precipitate symptoms.)
A 72-year-old female patient is admitted to the unit with pancreatic insufficiency. While assessing for the presence of malabsorption, the nurse recalls that malabsorption may be extra-intestinal in the older adult. What may the symptoms include? a) Shortness of breath and hypervolemia b) Fatigue and confusion c) Pruritus and muscle rigidity d) Darkening in skin pigmentation and tremors
B (Rationale: The older patient may have more subtle symptoms of malabsorption that may be extra-intestinal, including fatigue and confusion.)
The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation? a) Distilled water b) Tap water c) Sterile water d) Lactated Ringer's
B (Rationale: Warm tap water or saline solution is used to irrigate a colostomy. If the tap water is not suitable for drinking, then bottled water should be used.)
The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should: a) Contact the surgeon request an order for a narcotic for the pain. b) Maintain the client in a recumbent position. c) Place the client on NPO status. d) Apply heat to the abdomen in the area of the pain
C
You are caring for an elderly patient with a broken hip. When assessing the patient you find that they also have chronic constipation. What should be included in patient teaching to prevent constipation? a) Establish a bowel routine based upon the fact that the best time for defecation is after dinner. b) Exercise may prolong a bowel movement. c) Consume high-residue, high-fiber foods. d) Resist the urge to defecate until the scheduled time.
C
A client has an appendectomy. This is an example of what kind of surgery? a) Diagnostic b) Palliative c) Ablative d) Constructive
C (Rationale: Appendectomy is an example of ablative surgery. Diagnostic confirms or establishes a diagnosis, palliative relieves or reduces pain, and constructive restores function or appearance.)
A 57-year-old CEO of a large corporation presented at his primary physician's office with complaints of rectal bleeding and occasional lower abdominal pain. The nurse assessing the patient should suspect what? a) Ulcer b) Crohn's disease c) Rectal polyps d) Inflammatory bowel disease
C (Rationale: Clinical manifestations of polyps depend on the size of the polyp. The most common symptom is rectal bleeding. Lower abdominal pain may also occur. This patient would not have an ulcer, Crohn's disease, or inflammatory bowel disease with the presenting symptoms.)
A client's ulcerative colitis symptoms have been present for longer than 1 week. The nurse recognizes that the client should be assessed carefully for signs of which of the following complications? a) Heart failure b) DVT c) Hypokalemia d) Hypocalcemia
C (Rationale: Excessive diarrhea causes significant depletion of the body's stores of sodium and potassium as well as fluid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, DVT, or hypocalcemia.)
A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 pounds since the exacerbation of his ulcerative colitis. The nurse should anticipate that the physician will order which of the following treatment approaches to help the client meet his nutritional needs? a) Initiate continuous enteral feedings b) Encourage a high protein, high-caloric diet c) Implement total parenteral nutrition d) Provide six small meals a day
C (Rationale: Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client's nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into 6 small meals does not allow the bowel to rest. A high-calorie, high-protein diet will worsen the client's symptoms.)
The doctor ordered for a complete blood count. After the test, Nurse Ray received the result from the laboratory. Which laboratory values will confirm the diagnosis of appendicitis? a) RBC 5.5 x 106/mm3 b) Hct 44% c) WBC 13,000/mm3 d) Hgb 15 g/dL
C (Rationale: Increase in WBC counts is suggestive of appendicitis because of bacterial invasion and inflammation. Normal WBC count is 5,000- 10,000/mm3 . Other options are within normal values.)
Malabsorption can be caused by several disease processes. What is an infectious disease causing generalized malabsorption? a) Celiac sprue b) Zollinger-Ellison syndrome c) Whipple's disease d) Regional enteritis
C (Rationale: Infectious diseases causing generalized malabsorption {e.g., small bowel bacterial overgrowth, tropical sprue, Whipple's disease}. Celiac sprue and regional enteritis are mucosal transport diseases. Zollinger-Ellison syndrome is a luminal disorder.)
The student nurse is caring for a patient who is postoperative day 3 following a colostomy. While changing the dressing, the student nurse notes that the stoma is dusky in color. The student asks his preceptor what this might indicate. How should the nurse preceptor respond? a) This is a normal color postoperatively. b) The patient's oxygen saturation may be low. c) Circulation to the stoma is compromised. d) The stoma is blocked.
C (Rationale: Postoperative complications following colon resection may include hemorrhage, infection, and anastomosis. A healthy viable stoma should be pink. This does not indicate that the patient's oxygen saturation is low or that the stoma is blocked.)
An 18-year-old is admitted with an acute onset of right lower quadrant pain. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? a) Urinary retention b) Gastric hyperacidity c) Rebound tenderness d) Increased lower bowel motility
C (Rationale: Rebound tenderness is a classic subjective sign of appendicitis.)
A client with ulcerative colitis has an order to begin salicylate medication to reduce inflammation. The nurse instructs the client to take the medication; a) 30 minutes before meals b) On an empty stomach c) After meals d) On arising
C (Rationale: Salicylate compounds act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and to increase fluid intake throughout the day. This medication needs to be taken after meals to reduce GI irritation.)
A 16-year-old is brought to the clinic by her mother complaining of drainage at the top of her intergluteal cleft. The drainage is smelly, the diagnosis is pilonidal cyst, and the patient is started on antibiotics. Surgery to excise the cyst is scheduled. The nurse does preoperative teaching with the patient and her mother. The nurse explains the dressing the patient will have as the wound granulates. What kind of dressing will be used after surgery for a pilonidal cyst? a) Telfa and gauze packed into the wound b) Surgical pads packed into the wound c) Absorptive dressings placed in the wound 54 d) Wet to dry dressings placed in the wound
C (Rationale: The abscess is incised and drained under local anesthesia. After the acute process resolves, further surgery is performed to excise the cyst and the secondary sinus tracts. The wound is allowed to heal by granulation. Absorptive dressings are placed in the wound to keep its edges separated while healing process.)
A client with gastric cancer may exhibit which of the following symptoms? a) Abdominal cramping b) Constant hunger c) Feeling of fullness d) Weight gain
C (Rationale: The client with gastric cancer may report a feeling of fullness in the stomach, but not enough to cause him to seek medical attention. Abdominal cramping isn't associated with gastric cancer. Anorexia and weight loss (not increased hunger or weight gain) are common symptoms of gastric cancer.)
During the assessment of a client's mouth, the nurse notes the absence of saliva. The client is also complaining of pain near the area of the ear. The client has been NPO for several days because of the insertion of a NG tube. Based on these findings, the nurse suspects that the client is developing which of the following mouth conditions? a) Stomatitis b) Oral candidiasis c) Parotitis d) Gingivitis
C (Rationale: The lack of saliva, pain near the area of the ear, and the prolonged NPO status of the client should lea the nurse to suspect the development of parotitis, or inflammation of the parotid gland. Parotitis usually develops in cases of dehydration combined with poor oral hygiene or when clients have been NPO for an extended period. Preventative measures include the use of sugarless hard candy or gum to stimulate saliva production, adequate hydration, and frequent mouth care. Stomatitis (inflammation of the mouth) produces excessive salivation and a sore mouth)
A patient complaining of diarrhea presents at the walk in clinic and asks the nurse what they can do to find out what is causing their diarrhea. What would the nurse advise the patient? a) The doctor will just give you some medicine. b) Stay away from all food and drink you think might be causing the problem. c) An initial sensitivity may decrease with time. d) Any food or fluid can cause diarrhea.
C (Rationale: The nurse advises the patient to experiment with an irritating food several times before restricting it, because an initial sensitivity may decrease with time. The nurse can help identify any foods or fluids that may be causing diarrhea, such as fruits, high-fiber foods, soda, coffee, tea, or carbonated beverages.)
A 30-year-old client experiences weight loss, abdominal distention, crampy abdominal pain, and intermittent diarrhea after birth of her 2nd child. Diagnostic tests reveal gluten-induced enteropathy. Which foods must she eliminate from her diet permanently? a) Milk and dairy products b) Protein-containing foods c) Cereal grains (except rice and corn) d) Carbohydrates
C (Rationale: To manage gluten-induced enteropathy, the client must eliminate gluten, which means avoiding all cereal grains except for rice and corn. In initial disease management, clients eat a high calorie, high-protein diet with mineral and vitamin supplements to help normalize nutritional status.)
A client has surgery for a perforated appendix with localized peritonitis. In which position should the nurse place the client? a) Sims position b) Trendelenburg c) Semi-Fowler's d) Dorsal recumbent
C Rationale: Semi-Fowlers aids in drainage and prevents spread of infection throughout the abdominal cavitY.
The health care team is assessing a patient for acute pancreatitis after he presented to the emergency department with severe abdominal pain. Which laboratory value is the best diagnostic indicator of acute pancreatitis? a) Gastric pH b) Blood glucose c) Serum amylase d) Serum potassium
C Rationale: Serum amylase levels indicate pancreatic function, and they are used to diagnose acute pancreatitis. Blood glucose, gastric pH, and potassium levels are not direct indicators of acute pancreatic dysfunction.
Malabsorption Discharge Planning
Correct dietary and causative agent. Give vitamins and supplements. Understand and manage underlying cause. Replace and balance fluid and electrolytes.
You are caring for a patient diagnosed with malabsorption of calcium. When planning discharge teaching for this patient, what would be important to include? a) Risk of hypervitaminosis b) Risk of hypermagnesia c) Risk of osteomyelitis d) Risk of osteoporosis
D
Colon cancer is most closely associated with which of the following conditions? a) Appendicitis b) Hemorrhoids c) Hiatal hernia d) Ulcerative colitis
D (Rationale: Chronic ulcerative colitis, granulomas, and familial polyposis seem to increase a person's chance of developing colon cancer. The other conditions listed have not known effect on colon cancer risk.)
A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications? a) Deficient fluid volume b) Intestinal obstruction c) Bowel ischemia d) Peritonitis
D (Rationale: Complications of acute appendicitis are perforation, peritonitis, and abscess development. Signs of the development of peritonitis include abdominal pain and distention, tachycardia, tachypnea, nausea, vomiting, and fever. Because peritonitis can cause hypovolemic shock, hypotension can develop. Deficient fluid volume would not cause a fever. Intestinal obstruction would cause abdominal distention, diminished or absent bowel sounds, and abdominal pain. Bowel ischemia has signs and symptoms to those found with intestinal obstruction.)
Crohn's disease can be described as a chronic relapsing disease. Which of the following areas in the GI system may be involved with this disease? a) The entire length of the large colon b) Only the sigmoid area c) The entire large colon through the layers of mucosa and submucosa d) The small intestine and colon; affecting the entire thickness of the bowel
D (Rationale: Crohn's disease can involve any segment of the small intestine, the colon, or both, affecting the entire thickness of the bowel. Answers A and C describe ulcerative colitis; answer B is too specific and therefore, not likely.)
During the assessment of a patient with acute abdominal pain, the nurse should: a) Perform deep palpation before auscultation b) Obtain blood pressure and pulse rate to determine hypervolemic changes c) Auscultate bowel sounds because hyperactive bowel sounds suggest paralytic ileus d) Measure body temperature because an elevated temperature may indicate an inflammatory/infectious process
D (Rationale: For the patient complaining of acute abdominal pain, the nurse should take vital signs immediately. Increased pulse and decreasing blood pressure are indicative of hypovolemia. An elevated temperature suggests an inflammatory or infectious process. Intake and output measurements provide essential information about the adequacy of vascular volume. Inspect the abdomen first and then auscultate bowel sounds. Palpation is performed next and should be gentle.)
A client presents to the emergency room, reporting that he has been vomiting every 30 to 40 minutes for the past hours. Frequent vomiting puts him at risk for which of the following? a) Metabolic acidosis with hyperkalemia b) Metabolic acidosis with hypokalemia c) Metabolic alkalosis with hyperkalemia d) Metabolic alkalosis with hypokalemia
D (Rationale: Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive loss of these substances, such as from vomiting, can lead to metabolic alkalosis and hypokalemia.)
A nurse is caring for a patient with inflammatory bowel disease who is having an exacerbation and severe diarrhea. IV rehydration is in process. What would the nurse immediately report to the physician? a) Electrolyte imbalance b) Intractable pain c) Anorexia d) Dysrhythmias
D (Rationale: IV fluid therapy may be necessary for rapid rehydration in some patients, especially in elderly patients and in patients with preexisting GI conditions (e.g., inflammatory bowel disease). It is important to monitor serum electrolyte levels closely. The nurse immediately reports evidence of dysrhythmias or a change in a patient's level of consciousness. Options A, B, and C are important for the physician to know, but dysrhythmias are symptoms/complications that need to be treated immediately)
A client has an appendectomy and develops peritonitis. The nurse should assess the client for an elevated temperature and which additional clinical indication commonly associated with peritonitis? a) Hyperactivity b) Extreme hunger c) Urinary retention d) Local muscular rigidity
D (Rationale: Muscular rigidity over the affected area is a classic sign of peritonitis.)
Bobby, a 13-year-old is being seen in the emergency room for possible appendicitis. An important nursing action to perform when preparing Bobby for an appendectomy is to: a) Administer saline enemas to cleanse the bowels b) Apply heat to reduce pain c) Measure abdominal girth d) Continuously monitor pain
D (Rationale: Pain is closely monitored in appendicitis. In most cases, pain medication is not given until prior to surgery or until the diagnosis is confirmed to be able to closely monitor the progression of the disease. A sudden change in the character of pain may indicate rupture or bowel perforation. Administering an enema or applying heat may cause perforation and abdominal girth may not change with appendicitis.)
The client who has undergone creation of a colostomy has a nursing diagnosis of Disturbed body image. The nurse would evaluate that the client is making the most significant progress toward identified goals if the client: a) Watches the nurse empty the colostomy bag b) Looks at the ostomy site c) Reads the ostomy product literature d) Practices cutting the ostomy appliance
D (Rationale: The client is expected to have a body image disturbance after colostomy. The client progresses through normal grieving stages to adjust to this change. The client demonstrates the greatest deal of acceptance when the client participates in the actual colostomy care. Each of the incorrect options represent an interest in colostomy care but is a passive activity. The correct option shows the client is participating in self-care.)
A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care? a) Remove the dressing and leave the incision open to air. b) Remove the drain if wound drainage is minimal. c) Gently irrigate the drain to remove exudate. d) Clean the area around the drain moving away from the drain.
D (Rationale: The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and the drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should not the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated.)
A client complains of right lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory findings should be reported to the physician immediately? a) Hematocrit 42% b) Serum potassium 4.2 mEq/L c) Serum sodium 135 mEq/L d) WBC count 22.8/mm3
D (Rationale: The nurse should report the elevated WBC count. This finding, which is a sign of infection, indicates that the client's appendix might have ruptured. Hematocrit of 42%, serum potassium of 4.2 mEq/L, and serum sodium of 135 mEq/L are within normal limits. Alterations in these levels don't indicate appendicitis.)
A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left lower quadrant b) Left upper quadrant c) Right upper quadrant d) Right lower quadrant
D (Rationale: The pain of acute appendicitis localizes in the right lower quadrant (RLQ) at McBurney's point, an area midway between the umbilicus and the right iliac crest. Often, the pain is worse when manual pressure near the region is suddenly released, a condition called rebound tenderness.)
What would be a priority nursing diagnosis for a patient being treated for colon cancer? a) Risk for ineffective therapeutic regimen management r/t knowledge deficit concerning the diagnosis, the surgical procedure, and self-care before discharge b) Imbalanced nutrition, more than body requirements, r/t nausea and anorexia c) Risk for excess fluid volume r/t vomiting and dehydration d) Ineffective sexuality patterns r/t presence of ostomy and changes in body image and self-concept
D Rationale: Based on the assessment data, the major nursing diagnoses may include the following: Imbalanced nutrition, less than body requirements, related to nausea and anorexia; Risk for deficient fluid volume related to vomiting and dehydration; Anxiety related to impending surgery and the diagnosis of cancer; Risk for ineffective therapeutic regimen management related to knowledge deficit concerning the diagnosis, the surgical procedure, and self-care after discharge; Impaired skin integrity related to the surgical incisions (abdominal and perianal), the formation of a stoma, and frequent fecal contamination of peristomal skin; Disturbed body image related to colostomy; and Ineffective sexuality patterns related to presence of ostomy and changes in body image and self-concept.
Irritable Bowel Syndrome Nursing Interventions:
Encourage good dietary habits. Encourage to eat at regular times and to chew food slowly and thoroughly. Fluid should not be taken with meals because this results in abdominal distention. Avoid alcohol and smoking. Stress management via relaxation techniques, yoga, or exercise can be recommended.
Fecal Incontinence Nursing Intervention:
Initiate a bowel-training program that involves setting a schedule to establish bowel regularity. Use suppositories to stimulate the anal reflex. Biofeedback can be used to help the patient improve sphincter contractility and rectal sensitivity. (Biofeedback is the process of gaining greater awareness of many physiological functions primarily using instruments that provide information on the activity of those same systems, with a goal of being able manipulate them at will. Some of the processes that can be controlled include brainwaves, muscle tone, skin conductance, heart rate and pain perception). Give foods that thicken stool (e.g., applesauce) and fiber products (e.g., psyllium). Maintain skin hygiene. Teach the use of fecal incontinence devices such as external collection devices and internal drainage systems.
Irritable Bowel Syndrome Medical Management:
Limit foods that are irritating (beans, caffeinated products, corn, wheat, dairy lactose, fried foods, alcohol, spicy food, aspartame). Prescribe high-fiber diet (psyllium) to help control constipation. Metamucil for constipation; Imodium for diarrhea. Start first on anti-cholinergic and anti-spasmodic to decrease muscle spasms, cramping and constipation. Antidepressants not only treat depression but also slow the intestinal transit time and improve diarrhea and abdominal comfort. Tegaserod was previously used to treat women with IBS whose chief complaint was constipation, but stopped now, as it is associated with increased risk of myocardial infarction and stroke. Probiotics (Lactobacillus and Bifidobacterium) can be administered to help decrease bloating and gas. Complementary medicine approaches to treat IBS include artichoke leaf extract, peppermint oil, and caraway oil
Fecal Incontinence Causes:
Trauma after surgical procedures involving the rectum. Neurologic disorders such as CVA, multiple sclerosis, diabetic neuropathy, or dementia. Infection. Weak pelvic muscles. Laxative abuse. Weakness or loss of anal/rectal muscle tone due to advancing age.
