Porths Chapter 45
14. A 28-year-old man presents with complaints of diarrhea, fecal urgency, and weight loss. His stool is light colored and malodorous, and it tends to float and be difficult to flush. He has also noted tender, red bumps on his shins and complains of pain and stiffness in his elbows and knees. Sigmoidoscopy reveals discontinuous, granulomatous lesions; no blood is detected in his stool. Which of the following diagnoses would his care team first suspect? A) Crohn disease B) Ulcerative colitis C) Diverticulitis D) Colon cancer
Ans A Feedback: Crohn disease, like ulcerative colitis, causes diarrhea, fecal urgency, weight loss, and systemic symptoms such as erythema nodosum and arthritis. Unlike ulcerative colitis, it also causes steatorrhea but is not as likely to cause blood in the stool. The granulomatous "skip" lesions confirm the diagnosis of Crohn disease. Neither diverticulitis nor colon cancer would cause this combination of symptoms and signs.
3. A female neonate has been in respiratory distress since delivery and is unresponsive to oxygen therapy. Endoscopy has confirmed a diagnosis of esophageal atresia and tracheoesophageal fistulae (EA/TEF). Which of the following explanations should the care team provide to the infant's parents? A) "We will have to perform surgery to correct the hole in her throat to make sure that she is able to swallow and breathe normally." B) "This problem will require respiratory therapy and supplementary feeding, but it will likely resolve itself over time." C) "The biggest risk that your daughter will face until this is fixed is the danger of malnutrition and dehydration." D) "The priority in our immediate treatment prior to her surgery will be pain management, as the contents of her stomach can burn her lungs."
Ans A Feedback: EA/TFE necessitate surgery and preclude both normal respiration and swallowing. Aspiration is the primary immediate risk and the priority for treatment. Although the infant will require respiratory therapy to assist with proper tube placement and ventilator maintenance, the only effective treatment is surgery. Aspiration of feeding (aspiration pneumonia) is a major complication that can occur immediately and can be life threatening. Maintaining an open airway and adequate gas exchange are the priority nursing diagnoses for this infant.
16. A number of clients on a geriatric subacute medical floor of a hospital have developed foul-smelling diarrhea over the last several days, and subsequent culture of stool samples has confirmed the presence of Clostridium difficile in each case. The care team in the unit would recognize that which of the following factors likely contributed to the health problem and would anticipate which of the following treatments? A) The use of broad-spectrum antibiotics likely played a role in the development of infections, and most clients would likely receive metronidazole as a treatment. B) Genetic predisposition and the presence of the bacterium in clients' normal flora likely contributed, and treatment would consist of broad-spectrum antibiotics. C) Poor hand washing practice on the part of care providers led to the outbreak, and treatment will consist of hydration and nutritional support. D) Ingestion of contaminated food probably contributed to the infections, and corticosteroids will be needed to treat them.
Ans A Feedback: Elimination of the normal intestinal flora by broad-spectrum antibiotics commonly precedes infection by C. difficile, and metronidazole is the normal treatment. Neither genetic predisposition nor ingestion of contaminated food is a likely factor. While poor hand hygiene can spread the bacteria, treatment for C. difficile necessitates antibiotics and not simply hydration and nutritional support. The treatment of C. difficile is with antibiotics. Metronidazole is the drug of choice with vancomycin, being reserved for people who cannot tolerate metronidazole. Corticosteroids will not kill the bacterium.
4. A stroke patient is having difficulty swallowing food and beverages. The patient complains that he feels like "the food is sticking to the back of his throat." Given this information, the priority nursing interventions would be to A) make the patient "nothing per os" (NPO) and call the physician. B) feed the patient while he is sitting in an upright position. C) add a thickening agent to all of the patient's beverages. D) warrant no action since this is a normal occurrence after a stroke.
Ans A Feedback: People with dysphagia usually complain of choking, coughing, or an abnormal sensation of food sticking in the back of the throat or upper chest when they swallow. A neuromuscular cause involves lesions of the CNS, such as a stroke, which often involve the cranial nerves that control swallowing. Feeding in upright position is good once it is determined by swallowing evaluation that the patient can swallow food without it going into the lungs. Likewise, thickening agents help dysphagia patients after a swallow evaluation has been performed. No action could put the patient at risk for aspiration pneumonia.
9. A male patient has just been diagnosed with esophageal cancer. He knew that he was losing weight and fatigued most days, but he just attributed it to aging and working. The physician recommends chemotherapy and irradiation. However, the cancer has already metastasized. The patient asks the nurse what he can expect if he agrees to the treatments. The nurse responds, A) "The therapies may shrink the cancer." B) "The doctor is prescribing treatment measures to help you swallow better." C) "These therapies will most likely cure your cancer." D) "You need to talk with your physician some more. I will page him for you."
Ans A Feedback: The prognosis for people with cancer of the esophagus, although poor, has improved. Even with modern forms of therapy, the long-term survival is limited because, in many cases, the disease has already metastasized by the time the diagnosis is made. These therapies may help with food consumption, but that is not their primary purpose. Nor, will these therapies cure the cancer.
17. Parents have brought their 7-year-old child into the emergency room with abdominal pain. Which of the following clinical manifestations would lead the health care team to suspect the child has appendicitis? Select all that apply. A) Tenderness in right lower quadrant with palpation B) Rebound tenderness in inguinal areas with palpation C) Redness and warmth over right lower quadrant D) Bloating and flatulence noticeable E) Urine has the smell of stool with brown coloring
Ans A, B Feedback: Appendicitis usually has an abrupt onset. Palpation of the abdomen usually reveals a deep tenderness in the LRQ, which is confined to a small area approximately the size of the fingertip. It usually is located at approximately the site of the inflamed appendix. Rebound tenderness, which is pain that occurs when pressure is applied to the area and then released, and spasm of the overlying abdominal muscles are common. An abscess may display redness and warmth. Bloating and flatulence are usually seen with diverticular disease as is the development of fistula (vesicosigmoid), where stool is seen in the urine.
10. A 43-year-old male client has presented to the emergency department with vomiting that he claims is of a sudden onset. The client also states that the emesis has often contained frank blood in the hours prior to admission. His vital signs are stable with temperature 98.3°F, pulse 88, BP 140/87, and respiratory rate 18. Which of the following potential contributing factors would the health care team suspect first? A) Overuse of antacids B) Alcohol consumption C) Staphylococcal enterotoxins D) Effects of Helicobacter pylori
Ans B Feedback: Acute gastritis associated with alcohol use is characterized by intermittent vomiting and the possibility of hematemesis. Aspirin and H. pylori do not normally cause such an acute symptom onset, and infectious organisms do not normally cause bleeding of the stomach lining. A combination of calcium carbonate and magnesium is commonly found in antacids. Overdose of antacids can result in irregular heartbeat, poor balance, shallow, rapid breathing and stupor (lack of alertness).
19. The mother of a 19-week-old infant has brought her baby in for assessment to a pediatrician because of the baby's persistent weight loss and diarrhea. An intestinal biopsy has confirmed a diagnosis of celiac disease, and the child's mother is anxious to know what caused the disease. Which of the following aspects of the etiology of celiac disease would underlie the explanation that the physician provides? A) Bacterial or chemical invasion of the peritoneum leads to decreased nutrient absorption and transport. B) An inappropriate T-cell-mediated response results in increased levels of antibodies and an inflammatory response. C) Neurogenic or muscular inhibition of peristalsis results in inappropriate motility of ingested food in the lower small intestine and the colon. D) Inability to process or absorb the fat content of breast milk results in malnutrition and deficiency of fat-soluble vitamins.
Ans B Feedback: Celiac disease is rooted in an inappropriate immune response that initiates an inflammatory response, resulting in loss of absorptive villi. Bacterial or chemical invasion of the peritoneum is associated with peritonitis, while inhibition of peristalsis is associated with obstructions. An inability to process or absorb fat is associated with malabsorption syndrome.
11. A patient has recently been diagnosed with H. pylori gastritis. The nurse knows that this form of gastritis is usually treated with a combination of an antibiotic and A) antianxiety medications. B) proton pump inhibitors. C) lactulose, to reduce the blood ammonia levels. D) calcium carbonate, an antacid.
Ans B Feedback: H. pylori is associated with an increased risk of gastric adenocarcinoma, gastric atrophy, and peptic ulcer. It is less likely to contribute to IBD, esophagitis, or diverticular disease. Eradication of H. pylori is difficult. Treatment requires a combination therapy that includes the use of antibiotics and a proton pump inhibitor. The proton pump inhibitors have direct antimicrobial properties against H. pylori. Antianxiety medications will not kill the bacteria. H. pylori is not associated with elevated blood ammonia levels. Calcium carbonate is usually given to relieve heartburn caused by GERD.
2. A middle-aged male walks into the emergency department complaining of chest pain radiating to the neck, shortness of breath, and nausea. His heart rate is 120 and BP is 94/60. The ED physician recognizes the patient is having an acute MI with decreased cardiac output. The nurse identifies the nausea to be in response to A) the patient not having a very high pain tolerance. B) hypoxia exerting a direct effect on the chemoreceptor trigger zone. C) the patient not having digested his meal completely. D) fear of having to make major lifestyle changes.
Ans B Feedback: Hypoxia exerts a direct effect on the vomiting center (chemoreceptor trigger zone), producing nausea and vomiting. This direct effect probably accounts for the vomiting that occurs during periods of decreased cardiac output, shock, and environmental hypoxia. We are given no information about the patient's pain tolerance, when he last had a meal, or his routine lifestyle. This patient is going into shock (rapid pulse, low BP) that can result in shunting of blood away from the gut and other organs. During shock, the priority organs for oxygenation include the heart, brain, lungs, and kidneys.
13. Which of the following clients is most clearly displaying the signs and symptoms of irritable bowel disease (IBD)? A) A 32-year-old mother who complains of intermittent abdominal pain that is worse during her menstrual period B) A 51-year-old male who states that his stomach pain is in his lower abdomen, "comes and goes," and "feels more like a cramp than a dull ache" C) A 44-year-old man who works the evening shift at a factory and who states that his lower abdominal pain is much worse at night than during the day D) A 24-year-old man who has a stressful job but whose diarrhea and cramping do not worsen during periods of high stress
Ans B Feedback: IBD is commonly manifested as intermittent lower abdominal pain that feels like cramping. Defecation normally relieves the pain, and symptoms are normally not present at night or during sleep. Stress commonly exacerbates symptoms.
18. A 22-year-old student has developed a fever and diarrhea while on a backpacking trip in Southeast Asia. His oral temperature is 101.4°F. The diarrhea is bloody, frequent, and small in volume. These clinical manifestations are sufficiently distressing that he is visiting a local medical clinic in the area. Which of the following diagnoses best characterizes this health problem? A) Noninflammatory diarrhea B) Inflammatory diarrhea C) Factitious diarrhea D) Secretory diarrhea
Ans B Feedback: Inflammatory diarrhea is often characterized by small-volume diarrhea that is bloody and accompanied by a fever. Noninflammatory diarrhea is normally larger in volume and not bloody. Factitious diarrhea is normally attributable to laxative use, and secretory diarrhea is associated with increased secretory processes of the bowel; neither is likely to produce bloody stool.
8. A 68-year-old African American man who has smoked for at least 50 years reports that lately he feels as though food is getting stuck in his throat. At first, this was a problem just with dry food, but now his morning oatmeal is getting "stuck." On questioning, he reports drinking at least three alcoholic beverages nearly every day. His problem is most likely A) achalasia. B) squamous cell carcinoma of the esophagus. C) dysphagia secondary to scleroderma. D) gastrointestinal reflux disease.
Ans B Feedback: Squamous cell carcinoma of the esophagus is the seventh leading cause of cancer death among men, particularly black men; mean age at diagnosis is 67 years. Alcohol and tobacco use are the main risk factors for this cancer, and dysphagia is a common presenting complaint. An esophageal motility disorder involves the smooth muscle layer of the esophagus and the lower esophageal splincter (LES). Achalasia is characterized by difficulty swallowing and regurgitation. GERD (gastroesophageal reflux disease) is a condition that causes the esophagus to become irritated and inflamed. Clients with GERD usually feel a burning in the chest or throat called heartburn. Sometimes, they taste stomach fluid in the back of the mouth.
5. A nurse practitioner is providing care for a male client with a long-standing hiatal hernia. Which of the following statements most accurately captures an aspect of the pathophysiology of hiatal hernias? A) Paraesophageal hiatal hernias are common and are normally not treated if the client is asymptomatic. B) The root causes of hiatal hernias are normally treatable with medication. C) If esophageal acid clearance is impaired, esophagitis can result. D) An incompetent pyloric sphincter and high-fat diet are commonly implicated in the development of hiatal hernias.
Ans C Feedback: Erosive esophagitis can be a complication of hiatal hernias if esophageal acid clearance is significantly impaired. Paraesophageal hiatal hernias are more serious than the sliding variety and require treatment. The root cause of hiatal hernias, herniation of the stomach through the diaphragm, is not normally amenable to treatment with medication. The pyloric sphincter is not associated with hiatal hernias.
7. Parents of a 20-month-old infant report that he refuses food or eats poorly and that he grimaces when he swallows. He also is irritable and cries a lot. The mother is worried that he ate something inappropriate this morning, because he vomited something that looked like coffee grounds. Which of the following health problems would the care team first suspect? A) Rotavirus infection B) Appendicitis C) Esophagitis from gastrointestinal reflux D) Hirschsprung disease
Ans C Feedback: Esophagitis secondary to reflux can cause feeding problems, early satiety, and hematemesis. Infants may demonstrate signs of pain when swallowing and may be irritable and cry frequently. Rotavirus causes diarrhea and vomiting, but not the other symptoms. Appendicitis is inflammation of the appendix. Appendicitis usually starts with the main symptom of pain around the navel that moves to the lower right abdomen. Hirschsprung disease is a blockage of the large intestine due to improper muscle movement in the bowel. It is a congenital condition, which means it is present from birth. In Hirschsprung disease, the nerves are missing from a part of the bowel. One primary s/s is a failure to pass meconium shortly after birth.
12. Following a history of gastric pain and an endoscopy, a client has been diagnosed with a duodenal peptic ulcer. Which of the following teaching points should his caregiver provide? A) "While your diet most certainly contributed to this problem, the good news is that changing your diet can help solve it." B) "Ulcers like yours do not penetrate all layers of the stomach or duodenum, so you don't have to worry about losing too much blood." C) "Your family history, your smoking history, and NSAID use may all have contributed to this problem." D) "While there aren't really any effective medications for these ulcers, changes in lifestyle can keep them well controlled."
Ans C Feedback: Family history, NSAID use, and smoking have all been identified as contributing factors in the development of peptic ulcers. Diet therapy has not been shown to be effective, and duodenal peptic ulcers are more common than the gastric variant. Perforation occurs when an ulcer erodes through all layers of the stomach or duodenum wall. When perforation occurs in older adults, their mortality is significantly increased. Effective medication regimens are available with antacids, H2-receptor antagonists or proton pump inhibitors being the most common medications used.
20. A 71-year-old male has been recently diagnosed with a stage III tumor of colorectal cancer and is attempting to increase his knowledge base of his diagnosis. Which of the following statements about colorectal cancer demonstrates a sound understanding of the disease? A) "If accurate screening test for this type of cancer existed, it could likely have been caught earlier." B) "The NSAIDs and aspirin that I've been taking for many years probably contributing to me getting cancer." C) "While diet is thought to play a role in the development of colorectal cancer, the ultimate causes are largely unknown." D) "A large majority of patients who have my type of colon cancer survive to live many more years."
Ans C Feedback: The etiology of cancer of the colon and rectum remains largely unidentified, though dietary factors are thought to exist. The prognosis, especially with stage III tumors, is poor. Simple and accurate screening tests do exist for colorectal cancer, while drugs are not implicated in the etiology.
1. The nurse walks into a room and finds the patient forcefully expelling stomach contents into a wash basin. When documenting this occurrence, the nurse will use the term A) nauseous. B) retching. C) vomiting. D) expatriate.
Ans C Feedback: Vomiting or emesis is the sudden and forceful oral expulsion of the contents of the stomach. It is usually preceded by nausea. Nausea is a subjective and unpleasant sensation. Retching consists of rhythmic spasmodic movements of the diaphragm, chest wall, and abdominal muscles. It usually precedes or alternates with periods of vomiting. Expatriate means to banish or withdraw.
6. After several months of persistent heartburn, a 57-year-old female client has been diagnosed with gastroesophageal reflux disease (GERD). Which of the following treatment regimens is likely to best address the woman's health problem? A) Surgical correction of the incompetent pylorus B) Antacids; avoiding positions that exacerbate reflux; a soft-textured diet C) Weight loss and administration of calcium channel blocking medications D) Proton pump inhibitors; avoiding large meals; remaining upright after meals
Ans D Feedback: Proton pump inhibitors block the final stage of gastric acid production, effectively controlling the root cause of the esophageal damage associated with GERD. The pylorus is not involved, and a soft diet is not indicated. Calcium channel-blocking drugs would not address the problem. Calcium channel blockers are primarily heart disease drugs that relax blood vessels and increase the supply of blood and oxygen to the heart while also reducing the heart's workload.
15. A 20-year-old woman has visited her family physician due to occasional bouts of bloody diarrhea over the past several weeks, a phenomenon that she experienced 2 years prior as well. Her physician has diagnosed her with ulcerative colitis based on her history and visualization of the affected region by colonoscopy and sigmoidoscopy. Which of the following pathophysiological phenomena is most likely to underlie the client's health problem? A) Fissures and crevices developing in the mucosa that are seen as a characteristic "cobblestone" appearance B) Erosion of the endothelial lining of the distal small intestine by a combination of genetic, autoimmune, and environmental factors C) Compromise of the mucosal layer of the large intestinal surface by the effects of H. pylori D) Mucosal hemorrhages that have developed into crypt abscesses, which have in turn necrotized and ulcerated
Ans D Feedback: The etiology and course of ulcerative colitis involves mucosal hemorrhages developing into crypt abscesses, with consequent necrosis and ulceration. "Cobblestone" appearance of intestinal mucosa is associated with Crohn disease. Ulcerative colitis is confined to the colon and rectum, and H. pylori is not commonly implicated in the etiology.
