PREPU GI assessment/ glossary (final)

When examining the abdomen of a client with complaints of nausea and vomiting, which of the following would the nurse do first? Palpation Percussion Auscultation Inspection

Inspection

The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? Use all options. 1 Auscultation 2 Palpation 3 Inspection 4 Percussion

Inspection Auscultation Percussion Palpation

The nurse is working with clients with digestive tract disorders. Which of the following organs does the nurse realize has effects as an exocrine gland and an endocrine gland? Stomach Gallbladder Liver Pancreas

Pancreas

After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? Liver Stomach Large Intestine Ileum

Stomach

pepsin:

a gastric enzyme that is important in protein digestion

lipase:

an enzyme that aids in the digestion of fats

A client tells the nurse that the stool was colored yellow. The nurse assesses the client for a. occult blood. b. recent foods ingested. c. pilonidal cyst. d. ingestion of bismuth.

b. recent foods ingested.

esophagus:

collapsible tube connecting the mouth to the stomach, through which food passes as it is ingested

The nurse is assisting the physician in a percutaneous liver biopsy. In assisting with positioning, the nurse should assist the client into a: a. high Fowler's position. b. lithotomy position. c. dorsal recumbent position. d. supine position.

d. supine position.

The nurse recognizes which change of the GI system is an age-related change? a. increased motility b. increased mucus secretion c. hypertrophy of the small intestine d. weakened gag reflex

d. weakened gag reflex

stomach:

distensible pouch into which the food bolus passes to be digested by gastric enzymes

trypsin:

enzyme that aids in the digestion of protein

dyspepsia:

indigestion; upper abdominal discomfort associated with eating

fibroscopy (gastrointestinal):

intubation of a part of the GI system with a flexible, lighted tube to assist in diagnosis and treatment of diseases of that area

anus:

last section of the gastrointestinal (GI) tract; outlet for waste products from the GI system

small intestine:

longest portion of the GI tract, consisting of three parts—duodenum, jejunum, and ileum—through which food mixed with all secretions and enzymes passes as it continues to be digested and begins to be absorbed into the bloodstream

elimination:

phase of the digestive process that occurs after digestion and absorption, when waste products are evacuated from the body

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. The nurse tells the client that products of digestion are absorbed mainly in the: large intestine. small intestine. stomach. rectum.

small intestine.

large intestine:

the portion of the GI tract into which waste material from the small intestine passes as absorption continues and elimination begins; consists of several parts—ascending segment, transverse segment, descending segment, sigmoid colon, and rectum; also known as the colon

intrinsic factor:

a gastric secretion that combines with vitamin B12 so that the vitamin can be absorbed

digestion:

phase of the digestive process that occurs when digestive enzymes and secretions mix with ingested food and when proteins, fats, and sugars are broken down into their component smaller molecules

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? 4 days 2 days 1 day 3 days

3 days As much as 25% of the waste products from a meal may still be in the rectum 3 days after a meal is ingested.

Which of the following digestive enzymes aids in the digesting of starch? Lipase Amylase Bile Trypsin

Amylase

The nurse is caring for a client following gastrointestinal diagnostic testing. The client verbalizes being ashamed because he is having frequent gas. Which nursing suggestion is best? a. "Do not be ashamed. Everyone has gas following the procedure." b. "Nurses anticipate that client will have gas following the procedure and provide privacy." c. "The nursing staff is used to having clients with gas due to the procedure completed." d. "Having gas following the procedure is normal. Expel the gas to decrease discomfort."

d. "Having gas following the procedure is normal. Expel the gas to decrease discomfort."

A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test? a. "I'll drink full liquids the day before the test." b. "I'll take a laxative to clear my bowels before the test." c. "There is no need for special preparation before the test." d. "I'll avoid eating or drinking anything 6 to 8 hours before the test."

d. "I'll avoid eating or drinking anything 6 to 8 hours before the test."

ingestion:

phase of the digestive process that occurs when food is taken into the GI tract via the mouth and esophagus

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption? a. Hydrochloric acid b. Histamine c. Liver enzyme d. Intrinsic factor

Intrinsic factor

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? a. ileum b. duodenum c. jejunum d. cecum

b. duodenum

A client is scheduled for magnetic resonance imaging (MRI). During the client teaching, the nurse will discuss which of the following? a. "Do you experience any claustrophobia?" b. "You must remove all jewelry but can wear your wedding ring." c. "You must be NPO for the day before the examination." d. "The examination will take only 15 minutes."

a. "Do you experience any claustrophobia?" 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.

Which of the following is an enzyme secreted by the gastric mucosa? a. Pepsin b. Trypsin c. Ptyalin d. Bile

a. Pepsin

The nurses assesses the client for blood in the stool due to an upper GI condition. The nurse understands that if there is blood in the stool, the stool will be which color? a. tarry black b. green c. bright red d. milky white

a. tarry black

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are a. absent. b. sluggish. c. hypoactive. d. normal.

c. Normal Normal bowel sounds are heard every 5 to 20 seconds. Hypoactive bowel sound is the description given to auscultation of one to two bowel sounds in 2 minutes. Sluggish is not a term a nurse would use to accurately describe bowel sounds. The nurse records that bowel sounds are absent when no sound is heard in 3 to 5 minutes.

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? a. Green b. Dark brown c. Red d. Black

d. Black

The nurse prepares a client for a barium enema. The nurse should place the client on which diet prior to the procedure? a. nothing by mouth (NPO) 2 days prior b. high-fiber diet 1 to 2 days prior c. soft diet 1 day prior d. clear liquids day before

d. clear liquids day before

The nurse is caring for a geriatric client and notices polypharmacy. Which diagnostic studies are anticipated? a. Liver function studies b. Blood chemistry c. Urinalysis d. Complete blood count

a. Liver function studies The liver metabolizes and biotransforms the medications ingested. Geriatric clients who experience polypharmacy or multiple medications have an elevated risk of liver impairment. Routine liver function studies monitor the status of the liver and its ability to metabolize.

amylase:

an enzyme that aids in the digestion of starch

The nurse is preparing to measure the client's abdominal girth as part of the physical examination. At which location would the nurse most likely measure? a. At the lower border of the liver b. In the right upper quadrant c. Just below the last rib d. At the umbilicus

d. At the umbilicus Measurement of abdominal girth is done at the widest point, which is usually the umbilicus. The right upper quadrant, lower border of the liver, or just below the last rib would be inappropriate sites for abdominal girth measurement.

While completing an abdominal assessment, the nurse will use which landmark as the upper boundary for auscultating bowel sounds? a. Umbilicus b. Xiphoid process c. T12 to L3 vertebrae d. Symphysis pubis

b. Xiphoid process Understanding the division of the abdomen into four quadrants or nine regions helps the nurse to complete thorough assessment. The xiphoid process in the epigastric region is the upper boundary for auscultating bowel sounds.

A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test? a. "I'll drink full liquids the day before the test." b. "I'll take a laxative to clear my bowels before the test." c. "I'll avoid eating or drinking anything 6 to 8 hours before the test." d. "There is no need for special preparation before the test."

c. "I'll avoid eating or drinking anything 6 to 8 hours before the test."

Gastrin has which of the following effects on gastrointestinal (GI) motility? a. Relaxation of gastroesophageal sphincter b. Increased motility of the stomach c. Relaxation of the colon d. Contraction of the ileocecal sphincter

b. Increased motility of the stomach 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 of the following would be most important to ensure that a client does not retain any barium after a barium swallow? a. Monitoring the volume of urine. b. Observing the color of urine. c. Monitoring the stool passage and its color. d. Placing any stool passed in a specific preservative.

c. 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. (less)

A client is scheduled for several diagnostic tests to evaluate her gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when she identifies which test as not requiring the use of a contrast medium? a. Upper GI series b. Computer tomography c. Small bowel series d. Colonoscopy

d. Colonoscopy

The nurse is assisting the physician in a percutaneous liver biopsy. In assisting with positioning, the nurse should assist the client into a: a. high Fowler's position. b. lithotomy position. c. dorsal recumbent position. d. supine position.

d. supine position.

The nurse is preparing to examine the abdomen of a client complaining of a change in his bowel pattern. The nurse would place the client in which position? a. Lithotomy b. Knee-chest c. Supine with knees flexed d. Left Sim's lateral

c. Supine with knees flexed

Which of the following is considered the gold standard for the diagnosis of liver disease? Cholecystography Biopsy Ultrasonography Paracentesis

Biopsy

A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers: a. "It indicates if a cancer is present." b. "It determines functionality of the liver." c. "It detects a protein normally found in the blood." d. "It tells the physician what type of cancer is present."

a. "It indicates if a cancer is present."

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? Triglycerides Glucose Protein Starch

Triglycerides

An adult patient is scheduled 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. Fluids must be increased to facilitate the evacuation of the stool. b. The barium may cause diarrhea. c. Stool will be yellow for the first 24 hours postprocedure. d. This series includes analysis of gastric secretions.

a. Fluids must be increased to facilitate the evacuation of the stool.

A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered? a. Permit the client to drink only clear liquids. b. Allow the client to ingest fat-free meal. c. Provide saline gargles to the client. d. Instruct the client to have low-residue meals.

a. Permit the client to drink only clear liquids.

achalasia:

absence of peristalsis of the lower esophagus resulting in difficulty swallowing, regurgitation, and sometimes pain

hydrochloric acid:

acid secreted by the glands in the stomach; mixes with chyme to break it down into absorbable molecules and to aid in the destruction of bacteria

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? a. Ileocecal valve b. Pyloric sphincter c. Cardiac sphincter d. Hypoharyngeal sphincter

b. Pyloric sphincter

During a colonoscopy with moderate sedation, the patient groans with obvious discomfort and begins bleeding from the rectum. The patient is diaphoretic and has an increase in abdominal girth from distention. What complication of this procedure is the nurse aware may be occurring? a. Infection b. Rectal fissure c. Bowel perforation d. Colonic polyp

c. Bowel perforation

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? a. Observing for distended abdominal veins b. Examining the sclera if it is yellow c. Checking if the skin is discolored d. Checking if the mucous membranes are dry

d. Checking if the mucous membranes are dry

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? a. The client may eat a light meal before either test. b. Both tests need to be done before breakfast. c. The upper GI should be scheduled before the ultrasonography. d. The ultrasonography should be scheduled before the GI procedure.

d. The ultrasonography should be scheduled before the GI procedure.

The nurse determines one or two bowel sounds in 2 minutes should be documented as hypoactive. absent. normal. hyperactive.

hypoactive.

chyme:

mixture of food with saliva, salivary enzymes, and gastric secretions that is produced as food passes through the mouth, esophagus, and stomach

absorption:

phase of the digestive process that occurs when small molecules, vitamins, and minerals pass through the walls of the small and large intestine and into the bloodstream