Ch 42 Upper Gastrointestinal Problems

Following a Billroth II procedure, a patient develops dumping syndrome. The nurse should explain that the symptoms associated with this problem are caused by a. distention of the smaller stomach by too much food and fluid intake. b. hyperglycemia caused by uncontrolled gastric emptying into the small intestine. c. irritation of the stomach lining by reflux of bile salts because the pylorus has been removed. d. movement of fluid into the small bowel from concentrated food and fluids moving rapidly into the intestine.

. d. Because there is no sphincter control of food taken into the stomach following a Billroth II procedure, concentrated food and fluid move rapidly into the small intestine, creating a hypertonic environment that pulls fluid from the bowel wall into the lumen of the intestine, reducing plasma volume and distending the bowel. Postprandial hypoglycemia occurs when the concentrated carbohydrate bolus in the small intestine results in hyperglycemia and the release of excessive amounts of insulin into the circulation, resulting in symptoms of hypoglycemia. Irritation of the stomach by bile salts causes epigastric distress after meals, not dumping syndrome.

Which medications are used to decrease gastric or HCl secretion (select all that apply)? a. Famotidine (Pepcid) b. Sucralfate (Carafate) c. Omeprazole (Prilosec) d. Misoprostol (Cytotec) e. Bethanechol (Urecholine)

a, c, d. Famotidine (Pepcid) reduces HCl secretion by blocking histamine and omeprazole (Prilosec) decreases gastric acid secretion by blocking adenosine triphosphatase (ATPase) enzyme. Misoprostol (Cytotec) has antisecretory effects. Sucralfate (Carafate) coats the ulcer to protect it from acid erosion. Bethanechol (Urecholine) for GERD increases LES pressure and facilitates gastric emptying

The nurse is planning to teach the patient with gastroesophageal reflux disease (GERD) about foods or beverages that decrease LES pressure. What should be included in this list (select all that apply)? a. Alcohol b. Root beer c. Chocolate d. Citrus fruits e. Fatty foods f. Cola sodas

a, c, e, f. Alcohol, chocolate, fatty foods, and cola sodas (caffeine) as well as peppermint and spearmint will decrease lower esophageal sphincter (LES) pressure. Root beer and herbal tea do not have caffeine. Citrus fruits will not affect LES pressure.

Duodenal and gastric ulcers have similar as well as differentiating features. What characteristics are unique to duodenal ulcers (select all that apply)? a. Pain is relieved with eating food. b. They have a high recurrence rate. c. Increased gastric acid secretion occurs. d. Associated with Helicobacter pylori infection. e. Hemorrhage, perforation, and obstruction may result. f. There is burning and cramping in the midepigastric area.

a, c, f. Duodenal ulcers have increased HCl gastric secretion, which causes the burning and cramping in the midepigastric area; the pain is relieved with food. The other options occur with both duodenal and gastric ulcers

Nursing management of the patient with chronic gastritis includes teaching the patient to a. maintain a nonirritating diet with 6 small meals a day. b. take antacids before meals to decrease stomach acidity. c. eliminate alcohol and caffeine from the diet when symptoms occur. d. use nonsteroidal antiinflammatory drugs (NSAIDs) instead of aspirin for minor pain relief.

a. A nonirritating diet with 6 small meals a day is recommended to help control the symptoms of gastritis. Antacids are often used for control of symptoms but have the best neutralizing effect if taken after meals. Alcohol and caffeine should be eliminated entirely because they may precipitate gastritis. Nonsteroidal antiinflammatory drugs (NSAIDs) are often as irritating to the stomach as aspirin and should not be used in the patient with gastritis.

Which type of gastritis is most likely to occur in a college student who has an isolated drinking binge? a. Acute gastritis b. Chronic gastritis c. Helicobacter pylori gastritis d. Autoimmune metaplastic atrophic gastritis

a. Acute gastritis is most likely to occur with an isolated drinking binge. Chronic gastritis is usually caused by Helicobacter pylori or viral and fungal infections. Autoimmune gastritis is an inherited condition.

Which statement by a patient with dumping syndrome should lead the nurse to determine that further dietary teaching is needed? a. "I should eat bread and jam with every meal." b. "I should avoid drinking fluids with my meals." c. "I should eat smaller meals about 6 times a day." d. "I need to lie down for 30 to 60 minutes after my meals."

a. Dietary control of dumping syndrome includes small, frequent meals with low carbohydrate content and elimination of fluids with meals. The patient should also lie down for 30 to 60 minutes after meals. These measures help delay stomach emptying, preventing the rapid movement of a high-carbohydrate food bolus into the small intestine.

What type of bleeding will a patient with peptic ulcer disease with a slow upper GI source of bleeding have? a. Melena b. Occult blood c. Coffee-ground emesis d. Profuse bright-red hematemesis

a. Melena is black, tarry stools from slow bleeding from an upper gastrointestinal (GI) source when blood passes through the GI tract and is digested. Occult blood is the presence of guaiac-positive stools or gastric aspirate. Coffee-ground emesis is blood that has been in the stomach for some time and has reacted with gastric secretions. Profuse bright-red hematemesis is arterial blood that has not been in contact with gastric secretions, as in esophageal or oral bleeding.

Which patient is at highest risk of having a gastric ulcer? a. 55-year-old female smoker with nausea and vomiting b. 45-year-old female admitted for illicit drug detoxification c. 27-year-old male who is being divorced and has back pain d. 37-year-old male smoker who was in an accident while looking for a job

a. The 55-year-old female smoker experiencing nausea and vomiting is more likely to have a gastric ulcer. The other patients are not in the highest-risk age range or do not have enough risk factors. Although lower socioeconomic status, smoking, and drug use increase the risk of gastric ulcers, these patients are more likely to have duodenal ulcers but further assessment is needed.

Regardless of the precipitating factor, what causes the injury to mucosal cells in peptic ulcers? a. Acid back diffusion into the mucosa b. The release of histamine from gastrointestinal (GI) cells c. Ammonia formation in the mucosal wall d. Breakdown of the gastric mucosal barrier

a. The ultimate damage to the tissues of the stomach and duodenum, precipitating ulceration, is acid back diffusion into the mucosa. The gastric mucosal barrier is protective of the mucosa but without the acid environment and damage, ulceration does not occur. Ammonia formation by H. pylori and release of histamine impair the barrier but are not directly responsible for tissue injury.

Which statements describe the use of antacids for peptic ulcer disease (select all that apply)? a. Used in patients with verified H. pylori b. Neutralize HCl in the stomach c. Produce quick, short-lived relief of heartburn d. Cover the ulcer, protecting it from erosion by acids e. High incidence of side effects and contraindications f. May be given hourly after an acute phase of GI bleeding

b, c, f. Antacids provide a quick, short-lived relief of heartburn by neutralizing HCl in the stomach that prevents the conversion of pepsinogen to pepsin. Antacids may be given hourly, orally or through an NG tube, after an acute phase of GI bleeding to neutralize HCl in the stomach. Amoxicillin/clarithromycin/omeprazole are used in patients with verified H. pylori. Sucralfate (Carafate) covers the ulcer to protect it from acid erosion. The side effects are manageable.

Which esophageal disorder is described as a precancerous lesion and is associated with GERD? a. Achalasia b. Barrett's esophagus c. Esophageal strictures d. Esophageal diverticul

b. Barrett's esophagus is an esophageal metaplasia primarily related to gastroesophageal reflux disease (GERD). Achalasia is a rare chronic disorder with delayed emptying of the lower esophagus and is associated with squamous cell cancer. Esophageal strictures are narrowing of the esophagus from scarring by many causes. Esophageal diverticula are saclike outpouchings of 1 or more layers of the esophagus. They often occur above the esophageal sphincter.

Following a patient's esophagogastrostomy for cancer of the esophagus, what is most important for the nurse to do? a. Report any bloody drainage from the NG tube. b. Maintain the patient in semi-Fowler's or Fowler's position. c. Monitor for abdominal distention that may disrupt the surgical site. d. Expect to find decreased breath sounds bilaterally because of the surgical approach.

b. Following esophageal surgery, the patient should be positioned in semi-Fowler's or Fowler's position to prevent reflux and aspiration of gastric sections. NG drainage is expected to be bloody for 8 to 12 hours postoperatively. Abdominal distention is not a major concern following esophageal surgery, and even though the thorax may be opened during the surgery, clear breath sounds should be expected in all areas of the lungs.

Corticosteroid medications are associated with the development of peptic ulcers because of which pathophysiologic mechanism? a. The enzyme urease is produced. b. Secretion of hydrochloric acid is increased. c. The rate of mucous cell renewal is decreased. d. The synthesis of mucus and prostaglandins is inhibited.

c. Corticosteroids decrease the rate of mucous cell renewal. H. pylori produces the enzyme urease. Alcohol ingestion increases the secretion of HCl. Aspirin and NSAIDs inhibit the synthesis of mucus and prostaglandins.

The nurse determines that teaching for the patient with peptic ulcer disease has been effective when the patient makes which statement? a. "I should stop all my medications if I develop any side effects." b. "I should continue my treatment regimen as long as I have pain." c. "I have learned some relaxation strategies that decrease my stress." d. "I can buy whatever antacids are on sale because they all have the same effect."

c. Increased vagal stimulation from emotional stress causes hypersecretion of HCl, and stress reduction is an important part of the patient's management of peptic ulcers, especially duodenal ulcers. If side effects to medications develop, the patient should notify the HCP before altering the drug regimen. Although effective treatment will promote pain relief in several days, the treatment regimen should be continued until there is evidence that the ulcer has healed completely. Interchanging brands and preparations of antacids and histamine (H2 )-receptor blockers without checking with HCPs may cause harmful side effects, and patients should take only prescribed medications.

A patient with a history of peptic ulcer disease is hospitalized with symptoms of a perforation. During the initial assessment, what should the nurse expect the patient to report? a. Vomiting of bright-red blood b. Projectile vomiting of undigested food c. Sudden, severe generalized abdominal and back pain d. Hyperactive bowel sounds and upper abdominal swelling

c. Perforation of an ulcer causes sudden, severe abdominal pain that becomes generalized and may be referred to the back, accompanied by a rigid, boardlike abdomen, shallow respirations, and a weak rapid heart rate. Vomiting of blood indicates hemorrhage of an ulcer. Gastric outlet obstruction is characterized by projectile vomiting of undigested food, hyperactive stomach sounds, and upper abdominal swelling.

How should the nurse teach the patient with a hiatal hernia or GERD to control symptoms? a. Drink 10 to 12 ounces of water with each meal. b. Space 6 small meals a day between breakfast and bedtime. c. Sleep with the head of the bed elevated on 4- to 6-inch blocks. d. Perform daily exercises of toe-touching, sit-ups, and weight lifting.

c. The use of blocks to elevate the head of the bed facilitates gastric emptying by gravity and is strongly recommended to prevent nighttime reflux. Liquids should be taken between meals to prevent gastric distention with meals. Small meals should be eaten frequently, but patients should not eat at bedtime or lie down for 2 to 3 hours after eating. Activities that involve increasing intraabdominal pressure, such as bending over, lifting, or wearing tight clothing, should be avoided.

What does the nurse include when teaching a patient with newly diagnosed peptic ulcer disease? a. Maintain a bland, soft, low-residue diet. b. Use alcohol and caffeine in moderation and always with food. c. Eat as normally as possible, eliminating foods that cause pain or discomfort. d. Avoid milk and milk products because they stimulate gastric acid production.

c. There is no specific diet used for the treatment of peptic ulcers, and patients are encouraged to eat as normally as possible, eliminating foods that cause discomfort or pain. Eating 6 meals a day prevents the stomach from being totally empty and is recommended. Caffeine and alcohol should be eliminated from the diet because they are known to cause gastric irritation. Milk and milk products do not have to be avoided but they can add fat content to the diet

A patient with esophageal cancer is scheduled for a partial esophagectomy. Which nursing intervention has highest priority preoperatively? a. Practice turning and deep breathing. b. Brush the teeth and mouth well each day. c. Teach about postoperative tubes and care. d. Encourage a high-calorie, high-protein diet.

d. Eating a high-calorie, high-protein diet, perhaps in liquid form, is the highest priority preoperatively. Because of dysphagia, the patient often has poor nutritional status because of the inability to ingest adequate amounts of food before surgery. An esophageal stent may be placed to improve the nutritional status. Turning and deep breathing will be done. The patient will need to know about postoperative care, but these are not the preoperative priorities. Meticulous oral care is done but with swabs or gauze pads to prevent the injury and pain brushing may incur.

What is the rationale for treating acute exacerbation of peptic ulcer disease with NG intubation? a. Stop spillage of GI contents into the peritoneal cavity. b. Remove excess fluids and undigested food from the stomach. c. Feed the patient the nutrients missing from the lack of ingestion. d. Remove stimulation for hydrochloric acid (HCl) acid and pepsin secretion by keeping the stomach empty.

d. NG intubation is used with acute exacerbation of peptic ulcer disease (PUD) to remove the stimulation for HCl and pepsin secretion by keeping the stomach empty. Stopping the spillage of GI contents into the peritoneal cavity is used for peritonitis. Removing excess fluids and undigested food from the stomach is the rationale for using NG intubation for gastric outlet obstruction.

What physiologically occurs with vomiting? a. The acid-base imbalance most commonly associated with persistent vomiting is metabolic acidosis caused by loss of bicarbonate. b. Stimulation of the vomiting center by the chemoreceptor trigger zone (CTZ) is commonly caused by stretch and distention of hollow organs. c. Vomiting requires the coordination of activities of structures including the glottis, respiratory expiration, relaxation of the pylorus, and closure of the lower esophageal sphincter (LES). d. Immediately before the act of vomiting, activation of the parasympathetic nervous system causes increased salivation, increased gastric motility, and relaxation of the LES.

d. The parasympathetic nervous system causes increased salivation and gastric mobility as well as relaxation of the lower esophageal sphincter. The acid-base imbalance that occurs with vomiting is metabolic alkalosis from the loss of hydrochloric acid (HCl). The vomiting center in the chemoreceptor trigger zone (CTZ) can be caused by chemical stimuli of drugs, toxins, and labyrinthine stimulation. Vomiting requires the coordination of closing the glottis, deep inspiration with contraction of the diaphragm in the inspiratory position, closure of the pylorus, relaxation of the stomach and lower esophageal sphincter, and contraction of abdominal muscles.