Chapter 40: Management of Patients with Gastric and Duodenal Disorders
A patient is scheduled for a Billroth I procedure for ulcer management. What does the nurse understand will occur when this procedure is performed? A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum. A sectioned portion of the stomach is joined to the jejunum. The antral portion of the stomach is removed and a vagotomy is performed. The vagus nerve is cut and gastric drainage is established.
A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum. Explanation: A Billroth I procedure involves removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum. A vagotomy severs the vagus nerve; a Billroth I procedure may be performed in conjunction with a vagotomy. If the remaining part of the stomach is anastomosed to the jejunum, the procedure is a Billroth II. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1278
16. A patient is one month postoperative following restrictive bariatric surgery. The patient tells the clinic nurse that he has been having "trouble swallowing" for the past few days. What recommendation should the nurse make? A) Eating more slowly and chewing food more thoroughly B) Taking an OTC antacid or drinking a glass of milk prior to each meal C) Chewing gum to cause relaxation of the lower esophageal sphincter D) Drinking at least 12 ounces of liquid with each meal
Ans: A Feedback: Dysphagia may be prevented by educating patients to eat slowly, to chew food thoroughly, and to avoid eating tough foods such as steak or dry chicken or doughy bread. After bariatric procedures, patients should normally not drink beverages with meals. Medications or chewing gum will not alleviate this problem.
2. A patient comes to the clinic complaining of pain in the epigastric region. What assessment question during the health interview would most help the nurse determine if the patient has a peptic ulcer? A) "Does your pain resolve when you have something to eat?" B) "Do over-the-counter pain medications help your pain?" C) "Does your pain get worse if you get up and do some exercise?" D) "Do you find that your pain is worse when you need to have a bowel movement?"
Ans: A Feedback: Pain relief after eating is associated with duodenal ulcers. The pain of peptic ulcers is generally unrelated to activity or bowel function and may or may not respond to analgesics.
38. A patient with gastritis required hospital treatment for an exacerbation of symptoms and receives a subsequent diagnosis of pernicious anemia due to malabsorption. When planning the patient's continuing care in the home setting, what assessment question is most relevant? A) "Does anyone in your family have experience at giving injections?" B) "Are you going to be anywhere with strong sunlight in the next few months?" C) "Are you aware of your blood type?" D) "Do any of your family members have training in first aid?"
Ans: A Feedback: Patients with malabsorption of vitamin B12 need information about lifelong vitamin B12 injections; the nurse may instruct a family member or caregiver how to administer the injections or make arrangements for the patient to receive the injections from a health care provider. Questions addressing sun exposure, blood type and first aid are not directly relevant.
28. Diagnostic imaging and physical assessment have revealed that a patient with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? A) Peritonitis B) Gastritis C) Gastroesophageal reflux D) Acute pancreatitis
Ans: A Feedback: Perforation is the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. Chemical peritonitis develops within a few hours of perforation and is followed by bacterial peritonitis. Gastritis, reflux, and pancreatitis are not acute complications of a perforated ulcer.
8. A nurse in the postanesthesia care unit admits a patient following resection of a gastric tumor. Following immediate recovery, the patient should be placed in which position to facilitate patient comfort and gastric emptying? A) Fowler's B) Supine C) Left lateral D) Left Sim's
Ans: A Feedback: Positioning the patient in a Fowler's position postoperatively promotes comfort and facilitates emptying of the stomach following gastric surgery. Any position that involves lying down delays stomach emptying and is not recommended for this type of patient. Supine positioning and the left lateral (left Sim's) position do not achieve this goal.
3. A patient with a diagnosis of peptic ulcer disease has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medication's therapeutic action? A) "This medication will reduce the amount of acid secreted in your stomach." B) "This medication will make the lining of your stomach more resistant to damage." C) "This medication will specifically address the pain that accompanies peptic ulcer disease." D) "This medication will help your stomach lining to repair itself."
Ans: A Feedback: Proton pump inhibitors like Prilosec inhibit the synthesis of stomach acid. PPIs do not increase the durability of the stomach lining, relieve pain, or stimulate tissue repair.
29. A nurse is performing the admission assessment of a patient whose high body mass index (BMI) corresponds to class III obesity. In order to ensure empathic and patient-centered care, the nurse should do which of the following? A) Examine one's own attitudes towards obesity in general and the patient in particular. B) Dialogue with the patient about the lifestyle and psychosocial factors that resulted in obesity. C) Describe one's own struggles with weight gain and weight loss to the patient. D) Elicit the patient's short-term and long-term goals for weight loss.
Ans: A Feedback: Studies suggest that health care providers, including nurses, harbor negative attitudes towards obese patients. Nurses have a responsibility to examine these attitudes and change them accordingly. This is foundational to all other areas of assessing this patient.
35. A patient has received a diagnosis of gastric cancer and is awaiting a surgical date. During the preoperative period, the patient should adopt what dietary guidelines? A) Eat small, frequent meals with high calorie and vitamin content. B) Eat frequent meals with an equal balance of fat, carbohydrates, and protein. C) Eat frequent, low-fat meals with high protein content. D) Try to maintain the pre-diagnosis pattern of eating.
Ans: A Feedback: The nurse encourages the patient to eat small, frequent portions of nonirritating foods to decrease gastric irritation. Food supplements should be high in calories, as well as vitamins A and C and iron, to enhance tissue repair.
39. A nurse is presenting a class at a bariatric clinic about the different types of surgical procedures offered by the clinic. When describing the implications of different types of surgeries, the nurse should address which of the following topics? Select all that apply. A) Specific lifestyle changes associated with each procedure B) Implications of each procedure for eating habits C) Effects of different surgeries on bowel function D) Effects of various bariatric surgeries on fertility E) Effects of different surgeries on safety of future immunizations
Ans: A, B, C Feedback: Different bariatric surgical procedures entail different lifestyle modifications; patients must be well informed about the specific lifestyle changes, eating habits, and bowel habits that may result from a particular procedure. Bariatric surgeries do not influence the future use of immunizations or fertility, though pregnancy should be avoided for 18 months after bariatric surgery.
1. A nurse is caring for a patient who has just been diagnosed with a peptic ulcer. When teaching the patient about his new diagnosis, how should the nurse best describe a peptic ulcer? A) Inflammation of the lining of the stomach B) Erosion of the lining of the stomach or intestine C) Bleeding from the mucosa in the stomach D) Viral invasion of the stomach wall
Ans: B Feedback: A peptic ulcer is erosion of the lining of the stomach or intestine. Peptic ulcers are often accompanied by bleeding and inflammation, but these are not the definitive characteristics.
27. A patient with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the patient has a perforated ulcer? A) The patient has abdominal bloating that developed rapidly. B) The patient has a rigid, "boardlike" abdomen that is tender. C) The patient is experiencing intense lower right quadrant pain. D) The patient is experiencing dizziness and confusion with no apparent hemodynamic changes.
Ans: B Feedback: An extremely tender and rigid (boardlike) abdomen is suggestive of a perforated ulcer. None of the other listed signs and symptoms is suggestive of a perforated ulcer.
6. A nurse caring for a patient who has had bariatric surgery is developing a teaching plan in anticipation of the patient's discharge. Which of the following is essential to include? A) Drink a minimum of 12 ounces of fluid with each meal. B) Eat several small meals daily spaced at equal intervals. C) Choose foods that are high in simple carbohydrates. D) Sit upright when eating and for 30 minutes afterward.
Ans: B Feedback: Due to decreased stomach capacity, the patient must consume small meals at intervals to meet nutritional requirements while avoiding a feeling of fullness and complications such as dumping syndrome. The patient should not consume fluids with meals and low-Fowler's positioning is recommended during and after meals. Carbohydrates should be limited.
34. A patient has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the patient's level of anxiety. Which of the following actions is most likely to accomplish this? A) The nurse gauges the patient's response to hypothetical outcomes. B) The patient is encouraged to express fears openly. C) The nurse provides detailed and accurate information about the disease. D) The nurse closely observes the patient's body language.
Ans: B Feedback: Encouraging the patient to discuss his or her fears and anxieties is usually the best way to assess a patient's anxiety. Presenting hypothetical situations is a surreptitious and possibly inaccurate way of assessing anxiety. Observing body language is part of assessment, but it is not the complete assessment. Presenting information may alleviate anxiety for some patients, but it is not an assessment.
26. A patient has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? A) Administration of antiemetics B) Insertion of an NG tube for decompression C) Infusion of hypotonic IV solution D) Administration of proton pump inhibitors as ordered
Ans: B Feedback: In treating the patient with gastric outlet obstruction, the first consideration is to insert an NG tube to decompress the stomach. This is a priority over fluid or medication administration.
33. A patient who is obese is exploring bariatric surgery options and presented to a bariatric clinic for preliminary investigation. The nurse interviews the patient, analyzing and documenting the data. Which of the following nursing diagnoses may be a contraindication for bariatric surgery? A) Disturbed Body Image Related to Obesity B) Deficient Knowledge Related to Risks and Expectations of Surgery C) Anxiety Related to Surgery D) Chronic Low Self-Esteem Related to Obesity
Ans: B Feedback: It is expected that patients seeking bariatric surgery may have challenges with body image and self-esteem related to their obesity. Anxiety is also expected when facing surgery. However, if the patient's knowledge remains deficient regarding the risks and realistic expectations for surgery, this may show that the patient is not an appropriate surgical candidate.
10. A nurse is assessing a patient who has peptic ulcer disease. The patient requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the patient? A) Most affected patients acquired the infection during international travel. B) Infection typically occurs due to ingestion of contaminated food and water. C) Many people possess genetic factors causing a predisposition to H. pylori infection. D) The H. pylori microorganism is endemic in warm, moist climates.
Ans: B Feedback: Most peptic ulcers result from infection with the gram-negative bacteria H. pylori, which may be acquired through ingestion of food and water. The organism is endemic to all areas of the United States. Genetic factors have not been identified.
19. A patient comes to the bariatric clinic to obtain information about bariatric surgery. The nurse assesses the obese patient knowing that in addition to meeting the criterion of morbid obesity, a candidate for bariatric surgery must also demonstrate what? A) Knowledge of the causes of obesity and its associated risks B) Adequate understanding of required lifestyle changes C) Positive body image and high self-esteem D) Insight into why past weight loss efforts failed
Ans: B Feedback: Patients seeking bariatric surgery should be free of serious mental disorders and motivated to comply with lifestyle changes related to eating patterns, dietary choices, and elimination. While assessment of knowledge about causes of obesity and its associated risks as well as insight into the reasons why previous diets have been ineffective are included in the client's plan of care, these do not predict positive client outcomes following bariatric surgery. Most obese patients have an impaired body image and alteration in self-esteem. An obese patient with a positive body image would be unlikely to seek this surgery unless he or she was experiencing significant comorbidities.
30. A patient has been prescribed orlistat (Xenical) for the treatment of obesity. When providing relevant health education for this patient, the nurse should ensure the patient is aware of what potential adverse effect of treatment? A) Bowel incontinence B) Flatus with oily discharge C) Abdominal pain D) Heat intolerance
Ans: B Feedback: Side effects of orlistat include increased frequency of bowel movements, gas with oily discharge, decreased food absorption, decreased bile flow, and decreased absorption of some vitamins. This drug does not cause bowel incontinence, abdominal pain, or heat intolerance.
23. A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply. A) Malignant hyperthermia B) Atelectasis C) Pneumonia D) Metabolic imbalances E) Chronic gastritis
Ans: B, C, D Feedback: After surgery, the nurse assesses the patient for complications secondary to the surgical intervention, such as pneumonia, atelectasis, or metabolic imbalances resulting from the GI disruption. Malignant hyperthermia is an intraoperative complication. Chronic gastritis is not a surgical complication.
5. A nurse is preparing to discharge a patient after recovery from gastric surgery. What is an appropriate discharge outcome for this patient? A) The patient's bowel movements maintain a loose consistency. B) The patient is able to tolerate three large meals a day. C) The patient maintains or gains weight. D) The patient consumes a diet high in calcium.
Ans: C Feedback: Expected outcomes for the patient following gastric surgery include ensuring that the patient is maintaining or gaining weight (patient should be weighed daily), experiencing no excessive diarrhea, and tolerating six small meals a day. Patients may require vitamin B12 supplementation by the intramuscular route and do not require a diet excessively rich in calcium.
17. A patient is receiving education about his upcoming Billroth I procedure (gastroduodenostomy). This patient should be informed that he may experience which of the following adverse effects associated with this procedure? A) Persistent feelings of hunger and thirst B) Constipation or bowel incontinence C) Diarrhea and feelings of fullness D) Gastric reflux and belching
Ans: C Feedback: Following a Billroth I, the patient may have problems with feelings of fullness, dumping syndrome, and diarrhea. Hunger and thirst, constipation, and gastric reflux are not adverse effects associated with this procedure.
7. A nurse is completing a health history on a patient whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the patient's health problem? A) Consumes one or more protein drinks daily. B) Takes over-the-counter antacids frequently throughout the day. C) Smokes one pack of cigarettes daily. D) Reports a history of social drinking on a weekly basis.
Ans: C Feedback: Nicotine reduces secretion of pancreatic bicarbonate, which inhibits neutralization of gastric acid and can underlie gastritis. Protein drinks do not result in gastric inflammation. Antacid use is a response to experiencing symptoms of gastritis, not the etiology of gastritis. Alcohol ingestion can lead to gastritis; however, this generally occurs in patients with a history of consumption of alcohol on a daily basis.
21. A nurse is providing anticipatory guidance to a patient who is preparing for bariatric surgery. The nurse learns that the patient is anxious about numerous aspects of the surgery. What intervention is most appropriate to alleviate the patient's anxiety? A) Emphasize the fact that bariatric surgery has a low risk of complications. B) Encourage the patient to focus on the benefits of the surgery. C) Facilitate the patient's contact with a support group. D) Obtain an order for a PRN benzodiazepine.
Ans: C Feedback: Support groups can be highly beneficial in relieving preoperative and postoperative anxiety and in promoting healthy coping. This is preferable to antianxiety medications. Downplaying the risks of surgery or focusing solely on the benefits is a simplistic and patronizing approach.
31. A patient who is obese has been unable to lose weight successfully using lifestyle modifications and has mentioned the possibility of using weight-loss medications. What should the nurse teach the patient about pharmacologic interventions for the treatment of obesity? A) "Weight loss drugs have many side effects, and most doctors think they'll all be off the market in a few years." B) "There used to be a lot of hope that medications would help people lose weight, but it's been shown to be mostly a placebo effect." C) "Medications can be helpful, but few people achieve and maintain their desired weight loss with medications alone." D) "Medications are rapidly become the preferred method of weight loss in people for whom diet and exercise have not worked."
Ans: C Feedback: Though antiobesity drugs help some patients lose weight, their use rarely results in loss of more than 10% of total body weight. Patients are consequently unlikely to attain their desired weight through medication alone. They are not predicted to disappear from the market and results are not attributed to a placebo effect.
24. A patient is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the patient to first seek care? A) Hematemesis and persistent sensation of fullness B) Abdominal bloating and recurrent constipation C) Intermittent pain and bloody stool D) Unexplained bowel incontinence and fatty stools
Ans: C Feedback: When the patient is symptomatic from a tumor of the small intestine, benign tumors often present with intermittent pain. The next most common presentation is occult bleeding. The other listed signs and symptoms are not normally associated with the presentation of small intestinal tumors.
18. A patient has experienced symptoms of dumping syndrome following bariatric surgery. To what physiologic phenomenon does the nurse attribute this syndrome? A) Irritation of the phrenic nerve due to diaphragmatic pressure B) Chronic malabsorption of iron and vitamins A and C C) Reflux of bile into the distal esophagus D) A sudden release of peptides
Ans: D Feedback: For many years, it had been theorized that the hypertonic gastric food boluses that quickly transit into the intestines drew extracellular fluid from the circulating blood volume into the small intestines to dilute the high concentration of electrolytes and sugars, resulting in symptoms. Now, it is thought that this rapid transit of the food bolus from the stomach into the small intestines instead causes a rapid and exuberant release of metabolic peptides that are responsible for the symptoms of dumping syndrome. It is not a result of phrenic nerve irritation, malabsorption, or bile reflux.
37. A nurse is caring for a patient hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? A) Strategies for maintaining an alkaline gastric environment B) Safe technique for self-suctioning C) Techniques for positioning correctly to promote gastric healing D) Strategies for avoiding irritating foods and beverages
Ans: D Feedback: Measures to help relieve pain include instructing the patient to avoid foods and beverages that may be irritating to the gastric mucosa and instructing the patient about the correct use of medications to relieve chronic gastritis. An alkaline gastric environment is neither possible nor desirable. There is no plausible need for self-suctioning. Positioning does not have a significant effect on the presence or absence of gastric healing.
36. A nurse is caring for a patient who has a diagnosis of GI bleed. During shift assessment, the nurse finds the patient to be tachycardic and hypotensive, and the patient has an episode of hematemesis while the nurse is in the room. In addition to monitoring the patient's vital signs and level of consciousness, what would be a priority nursing action for this patient? A) Place the patient in a prone position. B) Provide the patient with ice water to slow any GI bleeding. C) Prepare for the insertion of an NG tube. D) Notify the physician.
Ans: D Feedback: The nurse must always be alert for any indicators of hemorrhagic gastritis, which include hematemesis (vomiting of blood), tachycardia, and hypotension. If these occur, the physician is notified and the patient's vital signs are monitored as the patient's condition warrants. Putting the patient in a prone position could lead to aspiration. Giving ice water is contraindicated as it would stimulate more vomiting.
25. A patient is recovering in the hospital following gastrectomy. The nurse notes that the patient has become increasingly difficult to engage and has had several angry outbursts at various staff members in recent days. The nurse's attempts at therapeutic dialogue have been rebuffed. What is the nurse's most appropriate action? A) Ask the patient's primary care provider to liaise between the nurse and the patient. B) Delegate care of the patient to a colleague. C) Limit contact with the patient in order to provide privacy. D) Make appropriate referrals to services that provide psychosocial support.
Ans: D Feedback: The nurse should enlist the services of clergy, psychiatric clinical nurse specialists, psychologists, social workers, and psychiatrists, if needed. This is preferable to delegating care, since the patient has become angry with other care providers as well. It is impractical and inappropriate to expect the primary care provider to act as a liaison. It would be inappropriate and unsafe to simply limit contact with the patient.
40. A patient has come to the clinic complaining of pain just above her umbilicus. When assessing the patient, the nurse notes Sister Mary Joseph's nodules. The nurse should refer the patient to the primary care provider to be assessed for what health problem? A) A GI malignancy B) Dumping syndrome C) Peptic ulcer disease D) Esophageal/gastric obstruction
Ans: A Feedback: Palpable nodules around the umbilicus, called Sister Mary Joseph's nodules, are a sign of a GI malignancy, usually a gastric cancer. This would not be a sign of dumping syndrome, peptic ulcer disease, or esophageal/gastric obstruction.
Clients with Type O blood are at higher risk for which of the following GI disorders? Gastric cancer Duodenal ulcers Esophageal varices Diverticulitis
Duodenal ulcers Familial tendency also may be a significant predisposing factor. People with blood type O are more susceptible to peptic ulcers than are those with blood type A, B, or AB. Blood type is not a predisposing factor for gastric cancer, esophageal varices, and diverticulitis. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1271
A nurse is monitoring a client with peptic ulcer disease. Which assessment findings would most likely indicate perforation of the ulcer? Select all that apply. Tachycardia Hypotension Mild epigastric pain A rigid, board-like abdomen Diarrhea
A rigid, board-like abdomen Tachycardia Hypotension Signs and symptoms of perforation include sudden, severe upper abdominal pain (persisting and increasing in intensity); pain, which may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm; vomiting; collapse (fainting); extremely tender and rigid (board-like) abdomen; and hypotension and tachycardia, indicating shock. Perforation is a surgical emergency. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1272
Which ulcer is associated with extensive burn injury? Cushing ulcer Curling ulcer Peptic ulcer Duodenal ulcer
Curling ulcer Explanation: Curling ulcer is frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1272
The nurse is caring for a client who has developed dumping syndrome while recovering from a gastrectomy. What recommendation should the nurse make to the client? Drink a minimum of 12 ounces of fluid with each meal. Eat several small meals daily spaced at equal intervals. Choose foods that are high in simple carbohydrates. Sit upright when eating and for 30 minutes afterward.
Eat several small meals daily spaced at equal intervals. Explanation: The client with dumping syndrome should consume small meals at intervals to reduce symptoms. The client should not consume fluids with meals. Carbohydrates should be limited and sitting upright does not relieve the symptoms. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1279
The nurse is assessing a client with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which condition as a sign/symptom of possible hemorrhage? Hematemesis Bradycardia Hypertension Polyuria
Hematemesis The nurse interprets hematemesis as a sign/symptom of possible hemorrhage from the ulcer. Other signs that can indicate hemorrhage include tachycardia, hypotension, and oliguria/anuria. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1270
The nurse advises the patient who has just been diagnosed with acute gastritis to: Take an emetic to rid the stomach of the irritating products. Refrain from food until the GI symptoms subside. Restrict food and fluids for 12 hours. Restrict all food for 72 hours to rest the stomach.
Refrain from food until the GI symptoms subside. Explanation: It usually takes 24 to 48 hours for the stomach to recover from an attack. Refraining from food until symptoms subside is recommended, but liquids should be taken in moderation. Emetics and vomiting can cause damage to the esophagus. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1268
Which of the following is the most successful treatment for gastric cancer? Removal of the tumor Chemotherapy Radiation Palliation
Removal of the tumor There is no successful treatment for gastric carcinoma except removal of the tumor. If the tumor can be removed while it is still localized to the stomach, the patient may be cured. If the tumor has spread beyond the area that can be excised, cure is less likely. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1278
A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake? Three meals and 120 ml fluid daily Three meals and three snacks and 120 mL fluid daily Six small meals and 120 mL fluid daily Six small meals daily with 120 mL fluid between meals
Six small meals daily with 120 mL fluid between meals Explanation: After the return of bowel sounds and removal of the nasogastric tube, the nurse may give fluids, followed by food in small portions. Foods are gradually added until the client can eat six small meals a day and drink 120 mL of fluid between meals.
14. A patient was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? A) Esophageal or pyloric obstruction related to scarring B) Uncontrolled proliferation of H. pylori C) Gastric hyperacidity related to excessive gastrin secretion D) Chronic referred pain in the lower abdomen
Ans: A Feedback: A severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Scarring can occur, resulting in pyloric stenosis (narrowing or tightening) or obstruction. Chronic referred pain to the lower abdomen is a symptom of peptic ulcer disease, but would not be an expected finding for a patient who has ingested a corrosive substance. Bacterial proliferation and hyperacidity would not occur.
12. A patient presents to the walk-in clinic complaining of vomiting and burning in her mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the physician is likely to order a diagnostic test to detect the presence of what? A) Infection with Helicobacter pylori B) Excessive stomach acid secretion C) An incompetent pyloric sphincter D) A metabolic acid-base imbalance
Ans: A Feedback: H. pylori infection may be determined by endoscopy and histologic examination of a tissue specimen obtained by biopsy, or a rapid urease test of the biopsy specimen. Excessive stomach acid secretion leads to gastritis; however, peptic ulcers are caused by colonization of the stomach by H. pylori. Sphincter dysfunction and acidbase imbalances do not cause peptic ulcer disease.
20. A nurse is providing patient education for a patient with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The patient has recently been prescribed misoprostol (Cytotec). What would the nurse be most accurate in informing the patient about the drug? A) It reduces the stomach's volume of hydrochloric acid B) It increases the speed of gastric emptying C) It protects the stomach's lining D) It increases lower esophageal sphincter pressure
Ans: C Feedback: Misoprostol is a synthetic prostaglandin that, like prostaglandin, protects the gastric mucosa. NSAIDs decrease prostaglandin production and predispose the patient to peptic ulceration. Misoprostol does not reduce gastric acidity, improve emptying of the stomach, or increase lower esophageal sphincter pressure.
15. A patient who underwent gastric banding 3 days ago is having her diet progressed on a daily basis. Following her latest meal, the patient complains of dizziness and palpitations. Inspection reveals that the patient is diaphoretic. What is the nurse's best action? A) Insert a nasogastric tube promptly. B) Reposition the patient supine. C) Monitor the patient closely for further signs of dumping syndrome. D) Assess the patient for signs and symptoms of aspiration.
Ans: C Feedback: The patient's symptoms are characteristic of dumping syndrome, which results in a sensation of fullness, weakness, faintness, dizziness, palpitations, diaphoresis, cramping pains, and diarrhea. Aspiration is a less likely cause for the patient's symptoms. Supine positioning will likely exacerbate the symptoms and insertion of an NG tube is contraindicated due to the nature of the patient's surgery.
13. A patient with a peptic ulcer disease has had metronidazole (Flagyl) added to his current medication regimen. What health education related to this medication should the nurse provide? A) Take the medication on an empty stomach. B) Take up to one extra dose per day if stomach pain persists. C) Take at bedtime to mitigate the effects of drowsiness. D) Avoid drinking alcohol while taking the drug.
Ans: D Feedback: Alcohol must be avoided when taking Flagyl and the medication should be taken with food. This drug does not cause drowsiness and the dose should not be adjusted by the patient.
32. A patient has been diagnosed with peptic ulcer disease and the nurse is reviewing his prescribed medication regimen with him. What is currently the most commonly used drug regimen for peptic ulcers? A) Bismuth salts, antivirals, and histamine-2 (H2) antagonists B) H2 antagonists, antibiotics, and bicarbonate salts C) Bicarbonate salts, antibiotics, and ZES D) Antibiotics, proton pump inhibitors, and bismuth salts
Ans: D Feedback: Currently, the most commonly used therapy for peptic ulcers is a combination of antibiotics, proton pump inhibitors, and bismuth salts that suppress or eradicate H. pylori. H2 receptor antagonists are used to treat NSAID-induced ulcers and other ulcers not associated with H. pylori infection, but they are not the drug of choice. Bicarbonate salts are not used. ZES is the Zollinger-Ellison syndrome and not a drug.
22. A patient has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. What would be the nursing care most needed by the patient at this time? A) Teaching the patient about necessary nutritional modification B) Helping the patient weigh treatment options C) Teaching the patient about the etiology of gastritis D) Providing the patient with physical and emotional support
Ans: D Feedback: For acute gastritis, the nurse provides physical and emotional support and helps the patient manage the symptoms, which may include nausea, vomiting, heartburn, and fatigue. The scenario describes a newly diagnosed patient; teaching about the etiology of the disease, lifestyle modifications, or various treatment options would be best provided at a later time.
A health care provider suspects that a client has peptic ulcer disease. With which diagnostic procedure would the nurse most likely prepare to assist? Barium study of the upper gastrointestinal tract Endoscopy Gastric secretion study Stool antigen test
Endoscopy Explanation: Barium study of the upper GI tract may show an ulcer; however, endoscopy is the preferred diagnostic procedure because it allows direct visualization of inflammatory changes, ulcers, and lesions. Through endoscopy, a biopsy of the gastric mucosa and of any suspicious lesions can be obtained. Endoscopy may reveal lesions that, because of their size or location, are not evident on x-ray studies. Less invasive diagnostic measures for detecting H. pylori include serologic testing for antibodies against the H. pylori antigen, stool antigen test, and urea breath test. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1272
The nurse is cautiously assessing a client admitted with peptic ulcer disease because the most common complication that occurs in 10% to 20% of clients is: Hemorrhage Intractable ulcer Perforation Pyloric obstruction
Hemorrhage Explanation: Hemorrhage, the most common complication, occurs in 10% to 20% of clients with peptic ulcers. Bleeding may be manifested by hematemesis or melena. Perforation is erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. Intractable ulcer refers to one that is hard to treat, relieve, or cure. Pyloric obstruction, also called gastric outlet obstruction (GOO), occurs when the area distal to the pyloric sphincter becomes scarred and stenosed from spasm or edema or from scar tissue that forms when an ulcer alternately heals and breaks down. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1276
A client is prescribed tetracycline to treat peptic ulcer disease. Which instruction would the nurse give the client? "Take the medication with milk." "Be sure to wear sunscreen while taking this medicine." "You will not experience GI upset while taking this medication." "Do not drive when taking this medication."
"Be sure to wear sunscreen while taking this medicine." Explanation: Tetracycline may cause a photosensitivity reaction in clients. The nurse should caution the client to use sunscreen when taking this drug. Dairy products can reduce the effectiveness of tetracycline, so the nurse should not advise him or her to take the medication with milk. GI upset is possible with tetracycline administration. Administration of tetracycline does not necessitate driving restrictions. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1269
A client with an H. pylori infection asks why bismuth subsalicylate is prescribed. Which response will the nurse make? "It improves digestion in the stomach." "It aids in the healing of the stomach lining." "It enhances the function of the pyloric sphincter." "It helps propel food from the stomach into the duodenum."
"It aids in the healing of the stomach lining." Explanation: Bismuth subsalicylate suppresses H. pylori bacteria in the gastric mucosa and assists with healing of mucosal ulcers. It does not affect digestion, enhance the function of the pyloric sphincter, or propel food from the stomach into the duodenum. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1269
A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.) "It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin." "It is a hereditary disease." "It is probably your nerves."
"It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin." Acute gastritis is often caused by dietary indiscretion—the person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1267
A client recovering from the removal of a gastric tumor asks why radiation therapy is needed. Which response will the nurse provide? "It is to heal the wound faster." "It is to kill any remaining cancer cells." "It is to reduce your need for medication." "It is to prevent the development of a wound infection." Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1279
"It is to kill any remaining cancer cells." Explanation: Radiation therapy may also be used alone or along with chemotherapy before surgery to decrease the size of the tumor, or after surgery to destroy any remaining cancer cells and to delay or prevent reoccurrence of the cancer. Radiation therapy is not used to heal the surgical wound, reduce the need for medication, or to prevent the development of a wound infection.
A client being treated for a peptic ulcer seeks medical attention for vomiting blood. Which statement indicates to the nurse the reason for the client developing hematemesis? "I think the soda that I drank irritated my stomach." "The pain stopped so I stopped taking the medications." "I felt better but then just got really nauseated and threw up." "I only ate dinner yesterday and it gave me an upset stomach."
"The pain stopped so I stopped taking the medications." Explanation: The client should be instructed to adhere to and complete the medication regimen to ensure complete healing of the peptic ulcer. Because most clients become symptom free within a week, it should be stressed to the client the importance of following the prescribed regimen so that the healing process can continue uninterrupted and the return of symptoms can be prevented. Since the client stopped taking the medication, the ulcer was not healed and became worse. The statements about soda, being nauseated, and eating only one meal would not explain the reason for the client's new onset of hematemesis during treatment for a peptic ulcer. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1272
11. A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patient's condition is now stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence? A) Tachycardia, hypotension, and tachypnea B) Tarry, foul-smelling stools C) Diaphoresis and sudden onset of abdominal pain D) Sudden thirst, unrelieved by oral fluid administration
Ans: A Feedback: Tachycardia, hypotension, and tachypnea are signs of recurrent bleeding. Patients who have had one GI bleed are at risk for recurrence. Tarry stools are expected short-term findings after a hemorrhage. Hemorrhage is not normally associated with sudden thirst or diaphoresis.
A client sustained second- and third-degree burns over 30% of the body surface area approximately 72 hours ago. What type of ulcer should the nurse be alert for while caring for this client? Curling's ulcer Peptic ulcer Esophageal ulcer Meckel's ulcer
Curling's ulcer Explanation: Curling's ulcer is frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum. Peptic, esophageal, and Meckel's ulcers are not related to burn injuries. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1272
The nurse is preparing to administer ondansetron to an older adult client. Which safety warning(s) should the nurse consider when administering the medication? Select all that apply. Do not use if the client has a heart block or prolonged QT interval. It increases sedation if used with opiates. Emphasize prevention. The client must take consistently to prevent nausea and vomiting. Explain that it must be started before travel to be effective. Explain that there is a risk for dehydration.
Do not use if the client has a heart block or prolonged QT interval. It increases sedation if used with opiates. Emphasize prevention. The client must take consistently to prevent nausea and vomiting. Not using the medication if the client has a heart block or prolonged QT interval, the fact that the medication increases sedation if used with opiates, and emphasizing prevention (the client must take the medication consistently to prevent nausea and vomiting) are all safety warnings that the nurse should consider when administering ondansetron. Ondansetron is not given to relieve motion sickness; therefore, beginning the medication before travel is not applicable. Prochlorperazine, not ondansetron, may increase dehydration in older adults.
A client diagnosed with a peptic ulcer says, "Now I have something else I have to worry about." Which actions will the nurse take to help reduce the client's anxiety? Select all that apply. Interact with the client in a relaxed manner. Help identify the client's current stressors. Discuss potential coping techniques with the client. Offer information about relaxation methods. Inform the client the medication will solve the problem.
Interact with the client in a relaxed manner. Help identify the client's current stressors. Discuss potential coping techniques with the client. Offer information about relaxation methods. A client with a peptic ulcer may have a problem with anxiety. To help reduce the client's anxiety, the nurse should interact with the client in a relaxed manner and help the client identify stressors. The nurse can also discuss potential coping techniques and offer information about relaxation methods. Stating that medication will solve the problem may not be sufficient if stress and anxiety are contributors to the development of the ulcer. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1276
The nurse visits the home of a client recovering from acute gastritis. Which observation indicates that teaching about the disorder was effective? Medications placed in a pillbox Extinguished cigarettes in an ashtray Tomato sauce simmering on the stove Cup of caffeinated coffee on the kitchen table
Medications placed in a pillbox Explanation: The client with acute gastritis should be instructed on methods of keeping track of medications such as placing the doses into a pillbox. The client should also be instructed about foods and substances that may cause gastritis, including nicotine, spicy seasoned foods, and caffeine. Cigarettes in the ashtray, tomato sauce, and caffeinated coffee indicate that additional teaching is required. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1270
Rebleeding may occur from a peptic ulcer and often warrants surgical interventions. Signs of bleeding include which of the following? Mental confusion Bradycardia Bradypnea Hypertension TAKE ANOTHER QUIZ
Mental confusion Explanation: Signs of bleeding include tachycardia, tachypnea, hypotension, mental confusion, thirst, and oliguria. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1276
A client is prescribed a histamine (H2)-receptor antagonist. The nurse understands that this might include which medication(s)? Select all that apply. Famotidine Lansoprazole Cimetidine Esomeprazole Nizatidine
Nizatidine Famotidine Cimetidine H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions. The other medications listed are proton-pump inhibitors. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1269
A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond? Notify the health care provider. Reposition the tube. Irrigate the tube. Increase the suction level.
Notify the health care provider. Explanation: The nurse should notify the health care provider because an NG tube that fails to drain during the postoperative period may be clogged, which could increase pressure on the suture site because fluid isn't draining adequately. Repositioning or irrigating an NG tube in a client who has undergone gastric surgery can disrupt the anastomosis. Increasing the level of suction may cause trauma to GI mucosa or the suture line. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1278
During a home visit the nurse notes that a client recovering from peptic ulcer disease is experiencing cool clammy skin and has a heart rate of 96 beats a minute. Which action will the nurse take? Notify the primary health care provider. Provide a dose of a proton pump inhibitor. Encourage the client to drink a warm beverage. Discuss the types of foods the client has been eating.
Notify the primary health care provider. Explanation: The client with peptic ulcer disease is demonstrating signs of hemorrhage which include cool skin and tachycardia. The health care provider should be immediately notified. The client should not be given any additional medication. A warm beverage could enhance bleeding. It is inappropriate to provide any teaching while the client is experiencing an acute condition. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1277
A nurse practitioner prescribes drug therapy for a patient with peptic ulcer disease. Choose the drug that can be used for 4 weeks and has a 90% chance of healing the ulcer. Nizatidine Famotidine Omeprazole Cimetidine
Omeprazole Omeprazole (Prilosec) is a proton pump inhibitor that, if used according to the health care provider's directions, will result in healing in 90% of patients. The other drugs are H2 receptor antagonists that need to be used for 6 weeks.
A client with peptic ulcer disease has been prescribed sucralfate. What health education should the nurse provide to this client? Ensure adequate potassium intake during therapy Blood levels will be evaluated after 1 week Take the medication at bedtime to accommodate sedative effects Take the medication 2 hours before or after other medications
Take the medication 2 hours before or after other medications Explanation: Sucralfate should be taken at least 2 hours before or after other medications. It does not decrease potassium levels and laboratory follow up is unnecessary. Sucralfate does not cause sedation. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1269
A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. What will the nurse suspect? Vasomotor symptoms associated with dumping syndrome Dehiscence of the surgical wound Peritonitis A normal reaction to surgery
Vasomotor symptoms associated with dumping syndrome Explanation: Early manifestations of dumping syndrome occur 15 to 30 minutes after eating. Signs and symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, diarrhea, nausea, and the desire to lie down. Dehiscence of the surgical wound is characterized by pain and a pulling or popping feeling at the surgical site. Peritonitis presents with a rigid, board-like abdomen, tenderness, and fever. The client's signs and symptoms aren't a normal reaction to surgery. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1279
A nurse is caring for a client who is undergoing a diagnostic workup for a suspected gastrointestinal problem. The client reports gnawing epigastric pain following meals and heartburn. What would the nurse suspect this client has? peptic ulcer disease ulcerative colitis appendicitis diverticulitis
peptic ulcer disease Explanation: Peptic ulcer disease is characterized by dull, gnawing pain in the midepigastrium or the back that worsens with eating. Ulcerative colitis is characterized by exacerbations and remissions of severe bloody diarrhea. Appendicitis is characterized by epigastric or umbilical pain along with nausea, vomiting, and low-grade fever. Pain caused by diverticulitis is in the left lower quadrant and has a moderate onset. It's accompanied by nausea, vomiting, fever, and chills.
A patient is scheduled for a Billroth I procedure for ulcer management. What does the nurse understand will occur when this procedure is performed? A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum. A sectioned portion of the stomach is joined to the jejunum. The antral portion of the stomach is removed and a vagotomy is performed. The vagus nerve is cut and gastric drainage is established.
A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum. A Billroth I procedure involves removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum. A vagotomy severs the vagus nerve; a Billroth I procedure may be performed in conjunction with a vagotomy. If the remaining part of the stomach is anastomosed to the jejunum, the procedure is a Billroth II. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1278
9. A community health nurse is preparing for an initial home visit to a patient discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? A) Enteral feeding via gastrostomy tube (G tube) B) Gastrointestinal decompression by nasogastric tube C) Periodic assessment for esophageal distension D) Monthly administration of injections of vitamin B12
Ans: D Feedback: Since vitamin B12 is absorbed in the stomach, the patient requires vitamin B12 replacement to prevent pernicious anemia. A gastrectomy precludes the use of a G tube. Since the stomach is absent, a nasogastric tube would not be indicated. As well, this is not possible in the home setting. Since there is no stomach to act as a reservoir and fluids and nutrients are passing directly into the jejunum, distension is unlikely.
4. A nurse is admitting a patient diagnosed with late-stage gastric cancer. The patient's family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor contributes to the fact that gastric cancer is often detected at a later stage? A) Gastric cancer does not cause signs or symptoms until metastasis has occurred. B) Adherence to screening recommendations for gastric cancer is exceptionally low. C) Early symptoms of gastric cancer are usually attributed to constipation. D) The early symptoms of gastric cancer are usually not alarming or highly unusual.
Ans: D Feedback: Symptoms of early gastric cancer, such as pain relieved by antacids, resemble those of benign ulcers and are seldom definitive. Symptoms are rarely a cause for alarm or for detailed diagnostic testing. Symptoms precede metastasis, however, and do not include constipation.
Which of the following manifestations are associated with a deficiency of vitamin B12? Select all that apply. Pernicious anemia Macrocytic anemia Thrombocytopenia Loss of hair Lethargy
Pernicious anemia Macrocytic anemia Thrombocytopenia Decreased vitamin B12 can result in pernicious anemia, macrocytic anemia, and thrombocytopenia. Decreased iron can result in lethargy and loss of hair. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1268
A client with peptic ulcer disease has been prescribed sucralfate. What health education should the nurse provide to this client? Take the medication 2 hours before or after other medications Blood levels will be evaluated after 1 week Take the medication at bedtime to accommodate sedative effects Ensure adequate potassium intake during therapy
Take the medication 2 hours before or after other medications Explanation: Sucralfate should be taken at least 2 hours before or after other medications. It does not decrease potassium levels and laboratory follow up is unnecessary. Sucralfate does not cause sedation. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1269
A client with a peptic ulcer is diagnosed with Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including metronidazole, omeprazole, and clarithromycin. Which statement by the client indicates the best understanding of the medication regimen? "My ulcer will heal because these medications will kill the bacteria." "I should take these medications only when I have pain from my ulcer." "The medications will kill the bacteria and stop the acid production." "These medications will coat the ulcer and decrease the acid production in my stomach."
"The medications will kill the bacteria and stop the acid production." Explanation: Currently, the most commonly used therapy for peptic ulcers is a combination of antibiotics, proton-pump inhibitors, and bismuth salts that suppress or eradicate H. pylori. Recommended therapy for 10 to 14 days includes triple therapy with two antibiotics (e.g., metronidazole [Flagyl] or amoxicillin [Amoxil] and clarithromycin [Biaxin]) plus a proton-pump inhibitor (e.g., lansoprazole [Prevacid], omeprazole [Prilosec], or rabeprazole [Aciphex]), or quadruple therapy with two antibiotics (metronidazole and tetracycline) plus a proton-pump inhibitor and bismuth salts (Pepto-Bismol). Research is being conducted to develop a vaccine against H. pylori. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1272
A client is preparing for discharge to home following a partial gastrectomy and vagotomy. Which is the best rationale for the client being taught to lie down for 30 minutes after each meal? Slows gastric emptying Provides much needed rest Allows for better absorption of vitamin B12 Removes tension on internal suture line
Slows gastric emptying Dumping syndrome is a common complication following subtotal gastrectomy. To avoid the rapid emptying of stomach contents, resting after meals can be helpful. Promoting rest after a major surgery is helpful in recovery but not the reason for resting after meals. Following this type of surgery, clients will have a need for vitamin B12 supplementation due to absence of production of intrinsic factor in the stomach. Resting does not increase absorption of B12 or remove tension on suture line. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1279
A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to: restrict fluid intake to 1 qt (1,000 ml)/day. drink liquids only with meals. don't drink liquids 2 hours before meals. drink liquids only between meals.
drink liquids only between meals. Explanation: A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in the prevention of rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals. Chapter 40: Management of Patients with Gastric and Duodenal Disorders - Page 1278
