EXAM 3 : Chapter 21 (Nursing Assessment: Digestive, Gastrointestinal, and Metabolic Function)

A client with a gastrointestinal condition asks why the mouth needs to be examined. Which response will the nurse make?

"Changes in the mouth can help explain why your condition is occurring."

A client reports having red stools lately. What will the nurse ask during assessment questioning?

"Have you been eating beets?"

A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers:

"It indicates if a cancer is present."

An elderly patient has developed Clostridium difficile-related diarrhea, a problem that has led to dehydration and hypokalemia. The increased peristalsis that characterizes diarrhea has the potential to cause fluid volume deficit and electrolyte deficits because:

An increase in peristalsis means that the colon cannot absorb the substances that it normally absorbs.

The nurse is preparing the client for an assessment of the abdomen. What should the nurse complete prior to this assessment?

Ask the client to empty the bladder.

When assisting with preparing a client scheduled for a barium swallow, which of the following would be appropriate to include?

Avoid smoking for at least 12 to 24 hours before the procedure.

Which of the following is the most definitive means of assessing for liver disease?

Biopsy

A patient is scheduled for a fiberoptic colonoscopy. What does the nurse know that fiberoptic colonoscopy is most frequently used to diagnose?

Cancer

A 56-year-old presented to her nurse practitioner because she had been experiencing unprecedented constipation and the passage of pencil-like stools despite her high fluid and fiber intake. The nurse recognized the need to assess the patient for colorectal cancer and ordered diagnostic evaluations. What component of the patient's blood work would be most indicative of the presence of cancer?

Carcinoembryonic antigen (CEA)

A client is scheduled for several diagnostic tests to evaluate gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when the client identifies which test as not requiring the use of a contrast medium?

Colonoscopy

A nurse is assessing a client for GI dysfunction. What is the most common symptom in a client with GI dysfunction?

Dyspepsia

The nurse is investigating a client's report of pain in the duodenal area. Where should the nurse perform the assessment?

Epigastric area and consider possible radiation of pain to the right subscapular region

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?

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

The nurse is assessing a client who is stating gastrointestinal upset and a feeling of bloating. Which type of meal would the nurse anticipate causing these types of symptoms?

Hamburger and French fries

A client with abdominal pain is scheduled for a CT scan of the abdomen with contrast. Which assessment will the nurse complete before transporting the client for the diagnostic test?

History of allergies

The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds?

Hyperactive

A client is scheduled for an upper gastrointestinal barium study. Which teaching will the nurse provide for the client to prepare for this diagnostic test?

Ingest nothing by mouth after midnight.

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.

Inspection Auscultation Percussion Palpation

After 20 seconds of auscultating for bowel sounds on a client recovering from abdominal surgery, the nurse hears nothing. What should the nurse do based on the assessment findings?

Listen longer for the sounds.

The nurse is caring for a geriatric client and notices polypharmacy. Which diagnostic studies are anticipated?

Liver function studies

A nurse practitioner examined a patient who had been diagnosed with hepatomegaly (enlarged liver) due to accumulated fat deposits in the liver, subsequent to obesity. The nurse would palpate the liver by placing:

One hand under the right lower rib cage and press downward with the other hand.

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?

Pancreas

The nurse is assisting the health care provider with a gastric acid stimulation test for a client. What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions?

Pentagastrin

Which of the following is an enzyme secreted by the gastric mucosa?

Pepsin

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?

Permit the client to drink only clear liquids.

The nurse is answering questions regarding fecal matter for a client who is scheduled for a colon resection. The client is asking questions regarding the composition of the fecal matter and when it becomes a formed mass. The nurse is most correct to state at which location?

Sigmoid colon

The nurse is preparing to examine the abdomen of a client who reports a change in bowel pattern. The nurse would place the client in which position?

Supine with knees flexed

The nurse is caring for a geriatric client experiencing diarrhea. When teaching about the site in the body where water and electrolytes are absorbed, the nurse is most correct to instruct on which location?

The large intestine

An individual has had a snack consisting of half a bagel with cream cheese, lox (smoked salmon), red onions, and capers. Stimulation of the person's gastrointestinal tract has resulted in the secretion of numerous digestive enzymes into the small intestine, including trypsin. What component of this person's snack will be primarily digested by the action of trypsin?

The lox

Which nursing instruction is correct to provide the client following a barium enema?

The stools may be a white or clay colored.

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?

The ultrasonography should be scheduled before the GI procedure.

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?

duodenum

The nurse prepares to administer the lavage solution to a client having a colonoscopy completed. The nurse stops and notifies the physician when noting that the client has which condition?

inflammatory bowel disease

What is the recommended order for performing an abdominal examination?

inspection, auscultation, percussion, palpation

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. What is the nurse's best response?

small intestine

The nurse is assisting the physician in a percutaneous liver biopsy. In assisting with positioning, the nurse should assist the client into a:

supine position.

The nurse recognizes which change of the GI system is an age-related change?

weakened gag reflex

The nurse recognizes which change of the gastrointestinal system is an age-related change?

weakened gag reflex

What would the nurse recognize as preventing a client from being able to take a fecal occult blood test (FOBT)?

The client has hemorrhoidal bleeding

Which term describes a gastric secretion that combines with vitamin B12 so that it can be absorbed?

intrinsic factor

The nurse is providing instructions to a client scheduled for a gastroscopy. What should the nurse be sure to include in the instructions? Select all that apply.

The client must fast for 8 hours before the examination. The throat will be sprayed with a local anesthetic. After gastroscopy, the client cannot eat or drink until the gag reflex returns (1 to 2 hours).