Gastrointestinal Assessment
While assessing a patient with a gastrointestinal disorder, which questions should a nurse ask to develop a deeper understanding of the disorder? Select all that apply.
"Are you having sleep disturbances?" "Have you traveled to foreign lands in the recent past?" "Have you undergone an abdominal or rectal surgery in the past?"
The primary health care provider has prescribed a barium swallow test for a patient with upper gastrointestinal disorder. The nurse explains the test to the patient before conducting it. Which statement by the patient indicates effective learning?
"I may pass white-colored stools up to 72 hours after the test." (During a barium swallow test, the patient receives an oral barium suspension. Barium is a contrast medium and may be excreted in the stools, due to which the patient may pass white-colored stools up to 72 hours after. The nurse should inform the patient to avoid drinking liquids or eating food for 8 to 12 hours before, rather than after, the test. The patient may feel cramping and the urge to defecate during a barium enema test. The patient is made to tilt in different positions during the test to obtain clear images of the esophagus, stomach, and duodenum.)
A patient reports a 2-month history of dark tarry stools and occasional blood on the toilet paper after wiping. The patient experiences generalized weakness and tires easily. The patient denies a history of taking iron pills or blueberry consumption. The nurse anticipates that which diagnostic tests will be prescribed to determine the cause of the blood? Select all that apply.
A guaiac test is used to detect the presence of blood in the stools indicating a possible GI bleed. Colonoscopy is used to visualize the colonic mucosa for any sign of bleeding lesions, polyps, diverticulosis, or tumors that can cause GI bleeding. A capsule endoscopy may be used for visualizing the GI tract for presence of GI bleeding. An MRI also helps in detecting the source of bleeding from the GI tract. Cholangiography and abdominal ultrasound would not be helpful in assessing the source of GI bleeding. Cholangiography is used to detect abnormalities in the liver and the bile duct. Abdominal ultrasound is used to detect abdominal masses, biliary and liver diseases, and gallstones.
A patient with gastroesophageal reflux disease (GERD) has undergone an esophagogastroduodenoscopy (EGD). A nurse assessing the patient after the procedure notes a sudden spike in body temperature. What could be the cause of the increase in temperature?
A high temperature after an endoscopic procedure is indicative of organ perforation. Bleeding ulcers, obstruction, and esophageal strictures are not associated with the GI endoscopy and do not cause fever. A bleeding ulcer would manifest as hematemesis. Obstruction in the GI tract would manifest as abdominal distention. Severe esophageal stricture is not a complication of esophagogastroduodenoscopy.
The nurse recalls that which term is used to describe the process of transferring broken down food components from the gastrointestinal system to the blood?
Absorption is the process in which the nutrients from the broken down food are assimilated by the blood and transferred into the circulatory system. Ingestion refers to the process of taking in of food. Digestion refers to the process of breaking down the food into simpler particles. Elimination is the process of removal of waste products of digestion from the body.
A patient with a strong family history of colon cancer is scheduled for a screening colonoscopy. After the procedure, the nurse should perform which interventions? Select all that apply.
After a colonoscopy procedure, the vital signs should be checked to observe changes in temperature. The patient should be observed for abdominal cramping, rectal bleeding, and abdominal distention. Abdominal cramps are caused due to the stimulation of peristalsis as the bowel is constantly inflated with air during the procedure. Rectal bleeding is common if polyps or diverticula are removed during the procedure. Abdominal distention after colonoscopy may indicate organ perforation. Gag reflex is checked after esophagogastroduodenoscopy. An enema is administered prior to the procedure to empty bowels and not after colonoscopy.
A patient reports severe pain in the upper right part of the abdomen. A nurse observes an enlarged abdomen and suspects a diagnosis of hepatocellular carcinoma. Which should be the first diagnostic test to confirm the disease?
Alpha-fetoprotein test (The elevated level of alpha fetoprotein in serum indicates hepatocellular carcinoma. Less than 10 ng/mL alpha fetoprotein in blood is normal. After assessing the test report, other diagnostic tests can be ordered. A liver MRI is helpful in determining the size and location of the tumor, whereas a liver biopsy is helpful in removing these tumors. Abdominal ultrasound is also used to determine the size and location of the tumor.)
A patient experiences a recent onset of diarrhea following a new medication regimen. The nurse recognizes that which drug most likely caused the diarrhea?
Antibiotics (Antibiotics disturb the normal bacterial composition of the large intestine and result in diarrhea. Diarrhea is not a known side effect of NSAIDs, amphetamines, and antacids. High doses of NSAIDs can cause hepatotoxicity. Amphetamines cause distention of the stomach. Antacids cause interference with the absorption of other drugs.)
A patient with liver fibrosis is scheduled for a closed biopsy procedure. What should the nurse include in the procedural plan of care? Select all that apply.
Assessing the vital signs Determining if drug allergies exist Instructing the patient to lie in the supine position during the procedure Instructing the patient to not breathe during needle insertion
The nurse is preparing to examine a patient's abdomen. Which procedure will the nurse perform first?
Auscultation
The patient can receive acetaminophen 650 mg per rectum every six hours as needed for fever greater than 102º F. What is the proper technique for the nurse to administer this medication?
Because of the curvature of the large bowel, the patient should be positioned on the left side for administration of the suppository. This will help prevent it from being expelled from the rectum as readily. The suppository should be lubricated with surgical lubricant, not petroleum jelly, should be inserted two inches into the anus, and should be inserted and allowed to dissolve following insertion.
A patient has been diagnosed with a blocked bile duct. The nurse realizes that this problem will affect the patient's digestion of food in which way?
Bile also consists of water, cholesterol, bile salts, electrolytes, and phospholipids. Bile salts are needed for fat emulsification and digestion. A lack of bile does not cause difficulty digesting proteins, a decrease in breakdown of carbohydrates, or decreased absorption of B vitamins.
A nurse observes yellowing of the skin when assessing a patient. On studying the blood reports, the nurse finds that the patient's bilirubin and alkaline phosphatase levels are elevated. Based on the assessment findings, the patient may be diagnosed with what? Select all that apply.
Biliary tract obstruction Stones in common bile duct (Yellowing of the skin is indicative of jaundice. Jaundice and elevated bilirubin and alkaline phosphatase levels are indicative of biliary tract obstruction, which may also be due to stones. Hepatic mass, pancreatic mass, and pancreatitis do not cause elevated bilirubin and alkaline phosphatase levels in the blood.)
While teaching about the large intestine to a group of nursing students, a nurse educator explains that various microbes, mainly bacteria, live symbiotically in the large intestine. What are the functions of these microbial floras? Select all that apply.
Breakdown of amino acids Synthesis of vitamin K (Bacteria in the colon live symbiotically. The bacteria in the colon are responsible for the breakdown of amino acids for better absorption. These bacteria also synthesize vitamin K. Bacteria are not capable of breaking down starch or synthesizing vitamin D. Bacteria also aids the production of flatus; they do not suppress it.)
Inspection of an older patient's mouth reveals the presence of white, curd-like lesions on the patient's tongue. What is the most likely etiology for this abnormal assessment finding?
Candida albicans (White, curd-like lesions surrounded by erythematous mucosa are associated with oral candidiasis. Herpes virus causes benign vesicular lesions in the mouth. Vitamin deficiencies may cause a reddened, ulcerated, swollen tongue. Irritation from ill-fitting dentures will cause friable, edematous, painful, bleeding gingivae.)
A nurse is performing gastrointestinal assessments on a group of elderly people in a community clinic. The nurse observes that most of the patients experience constipation. What are causes of constipation in the elderly population? Select all that apply.
Decreased peristalsis Decreased sensation to defecation (Decreased peristalsis and decreased sensation to defecation lead to constipation and fecal impaction. Atrophy of gastric mucosa, decreased anal sphincter tone, and decreased blood flow to the stomach are also the changes associated with aging. Atrophy of gastric mucosa causes anemia and food intolerance. Decreased anal sphincter tone can cause fecal incontinence. Decreased blood supply to the stomach also causes anemia and food intolerance.)
An older adult patient reports to the nurse that his mouth is dry and food tastes bland. Which anticipated aging changes related to the normal aging process should the nurse suspect? Select all that apply.
Decreased taste bud function, decreased sense of smell, and decreased salivary production are anticipated physiological changes related to a normal aging process. These natural occurrences can cause mouth dryness and a change in the sense of taste. For older adults, there is typically a decrease in appetite and decreased bowel sensation, which causes symptoms such as constipation. But the decreased bowel sensation is not directly relevant to this patient's chief complaint.
A patient who is scheduled for surgery with general anesthesia in one hour is observed with a moist, but empty, water glass in his or her hand. Which assessment finding may indicate that the patient drank a glass of water?
Easily heard, loud gurgling in the right upper quadrant (If the patient drank water on an empty stomach, gurgling can be assessed without a stethoscope or assessed with auscultation. A flat abdomen and tenderness do not indicate that the patient drank a glass of water. High-pitched, hollow sounds are tympanic and indicate an empty cavity.)
A nurse is assessing a patient who reports pain when swallowing and difficulty swallowing. The patient has a history of smoking for the past 15 years. What could be the most likely cause of the symptoms in this patient?
Esophageal cancer (The patient has dysphagia and is a chronic smoker. The most likely cause of these symptoms is esophageal cancer. Pain and difficulty in swallowing are not symptoms commonly observed in reflux disease, hiatal hernia, or peptic ulcer disease. Abdominal pain is the most common symptom in these conditions.)
A patient faces difficulty in defecation due to constipation. Which conditions should the nurse ask the patient about before advising him to perform the Valsalva maneuver? Select all that apply.
Hemorrhoids Cardiac problems Abdominal surgery (The Valsalva maneuver involves contraction of the chest muscles on a closed glottis with simultaneous contraction of the abdominal muscles. Before advising a patient to perform the Valsalva maneuver, it is important to enquire about hemorrhoids, cardiac problems, and abdominal surgery, because the maneuver may be contraindicated in patients having these conditions. The Valsalva maneuver increases the abdominal pressure and may aggravate hemorrhoids. The increased abdominal pressure may also put undue pressure on the incision if the maneuver is performed after an abdominal surgery. The maneuver increases the workload of the heart and thus is not advised in patients with cardiac problems. Coughing before the maneuver is not mandatory, and peptic ulcers are irrelevant.)
When the nurse is interviewing a patient about his health history, which conditions should the nurse include as relevant to the gastrointestinal system? Select all that apply.
Hemorrhoids, lactose intolerance, nausea and vomiting, and abdominal distension are conditions related to the gastrointestinal system. When interviewing the patient about this system, the nurse should enquire and obtain information about these conditions. Nasal polyps are a condition related to the upper respiratory system. Monthly income is not directly relevant to the gastrointestinal system in this context. Although economic status does influence diet and health from a broad public-health viewpoint, the health history is not about such topics; it is focused on specific conditions.
When performing an abdominal assessment on a 60-year-old man, the nurse is able to palpate the spleen. Which nursing action is the most appropriate?
If the spleen is palpable, the nurse should discontinue palpating, because manual compression of an enlarged spleen may cause it to rupture. In a 60-year-old healthy man, the spleen should not be palpable. Further tapping of the spleen and nearby area is not advisable, owing to the risk of splenic rupture. Thereafter, the patient can be prepared for further investigations as prescribed by the health care provider.
Which sequence should the nurse follow in examining a patient's abdomen?
Inspection first, then auscultation, percussion, and palpation
After a patient has had an esophagogastroduodenoscopy (EGD), which is the most important nursing action?
Keeping the patient nothing by mouth (NPO) until the gag reflex returns. (After an EGD, it is essential to keep patient NPO until gag reflex returns. Gently tickle back of throat to determine reflex. The patient should remain NPO until the gag reflex returns, so offering warm saline gargles is not safe. It is appropriate to use warm saline gargles for relief of sore throat, but this is not the most important priority after an EGD. Gas is present following a colonoscopy, not an EGD. The patient will not undergo anesthesia for this procedure.)
While caring for a bedridden patient, a nurse notices that the patient's stools are lighter than the usual brown color. What could this finding indicate? Select all that apply.
Liver failure Biliary obstruction (Bile is broken down in the intestine to form stercobilinogen and urobilinogen. Stercobilinogen gives a brown color to the feces. If the stools are light in color, it indicates there is reduced production of bile or bile is not reaching the intestine for breakdown. Liver cells form bile; therefore liver failure could cause decreased production of bile. Biliary tract obstruction prevents the bile from reaching the intestine. Pancreatitis causes impaired fat metabolism and therefore the stools are fatty and frothy. This is called steatorrhea. Stomach ulcers and colorectal cancers may cause bleeding in the GI tract, resulting in red-colored stools.)
An 85-year-old woman states that she has no appetite and no desire to eat at mealtimes. The nurse's response is based on the knowledge that the older adult experiences which of these changes that may affect her appetite? Select all that apply.
May have difficulty swallowing food May have difficulty chewing because of loss of teeth Has a diminished sense of taste, especially salty and sweet
The nurse is discussing the process of digestion with a patient. The patient is surprised to hear that microorganisms exist in the large intestine. Which of these are functions of microorganisms in the colon? Select all that apply.
Microorganisms in the colon are responsible for the breakdown of proteins not digested or absorbed in the small intestine. These amino acids are delaminated by the bacteria, leaving ammonia, which is carried to the liver and converted to urea, which is excreted by the kidneys. Bacteria in the colon also synthesize vitamin K and some of the B vitamins. Microorganisms do not secrete mucus, absorb water, or neutralize acid in fecal contents.
A nurse is performing an abdominal examination of a patient. The nurse auscultates loud gurgling sounds in the stomach and recognizes that this is indicative of what?
Normal finding (A loud gurgling sound in the stomach, also called as borborygmi, is a normal finding. It is usually found on auscultation after eating food. Abdominal artery obstruction causes bruit, which is heard as a humming or swishing sound. In paralytic ileus, there is no bowel sound heard on auscultation. In intestinal obstruction, there are tinkling rushes on auscultation.)
A nurse is assessing a patient who has constipation. Which information should the nurse obtain to assess the patient's elimination pattern? Select all that apply.
On assessment of the patient's elimination pattern, the nurse should get detailed information about the frequency of bowel movements, use of laxatives, enemas, or opioid medications, and consistency of stools. The frequency of bowel movements helps to assess the severity of constipation. Use of laxatives or enemas helps to assess the self-care interventions used by the patient. Consistency of stools helps to determine the cause of constipation. Information about the food intake in the past week is obtained while taking the history about the nutritional metabolism pattern of the patient. Presence of abdominal pain should be assessed while obtaining information about the cognitive-perceptual pattern.
A patient reports severe pain in the right upper quadrant of the abdomen. Which assessment techniques should the nurse use when examining the liver? Select all that apply.
Percussion helps to estimate the size of the liver, presence of fluid or masses, and liver distention. Deep palpation helps to inspect any masses or tenderness around the liver and other organs. The liver is not a superficial organ. Thus, direct observation or inspection will not determine the presence of liver abnormality. Similarly, light percussion would not be useful to assess the liver. Liver sounds (normal or abnormal) are not present; therefore auscultation cannot be of use while assessing the liver.
A nurse assesses a patient with abdominal pain. On deep palpation over the painful site, the nurse observes that the patient experiences pain upon withdrawal of the palpating fingers. Which condition is the patient most likely experiencing?
Rebound tenderness is a characteristic sign of peritoneal inflammation. It can be tested by pressing the painful area deeply and firmly and then withdrawing the fingers quickly. Withdrawal of the palpating fingers produces pain. Rebound tenderness is not indicative of cirrhosis, an enlarged spleen, or presence of an abdominal mass. These may be tender on deep palpation.
The nurse is performing a focused abdominal assessment of a patient who recently has been admitted. To palpate the patient's liver, where should the nurse palpate the patient's abdomen?
Right upper quadrant (Although the left lobe of the liver is located in the left upper quadrant of the abdomen, the bulk of the liver is located in the right upper quadrant. The liver is not located in the right lower quadrant or the left lower quadrant. Only the left lobe of the liver is located in the left upper quadrant.)
The health care team is assessing a male patient for acute pancreatitis after he presented to the emergency department with severe abdominal pain. Which laboratory value is the best diagnostic indicator of acute pancreatitis?
Serum amylase (Elevated serum amylase levels indicate early pancreatic dysfunction and are used to diagnose acute pancreatitis. Serum lipase levels stay elevated longer than serum amylase in acute pancreatitis. Blood glucose, gastric pH, and potassium levels are not direct indicators of acute pancreatic dysfunction.)
A patient experiences severe abdominal pain. A nurse performs a physical examination and finds that there is tenderness in the left upper quadrant. Which organs could cause this tenderness? Select all that apply.
Spleen Stomach (Tenderness in the left upper quadrant of the abdomen indicates abnormality in the spleen and stomach as they are located in the left upper abdominal quadrant. Hepatic flexure of the colon, right lobe of the liver, and duodenum are located in the right upper abdominal quadrant. Abnormality in any of these structures would cause tenderness in the right upper quadrant.)
The nurse is reviewing the function of the liver. Which of these are functions of the liver? Select all that apply.
The liver is responsible for many physiologic functions, including glycogenolysis, synthesis and breakdown of cholesterol, and storage of fat-soluble vitamins. The gallbladder stores bile. Amylase and lipase are secreted by the pancreas. The liver performs multiple major functions that aid in the maintenance of homeostasis. These include metabolism of proteins and steroids as well as detoxification of drugs and metabolic waste products. The Kupffer cells of the liver participate in the breakdown of old RBCs. The liver produces bile, but storage occurs in the gall bladder.
The digestion of food and the absorption of nutrients take place mainly in the stomach and small and large intestines with the help of the accessory organs. The nurse recalls that the stomach plays what roles during digestion and absorption? Select all that apply.
The parietal cells present in the fundus of the stomach secrete hydrochloric acid which serves as protection against organisms present in food. The food is mixed together with gastric juices in the stomach. Proteins are absorbed in the small intestine. Secretion of saliva is done by the salivary glands present in the oral cavity. Fats are broken down into fatty acids in the small intestine with the help of digestive enzymes. Bile is secreted by the liver.
The patient had a car accident and was "scared to death." The patient now is reporting constipation. The nurse should know that what affecting the gastrointestinal (GI) tract could be contributing to the constipation?
The sympathetic nervous system (SNS) was activated so the GI tract was slowed. (The constipation most likely is related to the sympathetic nervous system activation from the stress related to the accident. SNS activation can decrease peristalsis. Even without oral intake for a short time, stool will be formed. The parasympathetic system stimulates peristalsis. The circulation to the GI system is decreased with stress.)
A patient reports hematemesis and burning pain in the stomach. The nurse suspects the patient to have peptic ulcer disease. Which diagnostic test is appropriate to confirm the diagnosis?
Upper GI endoscopy (An upper GI endoscopy or esophagogastroduodenoscopy helps to visualize the stomach mucosa for ulcerations, inflammatory lesions, and tumors. Thus this procedure is very useful for detecting the presence of peptic ulcers. An MRI is usually used to detect hepatobiliary disease and staging of cancer. A colonoscopy is used to visualize the colon. Abdominal ultrasound would help in the diagnosis of obstruction, masses, tumors, and other structural abnormalities.)
A nurse assesses an elderly patient with colon cancer. The patient experiences much difficulty when moving and requires assistance with turning and ambulating. Which diagnostic test is appropriate to perform first?
Virtual colonoscopy should be the first diagnostic test for the patient as it is less invasive and provides a better view of the colon and rectum. It helps in detecting any polyps or tumors inside the colon. However, this technique is less sensitive and cannot detect flat or small (less than 10 mm) polyps. This procedure should be followed by conventional colonoscopy to obtain a biopsy and to remove the tumor. A lower GI series examination involves injection of air-contrast barium enema and is unsuitable for elderly patients, as they cannot retain the barium and may feel discomfort during the examination. However, if necessary, this test could be performed with extra care. Upper GI examination detects the structural abnormalities of the upper GI tract. Endoscopic retrograde cholangiopancreatography is used to examine the biliary and pancreatic ductal systems.
While assessing the abdomen, the nurse uses the bell of the stethoscope to auscultate below the diaphragm to assess for lower-pitched bowel sounds. What measure should the nurse take to prevent abdominal contraction while auscultating?
Warm the bell of the stethoscope with the hands
