Lower Gi, Liver, Pancreas, Biliary Tract Quiz

The nurse is teaching a client with an ostomy how to change the pouching system. Which information should the nurse include when teaching a client with no peristomal skin irritation? 1. Dry skin thoroughly after washing 2. Apply barrier powder 3. Apply triamcinolone acetonide spray 4. Dust with nystatin powder

1. Dry skin thoroughly after washing The nurse should teach the client without peristomal skin irritation to dry the skin thoroughly after washing. Barrier powder, triamcinolone acetonide spray, and nystatin powder are used when the client has peristomal skin irritation and/or fungal infection.

The nurse is conducting a community education program on colorectal cancer. Which statement should the nurse include in the program? 1. It is the third most common cancer in the United States. 2. The lifetime risk of developing colorectal cancer is 1 in 10. 3. The incidence of colorectal cancer decreases with age. 4. Colorectal cancer has no hereditary component.

1. It is the third most common cancer in the United States. Colorectal cancer is the third most common type of cancer in the United States. The lifetime risk of developing colorectal cancer is 1 in 20. The incidence increases with age (the incidence is highest in people older than 85). Colorectal cancer occurrence is higher in people with a family history of colon cancer.

Clostridium difficile infection has been moving through an extended-care facility, and several of the elderly residents have been experiencing severe diarrhea. One particularly sick resident has told the nurse that he is now experiencing extreme fatigue and muscle cramps and that his heart feels like it occasionally "skips a beat." The nurse should facilitate a stat assessment of this resident's: 1. Potassium levels 2. Calcium levels 3. Cardiac biomarkers 4. Hemoglobin and hematocrit

1. Potassium levels Elderly patients can become dehydrated quickly and develop low potassium levels (ie, hypokalemia) as a result of diarrhea. The nurse observes for clinical manifestations of muscle weakness, arrhythmias, or decreased peristaltic motility that may lead to paralytic ileus. Assessment of potassium levels would be prioritized over calcium, Hgb, and Hct. The resident's circumstances are more characteristic of hypokalemia than of ischemic heart disease.

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient? 1. Respiratory assessment related to increased thoracic pressure 2. Urinary output related to increased sodium retention 3. Peripheral vascular assessment related to immobility 4. Skin assessment related to increase in bile salts

1. Respiratory assessment related to increased thoracic pressure If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy.

A nurse is providing care for a client who has a diagnosis of irritable bowel syndrome (IBS). When planning this client's care, the nurse should collaborate with the client and prioritize what goal? 1. Client will demonstrate appropriate care of his ileostomy. 2. Client will accurately identify foods that trigger symptoms. 3. Client will demonstrate appropriate use of standard infection control precautions. 4. Client will adhere to recommended guidelines for mobility and activity.

2. Client will accurately identify foods that trigger symptoms. A major focus of nursing care for the client with IBS is to identify factors that exacerbate symptoms. Surgery is not used to treat this health problem and infection control is not a concern that is specific to this diagnosis. Establishing causation likely is more important to the client than managing physical activity.

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal? 1. Controlling bleeding 2. Maintaining the airway 3. Maintaining fluid volume 4. Relieving the client's anxiety

2. Maintaining the airway Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway can be compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.

Which is the most common cause of esophageal varices? 1. Jaundice 2. Portal hypertension 3. Ascites 4. Asterixis

2. Portal hypertension Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

Which symptoms will a nurse observe most commonly in clients with pancreatitis? 1. black, tarry stools and dark urine 2. severe, radiating abdominal pain 3. increased and painful urination 4. increased appetite and weight gain

2. severe, radiating abdominal pain The most common symptom in clients with pancreatitis is severe midabdominal to upper abdominal pain, radiating to both sides and straight to the back.

A client's colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the client has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurse's most appropriate response to this observation? 1. Ensure that the client knows that he or she will be responsible for care after discharge. 2. Reassure the client that many people are fearful after the creation of an ostomy. 3. Acknowledge the client's reluctance and initiate discussion of the factors underlying it. 4. Arrange for the client to be seen by a social worker or spiritual advisor.

3. Acknowledge the client's reluctance and initiate discussion of the factors underlying it. If the client is reluctant to participate in ostomy care, the nurse should attempt to dialogue about this with the client and explore the factors that underlie it. It is presumptive to assume that the client's behavior is motivated by fear. Assessment must precede referrals and emphasizing the client's responsibilities may or may not motivate the client.

A nurse is assessing a client's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding? 1. Irrigate the ostomy to clear a possible obstruction. 2. Contact the primary provider to report this finding. 3. Document that the stoma appears healthy and well perfused. 4. Document a nursing diagnosis of Impaired Skin Integrity.

3. Document that the stoma appears healthy and well perfused. A healthy, viable stoma should be shiny and pink to bright red. This finding does not indicate that the stoma is blocked or that skin integrity is compromised.

The nurse is conducting discharge teaching for a client with diverticulosis. Which instruction should the nurse include in the teaching? 1. Avoid unprocessed bran. 2. Avoid daily exercise. 3. Drink 8 to 10 glasses of fluid daily. 4. Use laxatives weekly.

3. Drink 8 to 10 glasses of fluid daily. The nurse should instruct a client with diverticulosis to drink at least 8 to 10 large glasses of fluid every day. The client should include unprocessed bran in the diet because it adds bulk, and should avoid the use of laxatives or enemas except when recommended by the physician. In addition, regular exercise should be encouraged if the client's current lifestyle is somewhat inactive.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure? 1. Administering an analgesic once per shift, as ordered, to prevent drug addiction 2. Encouraging frequent visits from family and friends 3. Positioning the client on the side with the knees flexed 4. Administering frequent oral feedings

3. Positioning the client on the side with the knees flexed The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching? 1. "I'll wash my hands often." 2. "I'll be very careful when preparing food for my family." 3. "I'll take all my medications as ordered." 4. "How did this happen? I've been faithful my entire marriage."

4. "How did this happen? I've been faithful my entire marriage." The client requires further teaching if he suggests that he acquired the virus through sexual contact. Hepatitis A is transmitted by the oral-fecal route or through ingested food or liquid that's contaminated with the virus. Hepatitis A is rarely transmitted through sexual contact. Clients with hepatitis A need to take every effort to avoid spreading the virus to other members of their family with precautions such as preparing food carefully, washing hands often, and taking medications as ordered.