Chapter 23: GI Disorders
The parents of a boy diagnosed with Hirschsprung disease are anxious and fearful of the upcoming surgery. The mother states, "I'm worried about having to care for our son's ostomy." Which intervention would be most helpful for the parents? Explaining to them about the diagnosis and surgery. Teaching them about the medications used to slow stool output. Reinforcing that the ostomy will be temporary. Having a wound, ostomy, and continence nurse meet with them.
Having a wound, ostomy, and continence nurse meet with them. Explanation: Although explaining about the diagnosis and surgery, reinforcing that the ostomy will be temporary, and teaching them about medications would be appropriate, the parents are voicing concerns about caring for the ostomy. Therefore, having a wound, ostomy, and continence nurse meet with them would address these concerns and help them deal with the anxieties and care of a newly placed stoma.
The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurately related to the diagnosis of colic? A partial or complete intestinal obstruction occurs. A thickened, elongated muscle causes an obstruction at the end of the stomach. In this disorder the sphincter that leads into the stomach is relaxed. There are recurrent paroxysmal bouts of abdominal pain.
There are recurrent paroxysmal bouts of abdominal pain. Explanation: Colic is described as episodes of crying in the infant, lasting up to several hours a day and recurring several times a week for several weeks. These episodes are often associated with recurrent gastrointestinal disturbances and are fairly common in young infants. Congenital aganglionic megacolon is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus, which leads to an obstruction at the distal end of the stomach. Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus is relaxed and allows gastric contents to be regurgitated back into the esophagus.
What occurs in the gastrointestinal system of the child with Hirschsprung disease? There is a partial or complete mechanical obstruction in the intestine. There is a relaxed sphincter in the lower portion of the esophagus. There is a severe narrowing of the lumen of the pylorus. There is an invagination or telescoping of one portion of the bowel into a distal portion.
There is a partial or complete mechanical obstruction in the intestine. Explanation: Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. A narrowing of the lumen of the pylorus is associated with pyloric stenosis in young infants. The telescoping of the bowel is intussusception. The relaxed sphincter in the lower portion of the esophagus is related to gastrointestinal reflux disorder.
A nurse is teaching a group of parents about hepatitis A viral infection. The nurse would describe which of the following as the route of transmission? direct contact transplacental airborne fecal-oral
fecal-oral Explanation: Hepatitis A viral infection (HAV) is commonly transmitted from person to person by fecal-oral contamination. Measles is spread directly by coughing or sneezing or indirectly by airborne suspended droplets. Syphilis may be transmitted through transplacental means from an infected mother to her fetus.
The nurse is conducting a physical examination of an infant with suspected pyloric stenosis. Which finding indicates pyloric stenosis? hard, moveable "olive-like mass" in the upper right quadrant perianal fissures and skin tags abdominal pain and irritability sausage-shaped mass in the upper mid abdomen
hard, moveable "olive-like mass" in the upper right quadrant Explanation: A hard, moveable "olive-like mass" in the right upper quadrant is the hypertrophied pylorus. A sausage-shaped mass in the upper mid abdomen is the hallmark of intussusception. Perianal fissures and skin tags are typical with Crohn disease. Abdominal pain and irritability is common with pyloric stenosis but are seen with many other conditions.
The nurse is caring for a 3-year-old with repeated diarrhea. The client is listless and clings to the parent. The nurse reviews the lab work, which reports a pH- 7.33, HCO3- 21, PaCO2- 42. Which would be documented? metabolic alkalosis normal serum pH metabolic acidosis high serum pH
metabolic acidosis Explanation: Diarrhea leads to a metabolic acidosis through the extreme loss of base substances in stools. This is noted in the ABG levels with blood pH indicating acidosis and the bicarb being abnormal.
The nurse is reviewing the medical record of a child with a cleft lip and palate. When reviewing the child's history, what would the nurse identify as a risk factor for this condition? mother age 42 with pregnancy maternal use of acetaminophen in third trimester preterm birth history of hypoxia at birth
mother age 42 with pregnancy Explanation: Advanced maternal age is a risk factor for cleft lip and palate. Drugs such as anticonvulsants, steroids, and other medications during early pregnancy are considered risk factors. Acetaminophen is not associated with an increased risk for cleft lip and palate. Preterm birth is not a risk factor for the development of cleft lip and palate. Hypoxia or anoxia is a risk factor for the development of necrotizing enterocolitis.
The nurse teaches a parent to differentiate between regurgitation and vomiting in the infant. The parent correctly states which characteristic of regurgitation? Select all that apply. followed by dry retching occurs with feeding no appearance of distress timing unrelated to feeding forceful expulsion of stomach contents
occurs with feeding no appearance of distress Explanation: Regurgitation occurs with feeding; the infant does not exhibit signs of distress. Forceful expulsion of stomach contents that is followed by dry retching unrelated to feeding are characteristics of vomiting.
The nurse is caring for an infant recovering from surgery for pyloric stenosis. Which nursing diagnosis should the nurse use to guide care during the immediate postoperative period? Excess fluid volume related to increased fluid intake prescribed postoperatively Anxiety related to new feeding method used postoperatively Risk for infection of incision line, related to disruption of skin barrier during surgery Ineffective tissue perfusion related to pressure on heart chambers
Risk for infection of incision line, related to disruption of skin barrier during surgery Explanation: Because the incision line for a pyloric stenosis repair is near the diaper area, the child is at risk of developing a surgical infection. The diagnosis risk for infection of incision line is the most appropriate during the immediate postoperative period. Anxiety might be appropriate after the immediate postoperative period has passed. There is not enough information to determine if the infant is being given excessive fluid or if the infant is experiencing ineffective tissue perfusion.
The nurse is discussing the treatment of congenital aganglionic megacolon with the caregivers of a child diagnosed with this disorder. Which statement is the best explanation of the treatment for this diagnosis? "Your child will be treated with oral iron preparations to correct the anemia." "The treatment for the disorder will be a surgical procedure." "We will give enemas until clear and then teach you how to do these at home." "Your child will receive counseling so the underlying concerns will be addressed."
The treatment for the disorder will be a surgical procedure." Explanation: Treatment of congenital aganglionic megacolon involves surgery with the ultimate resection of the aganglionic portion of the bowel. Chronic anemia may be present, but iron will not correct the disorder. Enemas may be given to initially achieve bowel elimination, but they will not treat the disorder. Differentiation must be made between this condition and psychogenic megacolon because of coercive toileting or other emotional problems. The child with aganglionic megacolon does not withhold stools or defecate in inappropriate places, and no soiling occurs.
The nurse performs an abdominal assessment of an infant and observes a prominent venous pattern. The nurse interprets this as indicating which of the following? malnourishment pyloric stenosis Hirschsprung disease cirrhosis of the liver
cirrhosis of the liver Explanation: Upon assessment, a prominent venous pattern may be seen in children with cirrhosis of the liver. Peristalsis may be visible in the thin, malnourished infant or in the infant with obstruction caused by pyloric stenosis. The abdomen is distended with Hirschsprung disease.
The nurse is reviewing the medical record of a child with a cleft lip and palate. When reviewing the child's history, what would the nurse identify as a risk factor for this condition? mother age 42 with pregnancy maternal use of acetaminophen in third trimester history of hypoxia at birth preterm birth
mother age 42 with pregnancy Explanation: Advanced maternal age is a risk factor for cleft lip and palate. Drugs such as anticonvulsants, steroids, and other medications during early pregnancy are considered risk factors. Acetaminophen is not associated with an increased risk for cleft lip and palate. Preterm birth is not a risk factor for the development of cleft lip and palate. Hypoxia or anoxia is a risk factor for the development of necrotizing enterocolitis.
The nurse enters a client's room to find the new mother crying softly. The client states, "I had my heart set on breastfeeding but my infant was born with a cleft lip. My dreams of breastfeeding are destroyed." Which response by the nurse is appropriate? "You can use a supplemental nursing system to get a similar experience." "I am so sorry your infant has a cleft lip. Bottle feeding will be easiest for you and your infant." "You should speak with a lactation consultant before making a decision on which feeding method to use." "You may still breastfeed your infant. I will show you appropriate techniques to use."
"You may still breastfeed your infant. I will show you appropriate techniques to use." Explanation: The nurse should be therapeutic and reassure the mother that breastfeeding may still be an option. Infants with cleft lips may still successfully breastfeed once appropriate techniques are learned and implemented. A supplemental nursing system is used to provide supplemental milk to breastfeeding babies. Telling the client to speak with a lactation consultant does not address the client's current concern.
Nurses will need to teach the parents of the infant being treated for Hirschsprung disease (aganglionic megacolon) to: avoid use of a pacifier. carefully monitor heart rate. care for a temporary colostomy. thicken formula feedings.
care for a temporary colostomy. Explanation: The aganglionic portion of the infant's colon will need to be removed. In most cases, bowel is allowed to rest and recoil for a period of time, necessitating a temporary colostomy. Later the colostomy can be closed and the two ends of the intestine rejoined. Thickening feedings will not relieve the colon distention and obstruction with stool. Pacifiers may be used and are soothing. Monitoring heart rate should not be necessary.
The nurse enters a client's room to find the new mother crying softly. The client states, "I had my heart set on breastfeeding but my infant was born with a cleft lip. My dreams of breastfeeding are destroyed." Which response by the nurse is appropriate? "I am so sorry your infant has a cleft lip. Bottle feeding will be easiest for you and your infant." "You can use a supplemental nursing system to get a similar experience." "You should speak with a lactation consultant before making a decision on which feeding method to use." "You may still breastfeed your infant. I will show you appropriate techniques to use."
"You may still breastfeed your infant. I will show you appropriate techniques to use." Explanation: The nurse should be therapeutic and reassure the mother that breastfeeding may still be an option. Infants with cleft lips may still successfully breastfeed once appropriate techniques are learned and implemented. A supplemental nursing system is used to provide supplemental milk to breastfeeding babies. Telling the client to speak with a lactation consultant does not address the client's current concern.
The nurse is caring for a pediatric client with idiopathic celiac disease. Which meal will the nurse select for this client? Meatloaf, green beans, peanut butter cookie, and fat-free milk Whole wheat pasta, meatballs, carrot sticks, apple, and water Ham and cheese sandwich, orange slices, chips, and whole milk Baked salmon, potato slices, vanilla ice cream, and apple juice
Baked salmon, potato slices, vanilla ice cream, and apple juice Explanation: Celiac disease is an autoimmune condition where contact with gluten causes a reaction from the body's immune system. Clients with celiac disease should be educated to eat a gluten-free diet to decrease symptoms and limit small intestine irritation. Gluten is a protein found in wheat, barley, and rye. Most commercially used flour contains wheat and should be avoided. The nurse would select foods such as meats/fish (salmon), fruits, vegetables (potatoes), and rice. Single flavor ice creams, such as chocolate, vanilla, and strawberry are gluten free, while cookies contain flour and should be avoided. Fruit juices, water, and milk are all gluten free. Meatloaf may contain oats; however, studies suggest oats are fine to consume, as long as the oats did not come into contact with wheat during processing. Reading the label would indicate if wheat was contacted. Sandwich bread and pastas contain gluten unless special gluten-free products are purchased or it is homemade. The nurse would not assume those items were gluten-free.
The mother of a newborn with a cleft lip reports she is having a hard time looking her baby. What is the best action by the nurse? Explain that surgery will make this better in the future. Tell the mother that while this is difficult it will get easier. Encourage the mother to provide care for her infant. Encourage the child's mother to hold her infant against her shoulder to provide closeness while not looking at the defect.
Encourage the mother to provide care for her infant. Explanation: Providing care to the infant is the best means for the mother to begin bonding with her baby. Activities such as feeding, diapering and bathing will be helpful. Encouraging the mother to avoid looking at the cleft lip will not assist her in the process of accepting it. While surgery will be performed it will not take place for a few months making it vital that she begin bonding with her infant. Telling the parent she will get used to it minimizes her concerns and is not the most therapeutic response by the nurse.
The parents of a boy diagnosed with Hirschsprung disease are anxious and fearful of the upcoming surgery. The mother states, "I'm worried about having to care for our son's ostomy." Which intervention would be most helpful for the parents? Explaining to them about the diagnosis and surgery. Reinforcing that the ostomy will be temporary. Having a wound, ostomy, and continence nurse meet with them. Teaching them about the medications used to slow stool output.
Having a wound, ostomy, and continence nurse meet with them Explanation: Although explaining about the diagnosis and surgery, reinforcing that the ostomy will be temporary, and teaching them about medications would be appropriate, the parents are voicing concerns about caring for the ostomy. Therefore, having a wound, ostomy, and continence nurse meet with them would address these concerns and help them deal with the anxieties and care of a newly placed stoma.
The nurse admits a 7-year-old child who reports pain in the lower right quadrant of the abdomen, nausea, and constipation. An assessment shows that the child has a fever of 101°F (38.3℃). Which nursing intervention should the nurse implement to safely address the child's reported pain? Help the child find a comfortable position. Place a heating pad or hot water bottle on the abdomen. Request a prescription for a laxative. Give the child an analgesic such as acetaminophen.
Help the child find a comfortable position. Explanation: The child's symptoms indicate possible appendicitis. When appendicitis is suspected, laxatives and enemas are contraindicated because they increase peristalsis, which increases the possibility of rupturing an inflamed appendix. Heat to the abdomen is also contraindicated because of the danger of rupture of the appendix. Medicating with analgesics is inappropriate, because medication may conceal signs of tenderness that are important for diagnosis. Comfort can be provided through positioning.
A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease? Ulcerative colitis (UC) Hirschsprung disease Short bowel syndrome (SBS) Gastroenteritis
Hirschsprung disease Explanation: The nurse should suspect Hirschsprung disease when the newborn does not pass meconium in the first 24 hours after birth, and has bilious vomiting or abdominal distention and feeding intolerance with bilious aspirates and vomiting. Typical signs and symptoms of gastroenteritis include diarrhea, nausea, vomiting, and abdominal pain. The characteristic GI manifestation of UC is bloody diarrhea accompanied by crampy, typically left-sided lower abdominal pain. Clinical manifestations of untreated SBS include profuse watery diarrhea, malabsorption, and failure to thrive.
The nurse is talking with a pregnant client about cleft lips and palates. The client has asked if these can be tested for. What information should be included in the nurse's response? Select all that apply. Ultrasounds can be used to assess for these conditions. The quadruple marker test can be used to detect these conditions. The nuchal translucency test can be used to screen for cleft lips and palates. Most cleft lips and palates are found at delivery. There are no ways to determine the presence of cleft lips or palates prior to delivery.
Ultrasounds can be used to assess for these conditions. Most cleft lips and palates are found at delivery. Explanation: Ultrasounds can be used to identify the presence of cleft lips or palates. Most, however, are found after birth. The quadruple screening test assesses for potential down syndrome and neuro tube defects. Nuchal translucency testing is used to assess for Down syndrome.
The nurse is caring for an infant born at 34 weeks' gestation who has developed necrotizing enterocolitis (NEC). When meeting the infant's nutritional needs, which type of supplies will be needed? a gastric tube for regularly scheduled gavage feedings an oral syringe for oral breastfeeding a nasogastric tube and a watch for use with "trophic feeds" an intravenous pole and pump for total parenteral nutrition (TPN)
an intravenous pole and pump for total parenteral nutrition (TPN) Explanation: The nurse gathers intravenous supplies for the administration of total parenteral nutrition (TPN). TPN should be administered to preterm infants with necrotizing enterocolitis (NEC). In NEC, there is acute inflammation of the bowel associated with ischemia. This can lead to bowel necrosis and perforation. Preterm infants are at higher risk of developing NEC due to gastric immaturity and an increased risk for infections. When NEC is detected in the preterm infant, TPN should be administered and enteral feeding should be withheld until the condition stabilizes. Gavage feeding and "trophic feeds" are different forms of enteral feeding given to preterm infants, but not to those having NEC. Oral breastfeeding should also be withheld in NEC. NEC is treated with IV fluids, antibiotics, blood transfusion, and surgical resection of the segment.
The nurse is caring for an infant born at 34 weeks' gestation who has developed necrotizing enterocolitis (NEC). When meeting the infant's nutritional needs, which type of supplies will be needed? an intravenous pole and pump for total parenteral nutrition (TPN) a nasogastric tube and a watch for use with "trophic feeds" an oral syringe for oral breastfeeding a gastric tube for regularly scheduled gavage feedings
an intravenous pole and pump for total parenteral nutrition (TPN) Explanation: The nurse gathers intravenous supplies for the administration of total parenteral nutrition (TPN). TPN should be administered to preterm infants with necrotizing enterocolitis (NEC). In NEC, there is acute inflammation of the bowel associated with ischemia. This can lead to bowel necrosis and perforation. Preterm infants are at higher risk of developing NEC due to gastric immaturity and an increased risk for infections. When NEC is detected in the preterm infant, TPN should be administered and enteral feeding should be withheld until the condition stabilizes. Gavage feeding and "trophic feeds" are different forms of enteral feeding given to preterm infants, but not to those having NEC. Oral breastfeeding should also be withheld in NEC. NEC is treated with IV fluids, antibiotics, blood transfusion, and surgical resection of the segment.
Nurses will need to teach the parents of the infant being treated for Hirschsprung disease (aganglionic megacolon) to: avoid use of a pacifier. thicken formula feedings. care for a temporary colostomy. carefully monitor heart rate.
care for a temporary colostomy. Explanation: The aganglionic portion of the infant's colon will need to be removed. In most cases, bowel is allowed to rest and recoil for a period of time, necessitating a temporary colostomy. Later the colostomy can be closed and the two ends of the intestine rejoined. Thickening feedings will not relieve the colon distention and obstruction with stool. Pacifiers may be used and are soothing. Monitoring heart rate should not be necessary.
Nurses will need to teach the parents of the infant being treated for Hirschsprung disease (aganglionic megacolon) to: carefully monitor heart rate. thicken formula feedings. care for a temporary colostomy. avoid use of a pacifier.
care for a temporary colostomy. Explanation: The aganglionic portion of the infant's colon will need to be removed. In most cases, bowel is allowed to rest and recoil for a period of time, necessitating a temporary colostomy. Later the colostomy can be closed and the two ends of the intestine rejoined. Thickening feedings will not relieve the colon distention and obstruction with stool. Pacifiers may be used and are soothing. Monitoring heart rate should not be necessary.
The nurse is determining maintenance fluid requirements for a child who weighs 25 kg (55 lb). How much fluid would the child need per day? 1,700 ml 1,650 ml 1,560 ml 1,600 ml
1,600 ml Explanation: Using the following formula of 100 ml/kg for the first 10 kg, plus 50 ml/kg for the next 10 kg, and then 20 ml/kg for the remaining kg, the child would require (100 × 10) + (50 × 10) + (20 × 5) = 1,000 + 500 + 100 = 1,600 mL in 24 hours.
The nurse is taking a health history of an 11-year-old child with recurrent abdominal pain. Which response will lead the nurse to suspect irritable bowel syndrome? "I have stomach cramps after eating bread and pasta." "I always feel better after I have a bowel movement." "I have pain in my mouth and abdomen, all the way to my anus." "My stools are loose with mucus and have blood on them."
"I always feel better after I have a bowel movement." Explanation: In cases of irritable bowel syndrome, the pain may be relieved by defecation. Abdominal pain associated with the eating of gluten-rich food such as pasta and bread may be indicative of celiac disease. Bloody stools and abdominal pain that starts in the mouth and abdomen, going all the way to the anus, are not symptoms of irritable bowel syndrome but of Crohn's disease.
A nurse is caring for a 6-year-old girl recently diagnosed with celiac disease and is discussing dietary restrictions with the girl's mother. Which response indicates a need for further teaching? "There is gluten hidden in unexpected foods." "My daughter is eating more vegetables." "My daughter can eat any kind of fruit." "There are many types of flour besides wheat."
"My daughter can eat any kind of fruit." Explanation: While most fruits and fruit juices are allowed, the nurse needs to make sure the mother knows that some fruit pie fillings and dried fruit may contain gluten.
The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac disease. The caregivers make the following statements. Which statement indicates a need for further teaching regarding the dietary restrictions for the child with celiac disease? "She loves hot dogs, and we always cut hers up into small pieces." "Even though milk and pudding are good for her, we don't give her those foods." "I have learned to make my own bread with no gluten." "The soup we eat at our house is all made from scratch."
"She loves hot dogs, and we always cut hers up into small pieces." Explanation: Commercially canned creamed soups, cold cuts, frankfurters, and pudding mixes generally contain wheat products and should not be included in the diet of the child with celiac syndrome. This caregiver needs further teaching regarding giving her child hot dogs, even if they are cut into small pieces. The other choices show an understanding of the dietary restrictions.
The nurse is collecting data on a 2-year-old child admitted with a diagnosis of gastroenteritis. When interviewing the caregivers, which question is most important for the nurse to ask? "How many times a day does your child urinate?" "Tell me about the types of stools your child has been having." "How long has your child been toilet trained?" "What foods has your child eaten during the last few days?"
"Tell me about the types of stools your child has been having." Explanation: For the child with gastroenteritis, the interview with the family caregiver must include specific information about the history of bowel patterns and the onset of diarrheal stools, with details on the number and type of stools per day. Recent eating patterns, determining if the child is toilet trained, and how many times a day the child urinates are important questions, but the highest priority is gathering data regarding the stools and stool pattern.
The nurse has admitted a child to the pediatric unit with diarrhea and vomiting. Accurate intake and output are important care measures for the child. The nurse correctly assesses that output parameters should be: 0.5 to 1 ml/kg/shift. 2 to 4 ml/kg/shift. 0.5 to 1 ml/kg/hr. 2 to 4 ml/kg/hr.
0.5 to 1 ml/kg/hr. Explanation: The child's hourly output should be 0.5 to 1 ml/kg/hour. Output of 0.5 to 1 mLl/kg/shift and 2 to 4 ml/kg/shift would be inadequate output for the child. Output of 2 to 4 ml/kg/hr is higher than necessary for adequate hydration.
The nurse is collecting data on a 2-year-old child admitted with a diagnosis of gastroenteritis. When interviewing the caregivers, which question is most important for the nurse to ask? "Tell me about the types of stools your child has been having." "What foods has your child eaten during the last few days?" "How many times a day does your child urinate?" "How long has your child been toilet trained?"
"Tell me about the types of stools your child has been having." Explanation: For the child with gastroenteritis, the interview with the family caregiver must include specific information about the history of bowel patterns and the onset of diarrheal stools, with details on the number and type of stools per day. Recent eating patterns, determining if the child is toilet trained, and how many times a day the child urinates are important questions, but the highest priority is gathering data regarding the stools and stool pattern.
The nurse is discussing the treatment of congenital aganglionic megacolon with the caregivers of a child diagnosed with this disorder. Which statement is the best explanation of the treatment for this diagnosis? "The treatment for the disorder will be a surgical procedure." "Your child will receive counseling so the underlying concerns will be addressed." "We will give enemas until clear and then teach you how to do these at home." "Your child will be treated with oral iron preparations to correct the anemia."
"The treatment for the disorder will be a surgical procedure." Explanation: Treatment of congenital aganglionic megacolon involves surgery with the ultimate resection of the aganglionic portion of the bowel. Chronic anemia may be present, but iron will not correct the disorder. Enemas may be given to initially achieve bowel elimination, but they will not treat the disorder. Differentiation must be made between this condition and psychogenic megacolon because of coercive toileting or other emotional problems. The child with aganglionic megacolon does not withhold stools or defecate in inappropriate places, and no soiling occurs.
The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of congenital aganglionic megacolon? A thickened, elongated muscle causes an obstruction at the end of the stomach. A partial or complete intestinal obstruction occurs. There are recurrent paroxysmal bouts of abdominal pain. In this disorder the sphincter that leads into the stomach is relaxed.
A partial or complete intestinal obstruction occurs. Explanation: Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus, which leads to an obstruction at the distal end of the stomach. Colic consists of recurrent paroxysmal bouts of abdominal pain. Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus is relaxed and allows gastric contents to be regurgitated back into the esophagus.
A child presents with intermittent abdominal pain, severe anorexia, and diarrhea. The child's height and weight are significantly behind standards for age. There is skin breakdown in the anal region. The nurse explains that this presentation is consistent with which diagnosis? Hirschsprung disease ulcerative colitis food poisoning Crohn disease
Crohn diseaseIntermittent abdominal pain, anorexia, diarrhea, growth delays, and perianal lesions are characteristic of Crohn disease. In ulcerative colitis, the pain is continuous with bloody diarrhea, but anorexia, weight loss, and growth delay are mild. Food poisoning is an acute condition and may result in weight loss but not growth delays. In Hirschsprung disease the bowel lacks nerve innervation, so it lacks motility and fecal output.
When providing diaper care to an infant after pyloric stenosis surgery, which approach is indicated? Sterile diapers should be used. Diapers should not be used. Diapers should be folded so that the incision line does not become contaminated. Diapers should be folded so that the incision line is well covered to prevent infection.
Diapers should be folded so that the incision line does not become contaminated. Explanation: Folding diapers low so they do not contact the incision line can help prevent infection following surgery.
The nurse is caring for a child admitted with gastroesophageal reflux (GER). Which clinical manifestation would likely be seen in this child? Effortless vomiting just after the child has eaten Forceful vomiting followed by the child being eager to eat again Severe constipation with occasional ribbon-like stools Bouts of diarrhea with failure to gain weight
Effortless vomiting just after the child has eaten Explanation: The child with GER usually gains weight and feeds well. It must be determined if there are underlying symptoms or complications that might suggest GERD. In the child with GERD, almost immediately after feeding, the child vomits the contents of the stomach. The vomiting is effortless, not projectile in nature. The child with GERD is irritable and hungry, but may refuse to eat. Aspiration after vomiting may lead to respiratory concerns, such as apnea, wheezing, cough, and pneumonia. Failure to thrive and lack of normal weight gain occurs. Symptoms seen in the older child may include heartburn, nausea, epigastric pain, and difficulty swallowing. Forceful vomiting with the child wanting to eat shortly after vomiting is associated with pyloric stenosis. Severe constipation with ribbon-like stools would be indicative of Hirschsprung disease. Bouts of diarrhea with failure to gain weight is associated with Crohn disease.
The parents of a 6-week-old boy come to the clinic for evaluation because the infant has been vomiting. The parents report that the vomiting has been increasing in frequency and forcefulness over the last week. The mother says, "Sometimes, it seems like it just bursts out of his mouth." A diagnosis of hypertrophic pyloric stenosis is suspected. When performing the physical examination, what would the nurse most likely find? Sausage-shaped mass in the upper mid-abdomen Hard, moveable, olive-shaped mass in the right upper quadrant Tenderness over the McBurney point in the right lower quadrant Abdominal pain in the epigastric or umbilical region
Hard, moveable, olive-shaped mass in the right upper quadrant Explanation: With hypertrophic pyloric stenosis, a hard, moveable, olive-shaped mass would be palpated in the right upper quadrant. A sausage-shaped mass in the upper mid-abdomen would suggest intussusception. Tenderness over the McBurney point would be associated with appendicitis. Epigastric or umbilical pain would be associated with peptic ulcer disease.
A nurse prepares a menu for a client with Crohn disease. What is the focus of dietary management for this disease? Low fiber, low calorie High carbohydrate, high protein High calorie, high fiber Low calorie, high carbohydrate
High carbohydrate, high protein Explanation: The goal of nutritional intervention is to provide adequate nutrient intake to optimize normal growth and development—including pubertal development, which is frequently delayed—and to prevent and correct nutrient deficiencies. Adequate nutrition with a high-protein and high-carbohydrate diet may be recommended.
The nurse is caring for a child with a diagnosis of pyloric stenosis during the preoperative phase of the child's treatment. What is the highest priority at this time? Promoting comfort Improving hydration Maintaining skin integrity Preparing family for home care
Improving hydration Explanation: Preoperatively, the highest priority for the child with pyloric stenosis is to improve nutrition and hydration. Maintaining mouth and skin integrity, and relieving family anxiety are important, but these are not the priority. The child will not likely have intense pain. Preparing the family for home care would be a postoperative goal.
The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of gastroesophageal reflux? A partial or complete intestinal obstruction occurs. There are recurrent paroxysmal bouts of abdominal pain. A thickened, elongated muscle causes an obstruction at the end of the stomach. In this disorder the sphincter that leads into the stomach is relaxed.
In this disorder the sphincter that leads into the stomach is relaxed. Explanation: Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus, which leads into the stomach, is relaxed and allows gastric contents to be regurgitated back into the esophagus. Congenital aganglionic megacolon is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Colic consists of recurrent paroxysmal bouts of abdominal pain. Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus, which leads to an obstruction at the distal end of the stomach.
A 9-month-old girl is brought to the emergency room with what appears to be bouts of intense abdominal pain 15 minutes apart in which she draws up her legs and cries, often accompanied by vomiting. In between the bouts, the child recovers and appears to be without symptoms. Blood is found in the stool. What condition should the nurse suspect in this case? Necrotizing enterocolitis Volvulus with malrotation Short-bowel/short-gut syndrome Intussusception
Intussusception Explanation: Intussusception, the invagination of one portion of the intestine into another, usually occurs in the second half of the first year of life. Children with this disorder suddenly draw up their legs and cry as if they are in severe pain; they may vomit. After the peristaltic wave that caused the discomfort passes, they are symptom-free and play happily. In approximately 15 minutes, however, the same phenomenon of intense abdominal pain strikes again. After approximately 12 hours, blood appears in the stool and possibly in vomitus, described as a "currant jelly" appearance. Volvulus with malrotation and necrotizing enterocolitis typically occur in the first 6 months of life and do not match the symptoms described above. Short-bowel/short-gut syndrome typically occurs when a large portion of the intestine has been removed due to a previous disease or trauma.
The nurse has developed a plan of care for a 12-month-old hospitalized with dehydration as a result of rotavirus. Which intervention would the nurse include in the plan of care? Offering Kool-Aid or popsicles as tolerated Encouraging milk products to boost caloric intake Encouraging consumption of fruit juice Maintaining the intravenous (IV) fluid rate as ordered
Maintaining the intravenous (IV) fluid rate as ordered Explanation:The nurse should maintain an IV line and administer the IV fluid as ordered to maintain fluid volume. High-carbohydrate fluids like fruit juice, Kool-Aid, and popsicles should be avoided as they are low in electrolytes, increase simple carbohydrate consumption, and can decrease stool transit time. Milk products should be avoided during the acute phase of illness as they may worsen diarrhea.
A mother calls the doctor's office and tells the nurse that she is concerned because her 4-month-old keeps "spitting up" with every feeding. What would indicate that the child is regurgitating as opposed to vomiting? Only occurs with feeding Is curdled and extremely sour smelling Continues until stomach is empty Is projected 1 ft away from infant
Only occurs with feeding explanation: Regurgitation typically occurs only with feeding, runs out of the mouth with little force, smells barely sour and is only slightly curdled, appears to cause no pain or distress, occurs only once per feeding, and amounts to only about 1 to 2 tsp. Vomiting may occur at times other than feeding, is forceful and is typically projected 1 ft or more away from infant, is extremely sour smelling and curdled, is typically accompanied by crying, continues until the stomach is empty, and amounts to the full stomach contents.
In caring for an infant diagnosed with pyloric stenosis the nurse would anticipate which intervention? Medicate the infant with analgesics. Change the infant's diet to one that is lactose-free. Assist in doing a barium enema procedure on the infant. Prepare the infant for surgery.
Prepare the infant for surgery. Explanation: In pyloric stenosis, the thickened muscle of the pylorus causes gastric outlet obstruction. The treatment is a surgical correction called a pyloromyotomy. The condition is not painful, so no analgesics would be needed until after surgical repair. The condition is not related to lactose in the diet, so changing to lactose-free formula would not correct the condition. A barium enema would be used to diagnose intussusception.
The nurse is caring for a child admitted with pyloric stenosis. Which clinical manifestation would likely have been noted in the child with this diagnosis? Severe abdominal pain Explosive diarrhea Projectile vomiting Frequent urination
Projectile vomiting Explanation: During the first weeks of life, the infant with pyloric stenosis often eats well and gains weight and then starts vomiting occasionally after meals. Within a few days the vomiting increases in frequency and force, becoming projectile. The child may have constipation, and peristaltic waves may be seen in the abdomen, but the child does not appear in severe pain. Urine output is decreased and urination is infrequent.
A child with gastroenteritis has been unable to keep oral medication down. What nursing intervention would be appropriate for this client? Place the child on NPO status. Give an antiemetic prior to giving oral medications. Request an intravenous form of the medication. Hold all medications until the vomiting stops.
Request an intravenous form of the medication. Explanation: Absorption is the transfer of the drug from its point of entry into the bloodstream, and vomiting and diarrhea interfere with absorption because the drug does not remain in the gastrointestinal tract long enough to be absorbed. Distribution is not affected by vomiting and diarrhea, as it involves movement of the drug through the bloodstream. Metabolism involves conversion of the drug into an active or inactive form, and is unaffected by gastroenteritis. Excretion is the elimination of the drug from the body, usually through the kidneys. This is also unaffected by vomiting and diarrhea.
A neonatal nurse examines an infant born with a congenital diaphragmatic hernia (CDH). The nurse is prepared for what condition associated with CDH that generally occurs at birth or within the first few hours of life? malrotation intussusception respiratory distress anemia
Respiratory distress explanation: Most infants with CDH experience respiratory distress at birth or within the first few hours of life. As the infant swallows air, the herniated segment distends and further compromises lung and diaphragm excursion.
A child with severe diarrhea cannot drink and requires intravenous rehydration. After beginning the therapy, the nurse determines that potassium can be added to the intravenous fluid because which of the following has occurred? The child's stool is becoming soft. The child has dry mucous membranes. The child is now vomiting. The child has voided.
The child has voided. Explanation: Potassium cannot be given until it is established that the child is not in renal failure. Giving potassium IV when the body has no outlet for excessive potassium can lead to excessively high potassium levels and heart block. Before initial IV fluid is changed to a potassium solution, the nurse must be certain that the infant or child has voided—proof that the kidneys are functioning.
A 6-week-old infant is diagnosed with pyloric stenosis. When taking a health history from the parent, which symptom would the nurse expect to hear described? Refusal to eat Vomiting immediately after feeding Vomiting about 2 hours after feeding Chronic diarrhea
Vomiting immediately after feeding Explanation: With pyloric stenosis the circular muscle pylorus is hypertrophied. This thickness causes gastric outlet obstruction. The condition is seen in younger infants starting at 3 to 6 weeks of age. The infant has projectile nonbilious vomiting. It occurs directly after eating and is not related to the feeding position. The infant is hungry shortly after eating. There is weight loss and/or dehydration. The treatment is a pyloromyotomy to reduce the increased size and increase the opening. Diarrhea is not associated with the disorder.
A mother is told that her child will receive total parenteral nutrition. She asks the nurse what this means. The nurse bases her response on knowledge that total parenteral nutrition is: nutrition through a nasogastric tube. administration of Ringer's lactate through a peripheral IV line. daily IM injections of vitamins. administration of fluids, electrolytes, amino acids, lipids, dextrose, and minerals through an IV.
administration of fluids, electrolytes, amino acids, lipids, dextrose, and minerals through an IV. Explanation: Total parenteral nutrition is an IV fluid that contains dextrose, amino acids, lipids, electrolytes, vitamins, and minerals through an IV. A peripheral IV might be used short term, but in most cases the fluid will be administered through a central IV line. TPN is not administered IM or through a nasogastric tube, and it includes more nutrients that those contained in Ringer's lactate.
A nurse is caring for a 4-year-old child who has undergone surgery to repair a hernia. Which of the following is a priority nursing intervention for this client? using nonpharmacologic interventions for pain management to prevent constipation restricting fluids to prevent fluid and electrolyte imbalance encouraging shallow breathing to protect the incision assisting with early ambulation to facilitate peristalsis
assisting with early ambulation to facilitate peristalsis Explanation: Peristalsis takes longer to return after abdominal surgery than after surgery involving other systems. The nurse should monitor for the return of bowel sounds by auscultating the child's abdomen periodically, assisting with early ambulation, and keeping the child NPO until peristalsis returns. Controlling pain, managing adequate fluids, and promoting deep breathing are particularly important for the child after abdominal surgery.
The nurse is caring for a 12-year-old child with Crohn disease. What assessment finding will the nurse report to the health care provider when caring for the child? clear lung sounds no joint swelling fever report of a headache
fever Explanation: Crohn disease may affect any area of the digestive tract. It causes acute and chronic inflammation. It may also cause abscesses and fistulas. Inflammation and abscesses can cause fever. An increasing temperature could be the manifestation of the inflammation worsening or the development of an abscess and subsequent infection. The progression of the disease will be reported to the health care provider. A headache may accompany the fever and is a sign of generally not feeling well. It does not indicate progression of the disease, thus does not need to be reported. Clear lung sounds and no swollen joints are good signs, but they are not associated with Crohn disease.
A 5-year-old arrives at the emergency department appearing pale and diaphoretic, with slow and shallow respirations and a weak and thready pulse. The mother states that the child has had nausea and vomiting for the last 3 days. Which diagnosis would be the most applicable for this client? fluid volume excess fluid volume deficit anxiety infection
fluid volume deficit
A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information the nurse documents that the infant has: severe dehydration. risk for fluid volume deficit. failure to thrive. malabsorption syndrome.
severe dehydration. Explanation: A loss of more than 10% of body weight in a day is a sign of severe dehydration. Failure to thrive and malabsorption syndrome are long-term conditions, not objectively defined by a 24-hour weight change. This child is no longer at risk for a fluid volume deficit but is showing signs of dehydration.
The caregiver of a child diagnosed with celiac disease tells the nurse that the child has large amounts of bulky stools and what looks like fat in the stools. The clinical manifestation this caregiver is describing is: projectile stools. currant jelly stools. steatorrhea. severe diarrhea.
steatorrhea.
Which finding would lead the nurse to suspect that a child is experiencing moderate dehydration? hypotension dusky extremities sunken fontantels (fontanelles) tenting of skin
sunken fontantels (fontanelles) Explanation: A child with moderate dehydration would exhibit sunken fontanels (fontanelles). Severe dehydration would be characterized by dusky extremities, skin tenting, and hypotension.
A child is diagnosed with intussusception. The nurse would prepare the child and family for which of the following? barium swallow abdominal computed tomography surgery upper endoscopy
surgery Explanation: Intussusception is a surgical emergency and must be promptly reduced either by instillation of a water-soluble solution, barium enema, or air into the bowel, or surgery to reduce the invagination before necrosis of the affected portion of the bowel occurs. The point of invagination is usually at the juncture of the distal ileum and proximal colon. Therefore, an upper endoscopy or barium swallow would be inappropriate. The condition must be reduced; thus, an abdominal computed tomography would be ineffective.
The nurse is assessing a 10-day-old infant for dehydration. Which finding indicates severe dehydration? Pale and slightly dry mucosa Soft and flat fontanels (fontanelles) Tenting of skin Blood pressure of 80/42 mm Hg
tenting of skin Explanation: Tenting of skin is an indicator of severe dehydration. Soft and flat fontanels (fontanelles) indicate mild dehydration. Pale and slightly dry mucosa indicates mild or moderate dehydration. Blood pressure of 80/42 mm Hg is a normal finding for an infant.
The nurse is caring for a 13-year-old girl with suspected autoimmune hepatitis. The girl inquires about the testing required to evaluate the condition. How should the nurse respond? "You will most likely have a blood test to check for certain antibodies." "You will most likely have an ultrasound evaluation." "You will most likely be tested for ammonia levels." "You will most likely have viral studies."
"You will most likely have a blood test to check for certain antibodies." Explanation: Anti-nuclear antibodies are one of the diagnostic tests performed to diagnose autoimmune hepatitis. Ultrasound is performed to assess for liver or spleen abnormalities. Viral studies are performed to screen for viral causes of hepatitis. Ammonia levels may be ordered if hepatic encephalopathy is suspected.
The nurse is providing care to a child with an intussusception. The child has a bowel movement and the nurse inspects the stool. The nurse would most likely document the stool's appearance as having what quality? Greasy Clay-colored Bloody Currant jelly-like
Currant jelly-like Explanation: The child with intussusception often exhibits currant jelly-like stools that may or may not be positive for blood. Greasy stools are associated with celiac disease. Clay-colored stools are observed with biliary atresia. Bloody stools can be seen with several gastrointestinal disorders, such as inflammatory bowel disease.
A child with gastroenteritis has been unable to keep oral medication down. What nursing intervention would be appropriate for this client? Request an intravenous form of the medication. Give an antiemetic prior to giving oral medications. Place the child on NPO status. Hold all medications until the vomiting stops.
Request an intravenous form of the medication. Explanation: Absorption is the transfer of the drug from its point of entry into the bloodstream, and vomiting and diarrhea interfere with absorption because the drug does not remain in the gastrointestinal tract long enough to be absorbed. Distribution is not affected by vomiting and diarrhea, as it involves movement of the drug through the bloodstream. Metabolism involves conversion of the drug into an active or inactive form, and is unaffected by gastroenteritis. Excretion is the elimination of the drug from the body, usually through the kidneys. This is also unaffected by vomiting and diarrhea.
A child has presented to the clinic with diarrhea. The nurse should teach the parent to give which item to properly care for the child? bananas salty soups salty crackers milk
bananas Explanation: Milk may cause diarrhea to worsen. Only unsalted crackers and soups should be used to prevent further exacerbation of diarrhea. Bananas in small amounts provide nutritive value and do not exacerbate diarrhea.
Which assessment findings suggest that an infant with diarrhea is severely dehydrated? low specific gravity of urine, moist skin moist and flushed skin, fontanels (fontanelles) depressed salty saliva and tears with crying elevated hematocrit and depressed eye globes
elevated hematocrit and depressed eye globes Explanation: When plasma amount is decreased, hematocrit is elevated with less subcutaneous fluid; eye globes are sunken. Moist and flushed skin indicates adequate hydration. Salty saliva and tears indicate cystic fibrosis.
A child is diagnosed with gastroesophageal reflux disease and is prescribed drug therapy. The primary health care provider prescribes medication that suppresses acid secretion. The nurse would anticipate administering which drug? famotidine esomeprazole metoclopramide cimetidine
esomeprazole Explanation: Proton pump inhibitors (esomeprazole, lansoprazole) are effective acid-suppressing agents and are superior in relieving symptoms. Antacid preparations and H2 blocking agents (e.g., famotidine, cimetidine) are used to provide symptomatic relief of esophagitis and to reduce the damaging effects of refluxed gastric contents on the esophageal mucosa. Prokinetic agents such as metoclopramide are used to enhance gastric emptying.
Pyloric stenosis has been diagnosed in a 3-week-old male infant who has frequent vomiting after feedings. An important preoperative nursing intervention is: maintaining NPO status while restoring hydration and electrolyte balance. reducing vomiting by feeding small amounts of clear liquids or breast milk frequently. providing adequate pain control. assessing the abdomen hourly for distention and bowel sounds.
maintaining NPO status while restoring hydration and electrolyte balance. Explanation: NPO is needed to avoid vomiting and aspiration during surgery. Hydration and electrolyte replacement is often needed because of the history of vomiting, which causes loss of both fluid and electrolytes. Feeding when surgery is pending would not be safe. Hourly abdominal assessment would not yield needed information and would further disturb the infant. Pain is not the source of crying. The infant is hungry.
A child weighing 10 kg is admitted with severe vomiting for the past 3 days. The nurse writes a nursing diagnosis of Risk for deficient fluid volume related to vomiting. When the nurse reassesses the child, which outcomes would indicate the effectiveness of the treatment plan? Select all that apply. urine specific gravity of 1.008 poor skin turgor on abdomen tolerating sips of clear fluids drinks 16 ounces of milk per nursing shift urine output of 15 mL/hour
urine specific gravity of 1.008urine output of 15 mL/hour tolerating sips of clear fluids Explanation: Outcome criteria include: skin turgor remains good; specific gravity of urine is 1.003 to 1.030, and urine output is more than 1 ml/kg/hr; and tolerating sips of clear fluids. Drinking large volumes of whole milk can increase the vomiting.
