Gastrointestinal Alterations

A patients lab results are as follows: increased urobilingogen, albumin of 20 g/L (decreased from normal), globulin of 39 g/L (increased from normal), and transferrin of 198 mcg/dL (decreased from normal). Which gastrointestinal disorder do these results most strongly indicate? A) Cirrhosis B) Acute pancreatitis C) Ulcerative colitis D) Escherichia coli infection

A) Cirrhosis

The nurse is caring for a patient who is passing bright red blood rectally. The nurse should expect to insert a nasogastric tube to a. rule out massive upper GI bleeding. b. detect the presence of melena in the stomach. c. visually determine the presence of occult bleeding. d. obtain samples for guaiac to confirm current bleeding.

ANS: A Bright red or maroon blood (hematochezia) is usually a sign of a lower GI source of bleeding but can be seen when upper GI bleeding is massive (more than 1000 mL). Melena is shiny, black, foul-smelling stool; it is not present in the stomach. Occult bleeding means that blood is not visible and is detected only by testing the stool with a chemical reagent (guaiac).

The patient is admitted with pancreatitis and has severe ascites. In caring for this patient, the nurse should a. monitor the patient's blood pressure and evaluate for signs of dehydration. b. restrict intravenous and oral fluid intake because of fluid shifts. c. avoid the use of colloid IV solutions in managing the patient's fluid status. d. only use crystalloid fluids to prevent IV lines from clotting.

ANS: A In patients with severe acute pancreatitis, some fluid collects in the retroperitoneal space and peritoneal cavity. Patients sequester up to one third of their plasma volume. Initially, most patients develop some degree of dehydration and, in severe cases, hypovolemic shock. Fluid replacement is a high priority in the treatment of acute pancreatitis.

The patient is admitted with acute pancreatitis and is later diagnosed as having a pseudocyst. The nurse realizes that a. surgery for pseudocysts must be done immediately. b. a cholecystectomy is usually done when pseudocysts are found. c. pseudocysts may resolve spontaneously, so surgery may be delayed. d. pseudocysts require pancreatic resection, removing the entire pancreas.

ANS: C Surgery may be indicated for pseudocysts; however, it is usually delayed because some pseudocysts resolve spontaneously. Surgery may also be performed when gallstones are thought to be the cause of the acute pancreatitis. A cholecystectomy is usually performed. Pancreatic resection for acute necrotizing pancreatitis may be performed to prevent systemic complications of the disease process. In this procedure, dead or infected pancreatic tissue is surgically removed while most of the gland is preserved. The indication for surgical intervention is clinical deterioration of the patient despite the use of conventional treatments, or the presence of peritonitis.

A patient with acute pancreatitis is being cared for in intensive care. After several days of therapy, the patient has worsening hypoxemia that does not respond to oxygen therapy, lung sounds are diminished, and there is a patchy infiltrate on the chest x-ray. The patient also has a fever, abdominal distention, and severe pain despite narcotic therapy. What complication of pancreatitis does the nurse most suspect? A) Acute respiratory distress syndrome (ARDS) B) Nonspecific arterial hypoxemia C) Compression of lung by abdominal fluid D) Hypoventilation secondary to severe pain

A) Acute respiratory distress syndrome (ARDS)

The nurse places a large-bore nasogastric tube in a patient who has acute upper gastrointestinal bleeding. What is the rationale for this intervention? Select all that apply. A) Aspiration of gastric contents B) Improvement of ventilation C) Decompression D) Enteral feeding E) Lavage of gastric contents F) Control of bleeding

A) Aspiration of gastric contents C) Decompression E) Lavage of gastric contents

A patient in the ICU vomits repeatedly. The contents of his emesis are brownish-black. What should the nurse suspect based on this finding? A) Gastrointestinal hemorrhaging B) Bile escaped through the pylorus and mixed with stomach acid C) Bile escaped through the pylorus but did not have time to mix with stomach acid D) Deficit of bile in the small intestine

A) Gastrointestinal hemorrhaging

A patient in the intensive care unit has abdominal cramping and is suspected of having a small intestine obstruction. Which finding on auscultation of the abdomen would tend to confirm this suspicion? A) High-pitched tinkling and rushing sounds B) High-pitched, rapid, and loud sounds C) Soft bubbling sounds with clicks and gurgles D) Absent bowel sounds

A) High-pitched tinkling and rushing sounds

A 20-year-old man presents with upper gastrointestinal bleeding. His health history indicates binge drinking on weekends. The nurse inquires about the patients alcohol use and learns that the patient frequently vomits violently after drinking. Which of the following underlying causes should the nurse suspect for this patients bleeding? A) Mallory-Weiss tears B) Dieulafoys lesions C) Peptic ulcer disease D) Stress-related erosive syndrome

A) Mallory-Weiss tears

In a patient with severe hepatic cirrhosis, what laboratory findings would the nurse expect to be decreased? A) Serum proteins B) Serum amylase C) Aspartate aminotransferase (AST) D) Prothrombin time (PT)

A) Serum proteins

An elderly patient with several comorbidities has experienced a massive upper GI hemorrhage from esophageal varices. No treatment has been initiated yet. What signs and symptoms does the nurse expect? A) Tachycardia and hypotension B) Alert and oriented times 3 C) Mild anemia without hypoxemia D) Normal peripheral circulation

A) Tachycardia and hypotension

A patient is experiencing severe abdominal pain from peptic ulcers. Which of the following should the nurse suspect as causes? Select all that apply. A) Bile salts from duodenal reflux B) Alcohol C) Hypersecretion of mucus D) Aspirin E) Nonsteroidal anti-inflammatory drugs (NSAIDs) F) Helicobacter pylori infection

A, B, D, E, F

The patient is admitted with upper GI bleeding following an episode of forceful retching following excessive alcohol intake. The nurse suspects a Mallory-Weiss tear and is aware that a. a Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa. b. this type of bleeding is treated by giving chewable aspirin. c. the bleeding, although impressive, is self-limiting with little actual blood loss. d. it is not usually associated with alcohol intake or retching.

ANS: A A Mallory-Weiss tear is an arterial hemorrhage from an acute longitudinal tear in the gastroesophageal mucosa and accounts for 10% to 15% of upper GI bleeding episodes. It is associated with long-term nonsteroidal anti-inflammatory drug or aspirin ingestion and with excessive alcohol intake. The upper GI bleeding usually occurs after episodes of forceful retching. Bleeding usually resolves spontaneously; however, lacerations of the esophagogastric junction may cause massive GI bleeding, requiring surgical repair.

The patient is admitted with generalized fatigue and low hemoglobin and hematocrit levels. The patient denies vomiting and states that the last bowel movement earlier that day was normal in color and consistency. However, because GI blood loss can be a cause of anemia, the nurse should expect to a. obtain a stool sample for guaiac testing. b. chart that the patient reports the presence of melena in his stool. c. inspect the patient's next stool for the presence of coffee-ground contents. d. obtain guaiac positive stools only if bleeding is current.

ANS: A GI blood loss is often occult or detected only by testing the stool with a chemical reagent (guaiac). Stool and nasogastric drainage can test guaiac positive for up to 10 days after a bleeding episode. Melena is shiny, black, foul-smelling stool and results from the degradation of blood by stomach acids or intestinal bacteria. Vomiting or drainage from a nasogastric tube that yields blood or coffee-ground-like material is associated with upper GI bleeding. However, blood or coffee-ground-like contents may not be present if bleeding has ceased or if it arises beyond a closed pylorus.

Infection by Helicobacter pylori bacteria is a major cause of a. duodenal ulcers. b. Cushing's ulcers. c. Curling's ulcers. d. stress ulcers.

ANS: A Infection with Helicobacter pylori bacteria is a major cause of duodenal ulcers. A stress ulcer is an acute form of peptic ulcer that often accompanies severe illness, systemic trauma, or neurological injury. Stress ulcers that develop as a result of burn injury are often called Curling's ulcers. Stress ulcers associated with severe head trauma or brain surgery are called Cushing's ulcers.

Pain control is a nursing priority in patients with acute pancreatitis because pain a. increases pancreatic secretions. b. is caused by decreased distension of the pancreatic capsule. c. decreases the patient's metabolism. d. is caused by dilation of the biliary system.

ANS: A Pain control is a nursing priority in patients with acute pancreatitis not only because the disorder produces extreme patient discomfort but also because pain increases the patient's metabolism and thus increases pancreatic secretions. The pain of pancreatitis is caused by edema and distension of the pancreatic capsule, obstruction of the biliary system, and peritoneal inflammation from pancreatic enzymes. Pain is often severe and unrelenting and is related to the degree of pancreatic inflammation.

The nurse is caring for a patient who has a peptic ulcer. To treat the ulcer and prevent more ulcers from forming, the nurse should be prepared to administer a. H2-histamine receptor blockers. b. gastrin. c. vagal stimulation. d. vitamin B12.

ANS: A Stimulants of hydrochloric acid secretion include vagal stimulation, gastrin, and the chemical properties of chyme. Histamine, which stimulates the release of gastrin, also stimulates the secretion of hydrochloric acid. Current drug therapies for ulcer disease use H2-histamine receptor blockers that block the effects of histamine and therefore hydrochloric acid stimulation.

When caring for the patient with upper GI bleeding, the nurse assesses for which of the following? (Select all that apply.) a. Severity of blood loss b. Hemodynamic stability c. Vital signs every 30 minutes d. Signs of hypervolemic shock e. Necessity for fluid resuscitation

ANS: A, B, E Initial evaluation of the patient with upper GI bleeding involves a rapid assessment of the severity of blood loss, hemodynamic stability and the necessity for fluid resuscitation, and frequent monitoring of vital signs and assessments of body systems for signs of hypovolemic shock. Vital signs should be monitored at least every 15 minutes.

Nursing priorities for the management of acute pancreatitis include: (Select all that apply.) a. managing respiratory dysfunction. b. assessing and maintaining electrolyte balance. c. withholding analgesics that could mask abdominal discomfort. d. stimulating gastric content motility into the duodenum. e. utilizing supportive therapies aimed at decreasing gastrin release.

ANS: A, B, E Nursing and medical priorities for the management of acute pancreatitis include several interventions. Managing respiratory dysfunction is a high priority. Fluids and electrolytes are replaced to maintain or replenish vascular volume and electrolyte balance. Analgesics are given for pain control, and supportive therapies are aimed at decreasing gastrin release from the stomach and preventing the gastric contents from entering the duodenum.

The patient is admitted with the diagnosis of GI bleeding. The patient's heart rate is 140 beats per minute, and the blood pressure is 84/44 mm Hg. These values may indicate: a. a need for hourly vital signs. b. approximately 25% loss of total blood volume. c. resolution of hypovolemic shock. d. increased blood flow to the skin, lungs, and liver.

ANS: B Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL—25% of the total blood volume. Vital signs should be monitored at least every 15 minutes. As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys.

The patient is admitted for GI bleeding, but the source is unknown. Before ordering endoscopy, the provider orders octreotide to be given intravenously. The purpose of this medication is to a. increase portal pressure and improve liver function. b. decrease splanchnic blood flow and portal pressure. c. vasodilate the splanchnic arteriolar bed. d. increase blood flow in the liver's collateral circulation.

ANS: B Octreotide is commonly ordered to slow or stop bleeding. Early administration provides for stabilization before endoscopy. These drugs decrease splanchnic blood flow, reduce portal pressure, and have minimal adverse effects Octreotide does not increase portal pressure, vasodilate the splanchnic arteriolar bed, or increase blood flow in the liver's collateral circulation.

The patient is admitted with acute pancreatitis and is demonstrating severe abdominal pain, vomiting, and ascites. Using the Ranson classification criteria, the nurse determines that this patient a. has a 99% chance of survival. b. has a 15% chance of dying. c. has a 40% chance of dying. d. has no chance of survival.

ANS: B Patients with acute pancreatitis can develop mild or fulminant disease. As a consequence, research has addressed criteria for predicting the prognosis of patients with acute pancreatitis. The early classification criteria were developed by Ranson, who suggested that the number of signs present within the first 48 hours of admission directly relates to the patient's chance of significant morbidity and mortality. In Ranson's research, patients with fewer than three signs had a 1% mortality rate, those with three or four signs had a 15% mortality rate, those with five or six signs had a 40% mortality rate, and those with seven or more signs had a 100% mortality rate.

The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patient's care to prevent stress ulcers, the nurse would provide: (Select all that apply.) a. vagal stimulation. b. proton pump inhibitors. c. anticholinergic drugs. d. antacids. e. cholinergic drugs.

ANS: B, C, D Administration of antacids and H2-receptor blockers, and the suppression of vagal stimulation with anticholinergic drugs and proton pump inhibitors (PPI) are effective forms of therapy.

The nurse is caring for a patient with active GI bleeding. Estimated blood loss is 1,000 mL. Which of the following assessments would the nurse expect to find with this amount of blood loss? a. All vital signs would expect to be normal. b. Oral temperature of 103°. c. Heart rate 125 beats per minute. d. Systolic blood pressure of 120 mm Hg.

ANS: C As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys. Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL—25% of the total blood volume.

The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, "What causes this? Why does it hurt so much?" The nurse should answer: a. "Pancreatitis is extremely rare, and no one knows why it causes pain." b. "Pancreatitis is caused by diabetes; you should be checked." c. "Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain." d. "The pain is localized to the pancreas. Fortunately, it will not affect anything else."

ANS: C The most common theory regarding the development of pancreatitis is that an injury or disruption of pancreatic acinar cells allows leakage of the pancreatic enzymes into pancreatic tissue. The leaked enzymes (trypsin, chymotrypsin, and elastase) become activated in the tissue and start the process of autodigestion. Pancreatitis is one of the most common pancreatic diseases; it is not caused by diabetes. The activated enzymes break down tissue and cell membranes, causing edema, vascular damage, hemorrhage, necrosis, and fibrosis. These now toxic enzymes and inflammatory mediators are released into the bloodstream and cause injury to vessel and organ systems, such as the hepatic and renal systems.

In a patient with a complete small bowel obstruction, what symptoms would the nurse be most likely to find? A) Absence of bowel sounds B) Acute, intermittent abdominal cramps C) Pain increased with emesis D) No evidence of hypovolemia

B) Acute, intermittent abdominal cramps

What is the underlying pathophysiologic process for pancreatitis? A) Inflammation from bowel endotoxins B) Autodigestion by pancreatic enzymes C) Inability of the pancreas to activate its enzymes D) Destruction of pancreatic tissue by bile

B) Autodigestion by pancreatic enzymes

A patient is diagnosed with cirrhosis. The nurse sees that there is no indication of alcohol use in the patients health history, and the patient denies drinking alcohol. What is another likely cause of this disease that the nurse should suspect? A) Peptic ulcer disease B) Hepatitis C virus (HCV) infection C) Dieulafoys lesions D) Diverticulosis

B) Hepatitis C virus (HCV) infection

A patient with a massive upper gastrointestinal hemorrhage is exhibiting signs and symptoms of hypovolemic shock. What initial treatment does the nurse anticipate? A) Admission to a general care nursing unit for monitoring B) Initial fluid resuscitation with intravenous crystalloids C) Diet of clear liquids, advanced as tolerated D) Bed rest in semi-Fowlers position

B) Initial fluid resuscitation with intravenous crystalloids

An elderly patient is experiencing lower gastrointestinal bleeding. On questioning the patient, the nurse learns that she consumes little fiber in her diet, takes aspirin daily, and frequently has constipation. The nurse should suspect which of the following as the most likely cause of this patients bleeding? A) Hemorrhoids B) Crohns disease C) Diverticulosis D) Ulcerative colitis

C) Diverticulosis

The patient has an upper gastrointestinal hemorrhage. What pathological basis does the nurse least expect? A) Peptic ulcer disease B) Helicobacter pylori infection C) Infectious colitis D) Esophageal varices

C) Infectious colitis

A critically ill patient with cirrhosis has developed hepatic encephalopathy. What is the most effective therapeutic management strategy? A) Surgical portosystemic shunt B) Increased nutritional protein C) Lactulose or neomycin enterally D) Sedation with midazolam (Versed)

C) Lactulose or neomycin enterally

A patient has an acute upper gastrointestinal hemorrhage secondary to esophageal varices. What is the underlying pathophysiology of this type of gastrointestinal hemorrhage? A) Helicobacter pylori infection of esophagus, stomach, and duodenum B) Prolonged stress from multiple causes C) Portal hypertension from cirrhosis or other liver disease D) Overwhelming infection of jejunum and ileum

C) Portal hypertension from cirrhosis or other liver disease

A patient with severe hepatic cirrhosis has developed severe ascites. What is the most important nursing assessment? A) Abdominal girth B) Intake and output C) Respiratory status D) Nutritional intake

C) Respiratory status

In a patient with acute pancreatitis, what elevation in laboratory study results would the nurse expect? A) Serum potassium and calcium B) Arterial ionized calcium C) Serum amylase and lipase D) Arterial partial pressure of oxygen

C) Serum amylase and lipase

Intravenous vasopressin (Pitressin) has been ordered for a patient with recurrent esophageal varices causing upper gastrointestinal hemorrhage. What is the purpose of this therapy? A) Increases systemic blood pressure in shock B) Increases myocardial oxygen use and demand C) Reduces blood flow to the mesenteric circulation D) Causes constriction of the splanchnic arteries

D) Causes constriction of the splanchnic arteries

A patient in the critical care unit presents with abdominal pain, distention, and progressive obstipation. The patient is currently being treated for colon cancer and mentions a gradual decrease in amount and size of stool passed in recent weeks. What finding should the nurse most expect in this patient? A) Marked leukocytosis B) A history of laxative use C) Left lower quadrant pain D) Iron deficiency

D) Iron deficiency

The source of lower gastrointestinal bleeding has been found in a patient during colonoscopy. Which of the following should the nurse expect as the next intervention? A) Endoscopy B) Angiography C) Radionucleotide imaging D) Thermal coagulation

D) Thermal coagulation

The patient is admitted with acute pancreatitis. The nurse should a. assess pain level because pancreatic pain is unique in character. b. examine laboratory values for low amylase levels. c. expect lipase levels to decrease within 24 hours. d. evaluate C-reactive protein as a gauge of severity.

ANS: D The diagnosis of acute pancreatitis is based on clinical findings, the presence of associated disorders, and laboratory testing. Pain associated with acute pancreatitis is similar to that associated with peptic ulcer disease, gallbladder disease, intestinal obstruction, and acute myocardial infarction. This similarity exists because pain receptors in the abdomen are poorly differentiated as they exit the skin surface. Serum lipase and amylase tests are the most specific indicators of acute pancreatitis because as the pancreatic cells and ducts are destroyed, these enzymes are released. An elevated serum amylase level is a characteristic diagnostic feature. Amylase levels usually rise within 12 hours after the onset of symptoms and return to normal within 3 to 5 days. Serum lipase levels increase within 4 to 8 hours of clinical symptom onset and then decrease within 8 to 14 days. C-reactive protein increases within 48 hours and is a marker of severity.

A patient with small bowel obstruction (SBO) due to adhesions is no longer passing gas. She has a fever and has shown no signs of improvement in 24 hours. There is no evidence of stool or gas in the distal intestine on radiograph. What is the most important intervention for this patient at this point? A) Withholding oral food and fluid B) Laparoscopic lysis of adhesions C) Placement of nasogastric tube D) Aggressive treatment with IV fluid and electrolytes

B) Laparoscopic lysis of adhesions