IGGY CH 45: Assessment of the Gastrointestinal System

While working in the outpatient procedure unit, the RN is assigned to four clients. Which client will the nurse assess first? A. Client who just had an endoscopic retrograde cholangiopancreatography (ERCP) B. Client who is ready for discharge following a colonoscopy C. Client who has just arrived for a sigmoidoscopy D. Client who has questions about an endoscopic ultrasound examination

A ERCP requires conscious sedation, so the client needs immediate assessment of respiratory and cardiovascular status. The endoscopic procedure and nursing care for a client having an ERCP are similar to those for the EGD procedure, except that the endoscope is advanced farther into the duodenum and into the biliary tract. All other clients can be seen subsequently.

The nurse is teaching an older adult client. Which gastrointestinal change does the nurse discuss that occurs as a result of normal aging? A. Decreased hydrochloric acid levels B. Excess lipase production C. Increased liver size D. Increased peristalsis

A In older adults, decreased hydrochloric acid levels (hypochlorhydria) results from atrophy of the gastric mucosa. A decrease in lipase production results from calcification of pancreatic vessels. A decrease in the number and size of hepatic cells leads to decreased liver weight and mass. Peristalsis decreases, and nerve impulses are dulled.

Which client does the charge nurse assign to an experienced LPN/LVN working on the adult GI medical unit? A. Client with constipation who has received a laxative B. Client who needs teaching about an endoscopic retrograde cholangiopancreatography C. Client who needs administration of IV midazolam hydrochloride during an upper endoscopy D. Client who is admitted with abdominal cramping and diarrhea of unknown causes

A The LPN/LVN can best assist the RN by monitoring the client with constipation who has received a laxative. Assessment, IV hypnotic medication administration, and client teaching must be done by an RN.

The nurse is assessing an alert client who had abdominal surgery yesterday. Which assessment method will the nurse use to most accurately determine whether peristalsis has resumed? A. Ask if the client has passed flatus (gas) within the previous 8 hours. B. Listen for bowel sounds in all abdominal quadrants. C. Count the number of bowel sounds in each abdominal quadrant over 1 minute. D. Perform auscultation with the diaphragm of the stethoscope.

A The best and most reliable method for assessing the return of peristalsis following abdominal surgery is the client's report of passing flatus within the past 8 hours or stool within the past 8 hours. Although auscultation, even with the stethoscope diaphragm, and counting the number of sounds can help to assess for bowel activity, it is not the most reliable method.

The nurse is assessing a very thin client who has come to the emergency department with acute abdominal pain. Upon assessment, visible peristaltic movements are noted. What is the appropriate nursing action? A. Report finding to the health care provider. B. Toilet quickly as diarrhea is imminent. C. Monitor laboratory values for possible pancreatitis. D. Prepare to administer antibiotics as prescribed.

A The nurse will report the finding to the health care provider, as it is possible that the client has an obstruction. Peristaltic movements are rarely seen except in thin clients. Acute diarrhea does not cause visible peristaltic movements. Pancreatitis is not characterized by visible peristaltic movement. Antibiotics are not indicated as the client likely has an obstruction, not an infection.

Which of the following statements would the nurse include when educating a client who is scheduled to have a video capsule endoscopy (VCE)? Select all that apply. A. "You will wear an abdominal belt with a data recorder throughout the test." B. "The capsule is a single-use item and will be discarded on elimination." C. "Contact your health care provider if the capsule is not passed within 3 days." D. "No drink or food should be consumed in the 12 hours prior to the testing." E. "There are no restrictions you have to observe before and during the testing period."

A, B, D : VCE is a diagnostic test that visualizes the small bowel. Preparation includes client teaching such as the placement of sensors and the need to wear an abdominal belt with a data recorder throughout the test (Choice A). There is no need to return the capsule, as once eliminated it will be discarded (Choice B). The client will be required to be NPO for 12 hours before the test and 2 hours after the test begins (Choice D). The client should report if the capsule has not passed within 2 weeks—not 3 days—(Choice C) or if any of the clinical manifestations of gastrointestinal obstruction occur. Some client activities are restricted; the nurse will teach that clients should not vigorously exercise and they should try to avoid stress during the testing period (Choice E).

The nurse is caring for several clients who wish to use a home-based screening test to identify possible colorectal cancer. Which of the following clients would the nurse recommend receive a colonoscopy instead? Select all that apply. A. Client whose mother died from colon cancer 20 years ago B. Client with a history of being treated for Clostridium difficile C. Client undergoing current treatment for Crohn's disease D. Client who chronically uses laxatives to relieve chronic constipation E. Client with a positive fecal occult blood test in the past

A, C, E : Clients at high risk for colon cancer should be taught that visual examination of the colon is the best way to detect colorectal cancer instead of using a home-based screening test. High risks for colon cancer include a personal or family history of colorectal cancer (Choice A), the presence of inflammatory bowel or Crohn's disease (Choice C), and a positive screening test in the past (Choice E). A history of treatment for Clostridium difficile (Choice B), chronic constipation, and chronic use of laxatives (Choice D) are not known to increase the risk of colorectal cancer.

While performing an abdominal assessment on a client, the nurse notes rigidity over the left upper quadrant. Which GI disorder would the nurse anticipate? A. Gastroenteritis B. Peritoneal inflammation C. Intestinal obstruction D. Paralytic ileus

B Abdominal rigidity is a potential finding of the nurse generalist during light palpation. This finding may cause the nurse to anticipate peritoneal inflammation (Choice B). During auscultation the nurse may hear increased high-pitched bowel sounds, which may indicate gastroenteritis (Choice A) or diarrhea. Loud gurgling sounds may be heard above an intestinal obstruction (Choice C). Paralytic ileus will be accompanied by absent or diminished bowel sounds (Choice D).

Immediately following an esophagogastroduodenoscopy (EGD), which of the following interventions would the nurse implement to promote client safety? Select all that apply. A. Remind the client to drive themselves safely home. B. Do not allow any food or drink until the gag reflex returns. C. Check vital signs hourly until sedation wears off. D. Discontinue IV fluids upon completion of the procedure. E. Ensure only one side rail is up throughout recovery.

B After an EGD the nurse will keep the client NPO until the gag reflex returns (Choice B). The nurse will ensure that the client has someone to drive them home following the procedure; the client should not drive themself, as they have just been under sedation (Choice A). Vital signs should be checked every 15 to 30 minutes following the procedure until sedation begins to wear off (Choice C). IV fluids should not be discontinued until the client can tolerate oral intake (Choice D). Both side rails will remain up until sedation has subsided (Choice E)

A client is being observed after a routine sigmoidoscopy with a tissue biopsy. Which assessment finding will the nurse report to the health care provider? A. Mild abdominal pain B. Rectal bleeding C. Flatulence D. Borborygmi

B Bleeding is a possible complication following a sigmoidoscopy. It must be reported immediately to the health care provider. Mild abdominal pain (usually gas pain) and flatulence are expected findings after a sigmoidoscopy. Borborygmi may be heard, especially if the client is hungry if they have followed a clear liquid diet prep before the procedure.

A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? A. Assesses the following sequence: inspection, palpation, auscultation. B. Examines the RUQ of the abdomen last following all other assessment techniques. C. Has the client lie in a supine position with legs straight and arms above the head. D. Palpates any bulging mass very gently and documents findings.

B If the client reports pain in the RUQ, the nurse examines this area last. This action prevents the client from tensing abdominal muscles because of the pain, which would make the assessment difficult. Inspection and auscultation always come before palpation; the health care provider performs percussion. This sequence prevents the increase in intestinal activity and bowel sounds caused by palpation and percussion. The client would be positioned supine with the knees bent while keeping the arms at the sides to prevent tensing of the abdominal muscles. If a bulging, pulsating mass is present during assessment of the abdomen, the nurse must never touch the area because the client may have an abdominal aortic aneurysm, a life-threatening problem. The nurse would notify the health care provider of this finding immediately!

Which client does the charge nurse on the adult GI medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) clinic? A. Client who needs discharge teaching after an endoscopic retrograde cholangiopancreatography (ERCP) B. Client who has had laxatives administered and needs monitoring before a colonoscopy C. Client admitted with nausea, abdominal pain, and abdominal distention D. Client with epigastric pain who needs conscious sedation during endoscopy

B The client who needs laxatives administered and effectiveness monitored before a colonoscopy is the least complicated client. This client would be assigned to the float nurse who would have the experience and education to adequately care for this client. Discharge instructions following an ERCP, assessment of an admitted acutely ill client, and monitoring a client who is receiving conscious sedation is accomplished best by a nurse with experience in caring for adults with acute GI problems.

Which factor does the nurse identify that places a client at risk for gastrointestinal (GI) problems? (Select all that apply.) A. Eating a high-fiber diet B. Smoking a half-pack of cigarettes per day C. Financial concerns D. Use of herbal preparations E. Taking nonsteroidal anti-inflammatory drugs (NSAIDs)

B, C, D, E Smoking or any tobacco use places a client in a higher-risk category for GI problems. Financial concerns can also influence the risk for GI problems; clients may not be able to afford to seek care or treatment and may put off seeking help. Some herbal preparations contribute to GI problems which can affect appetite, absorption, and elimination. NSAIDs can predispose clients to peptic ulcer disease or GI bleeding. High-fiber diets are generally believed to be healthy for most clients.

A client who is hospitalized with ongoing abdominal tenderness reports an increase in generalized abdominal pain today. Which assessment technique will the nurse perform? (Select all that apply.) A. Auscultate beginning in the RLQ. B. Visually observe for contour and symmetry. C. Deeply palpate the area of tenderness. D. Percuss to determine size of liver and spleen. E. Ask for a pain scale rating on a scale of 0-10.

B, E The nurse will visually observe the abdomen for contour and symmetry, auscultate beginning in the RUQ (not the RLQ), lightly palpate for any large masses or areas of tenderness, ask the client to rate the pain level on a 0-10 scale, and document the findings. The abdominal assessment starts with inspection and auscultation, followed by gentle palpation. The health care provider performs any necessary deep palpation and percussion.

A client is preparing to undergo a stool DNA (sDNA) test to screen for colon cancer. What teaching does the nurse provide before the test? A. "Begin a clear liquid diet at least 24 hours before the test." B. "Do not eat or drink anything prior to the test for 12 hours." C. "Give yourself tap water enemas until the fluid returns are clear." D. "No special preparation is needed prior to completing this test."

D The nurse will teach the client that no special preparation is needed prior to completing the sDNA test. This is a home screening test that the client can perform at any time, with no traditional bowel cleaning preparation or fasting necessary.

The nurse and health care provider are discussing a client who has pernicious anemia. The nurse anticipates that the client has which deficiency? A. Glucagon B. Hydrochloric acid C. Intrinsic factor D. Pepsinogen

C Intrinsic cells are produced by the parietal cells in the stomach. This substance facilitates the absorption of vitamin B12. Absence of intrinsic factor causes pernicious anemia. Glucagon, which is produced by the alpha cells in the pancreas, is essential for the regulation of metabolism. Parietal cells secrete hydrochloric acid, but this does not facilitate the absorption of vitamin B12. Pepsinogen is secreted by the chief cells; pepsinogen is a precursor to pepsin, a digestive enzyme.

Which of the following GI findings in the older adult would the nurse associate with aging? Select all that apply. A. Increased lipase levels B. More frequent bowel movements C. Elevated bacterial growth D. Retention of drug products E. Enhanced fat absorption

C, D The normal growth of bacterial flora in the older adult can become disrupted over time, contributing to inflammatory processes and reduction of immunity. Bacterial overgrowth occurs as a result of decreased hydrochloric acid in the stomach (Choice C). Decreased liver function and enzymatic changes result in retention of drug products (Choice D). Lipase levels are decreased as pancreatic inefficiency progresses with age (Choice A). Bowel movements become more infrequent as the stimulation to defecate is reduced (Choice B). A decrease in gastrointestinal motility that occurs during the aging process can contribute to slower absorption of fat (Choice E).