Med-Surg CH 27: The Gastrointestinal System
A patient is to collect a specimen for a stool guaiac test. Which direction should the patient be given? A. "Do not eat red meat for at least 3 days before collecting the specimen." B. "Be sure to take a laxative 2 days prior to collecting the stool." C. "Be sure to use a sterile container to collect the specimen." D. "Do not drink carbonated beverages for 8 h before collecting the specimen."
"Do not eat red meat for at least 3 days before collecting the specimen." *The stool guaiac test assesses for the presence of blood in the specimen. The patient must have a red meat-free diet for at least 3 days before a stool guaiac test can be considered accurate. Laxative use is not needed prior to collection of the specimen. The container used will be clean but not sterile. Intake of carbonated beverages will not impact the specimen.
The nurse is obtaining a history of a patient with hepatitis A. Which question is most appropriate for the nurse to ask? A. "If using drugs, do you share needles?" B. "Do you always practice safe sex?" C. "Have you traveled to Canada in the last month?" D. "Do you eat shellfish or oysters often?"
"Do you eat shellfish or oysters often?" *Shellfish and mollusks can be contaminated by living in feces-contaminated water. Drug use and unprotected sex are not part of the etiology of hepatitis A but are for hepatitis B. Travel to Canada is not associated with hepatitis A
The nurse is performing pre-procedure teaching for a patient scheduled to undergo a liver biopsy. After listening to the information, the patient states, "I am so scared. I just don't know if I can do this procedure." Which response is best? A. "The procedure will only last about 15 minutes." B. "Most patients say it feels similar to a punch in the shoulder." C. "You do not have to have the procedure." D. "I understand that you are afraid. Tell me more about your concerns."
"I understand that you are afraid. Tell me more about your concerns." *The nurse should acknowledge the patient's feelings and promote therapeutic communication. While all of the other statements are true, none of them investigate the underlying cause of the patient's fear. Reassurance about the length of the procedure or the sensation that the patient might experience may be indicated after the patient explains more about specific concerns. While the patient can refuse to have the procedure, dismissing the patient is not an appropriate or therapeutic statement
You emphasize the importance of eating natural sources of fiber to a patient who has frequent constipation. Which patient statement indicates effective health teaching? A. "I will consider eating more white bread." B. "I will drink fluids only while consuming meals." C. "I will add more milk to my morning cereal." D. "I will eat more fruits and vegetables."
"I will eat more fruits and vegetables." *The patient has understood that fruits and vegetables are good sources of fiber. (1) White bread and dairy products do not supply fiber. (2) Fluid consumption must be spaced throughout the day. If fluids are restricted to mealtimes, it will be very difficult to drink the recommended amount. (3) Adding milk to cereal does not increase the fiber content.
The nurse is caring for a patient who is preparing for discharge after having had an upper GI series. Which patient statement demonstrates a need for further discharge instruction? A. "I can expect my stool to be white for up to 3 days." B. "I'll drink lots of water." C. "I'll take a laxative." D. "I will not be able to drink fluids that contain any caffeine."
"I will not be able to drink fluids that contain any caffeine." *After an upper GI series, the patient does not have any dietary intake restrictions. Caffeine use is not contraindicated. Increased fluids, laxatives, and white stools are included in the education of the patient after an upper GI series.
The nurse is caring for a patient who complains, "I don't see why I can't have a CT scan instead of the expensive MRI!" Which response is most appropriate for the nurse to make?" A. "The MRI provides better contrast between normal and pathologic tissue." B. "The MRI requires less analysis and is easier to read." C. "The MRI produces a digital image that can be transmitted via email." D. "The MRI exposes the patient to less radiation."
"The MRI provides better contrast between normal and pathologic tissue." *MRI uses radiofrequency signals to determine how hydrogen atoms behave in the magnetic field. In addition, the MRI provides a better contrast than computed tomography (CT) between healthy tissues and pathologic tissues
The nurse is caring for a patient scheduled to have an MRI study. Which instruction(s) should the nurse include in the teaching? (select all that apply) A. Radiation exposure is extremely minimal B. All metal objects, including dental bridges, jewelry, and body piercings, must be removed C. Do not eat or drink for 4 h before the procedure D. A radiopaque medium ma be injected during the procedure E. There may be a tingling sensation in metal alloy filling the teeth
1. All metal objects, including dental bridges, jewelry, and body piercings, must be removed 2. A radiopaque medium may be injected during the procedure 3. There may be a tingling sensation in metal alloy filling the teeth *The MRI places the patient in a magnetic field and uses radiofrequency signals to determine how hydrogen atoms behave in the field. All metal must be removed, contrast medium may be injected, and the patient may have a tingling sensation in the teeth with metal allow fillings. There is no restriction on food or fluid intake in relation to the test. The test does not expose the patient to radiation
The nurse is caring for a patient with anorexia nervosa. Which intervention(s) might the nurse use to stimulate appetite? (select all that apply) A. Offer oral care after meals B. Arrange for preferred foods to be served C. Encourage family members to bring food from home D. suggest that family members or friends come and socialize during the meal E. Allow ample time to eat and enjoy the meal
1. Arrange for preferred foods to be served 2. Encourage family members to bring food from home 3. suggest that family members or friends come and socialize during the meal 4. Allow ample time to eat and enjoy the meal *Appetite depends on complex mental processes having to do with memory and mental associations that can be pleasant or extremely unpleasant. Appetite is stimulated by the site, smell, and thought of food. The physical and social environment in which a person is eating stimulates appetite. The enjoyment of eating can be inhibited by unattractive or unfamiliar food, by unpleasant surroundings, and by emotional states such as anxiety, anger, and fear. By serving food based on patient's preferences, encouraging positive interaction, and allowing ample times for meals, the nurse can stimulate appetite. Oral care should be offered before meals to aid in stimulating the appetite.
You are preparing a patient for a liver biopsy. Which nursing interventions should be included? (select all that apply) A. Attending to patient's fears and anxiety B. Checking for a signed consent form for the procedure C. Assessing for dehydration and electrolyte imbalance D. Positioning on right side E. Checking coagulation studies for bleeding problems F. Noting any allergy to local anesthetics
1. Attending to patient's fears and anxiety 2. Checking for a signed consent form for the procedure 3. Checking coagulation studies for bleeding problems 4. Noting any allergy to local anesthetics *Decreasing fears and anxieties promotes psychological well-being related to the upcoming procedure. A signed consent form is necessary for a liver biopsy. Coagulation studies are assessed before a liver biopsy to determine any increased risk of bleeding. Allergy to local anesthetic used during the procedure must be determined before the test. (3) Assessing for dehydration and electrolyte balance is not indicated for a liver biopsy. (4) The patient should be positioned supine or on the left side for a liver biopsy.
A nurse is discussing healthy lifestyle measures with a group of older adults during a senior seminar. What instruction(s) should you include as accurate information? (select all that apply) A. Consume sufficient fiber B. Eat a normal, well-balanced diet C. Exercise regularly D. Drink at least three glasses of fluids a day E. Take laxatives regularly
1. Consume sufficient fiber 2. Eat a normal, well-balanced diet 3. Exercise regularly *Sufficient fiber, a well-balanced diet, and regular exercise are all good advice. (4) Encourage at least eight glasses of fluid a day, unless there is a medical reason for fluid restriction. (5) Routine use of laxatives should be discouraged to avoid physiologic dependence.
The nurse explains that the older adult is prone to digestive disorders related to which age-related change(s)? (select all that apply) A. Decreased hydrochloric acid B. Increased enzyme levels C. Inadequate chewing D. Diminished intestinal motility E. Gastroesophageal sphincter incompetence
1. Decreased hydrochloric acid 2. Inadequate chewing 3. Diminished intestinal motility 4. Gastroesophageal sphincter incompetence *Age does not decrease digestive enzyme levels
An 82-year-old patient is undergoing bowel preparation for a diagnostic procedure. What are the potential complications of the bowel prep? (select all that apply) A. Constipation B. Rashes C. Dehydration D. Muscle cramps E. Chest pains F. Hypotension
1. Dehydration 2. Muscle cramps 3. Hypotension *Dehydration is a possible adverse effect of rigorous bowel preparations. Muscle cramps can occur with the loss of potassium caused by the diarrhea from the bowel prep. Loss of fluid that causes dehydration can lower blood pressure. (1) Constipation will not occur because of the bowel preparation; it causes diarrhea. (2) Rash could occur if the patient has an allergy to a component of the fluid, but it is not a likely side effect. (5) Chest pains are not a likely side effect.
An older adult woman of Puerto Rican descent is admitted for persistent anorexia and dehydration. There are no apparent underlying organic causes for loss of appetite. Which intervention(s) would be culturally appropriate? (select all that apply) A. Determine food preference B. Encourage family visits C. Provide small amounts of food and fluid frequently D. Consider parenteral nutrition E. Consult a dietitian and speech therapy
1. Determine food preference 2. Encourage family visits 3. Provide small amounts of food and fluid frequently *Determining food preferences and encouraging family visits are appropriate to meet the cultural needs of the patient. Offering small, frequent amounts of foods and fluids is an appropriate intervention regardless of cultural background. (4) Considering parenteral nutrition is premature if enteral methods are still an option. (5) Consulting a dietitian might be appropriate after cultural needs are explored. Consulting speech therapy is appropriate if there are problems with chewing and swallowing.
A patient reports discomfort from flatus after surgery. What action(s) can be suggested by the nurse to help to relieve the flatus buildup? (Select all that apply.) A. Drink hot coffee. B. Drink chilled carbonated beverages. C. Encourage bed rest until the pain subsides. D. Encourage ambulation. E. Trendelenburg position.
1. Encourage ambulation. 2. Trendelenburg position. *During the postoperative period, patients are at an increased risk for flatus buildup. This is due to analgesics, bowel manipulation, and anesthetic agents. Activities that will aid in the passage of flatus include ambulation and the use of a slight Trendelenburg position. Inactivity and hot and chilled beverages are associated with increased flatus buildup.
Which action(s) should the nurse recommend to promote a patient's bowel health? (select all that apply) A. Exercise regularly B. Include adequate bulk in the diet C. Drink adequate water D. Defecate at approximately the same time every day E. Take a laxative to maintain a regular defecation pattern
1. Exercise regularly 2. Include adequate bulk in the diet 3. Drink adequate water 4. Defecate at approximately the same time every day *Daily exercise and intake of adequate bulk and water are contribution to bowel health. Heeding the need to defecate and defecating at the same time daily will help to keep the gastrocolic reflex healthy. Taking daily laxatives is not conducive to good bowel health
A patient is admitted with anorexia, nausea and vomiting, and weight loss. When developing the plan of care, which information is a priority to be obtained? (Select all that apply.) A. Ability to cook own food B. Factors that cause vomiting C. Pattern of anorexia D. Dietary history E. Cultural preferences for food
1. Factors that cause vomiting 2. Pattern of anorexia 3. Dietary history *Dietary history, pattern of anorexia, and factors that cause vomiting are needed to initiate a plan of care. Determining the ability to cook and the cultural preferences for food are not immediately necessary to formulate a nursing care plan for the patient; they may be obtained at a later time.
Before a nurse can document the presence of diarrhea, which criteria must be met? (select all that apply) A. One loose stool in a 24-h period B. Multiple liquid or semiliquid in a 24-h period C. Hyperactive bowel sounds D. Cramping E. Fever
1. Multiple liquid or semiliquid in a 24-h period 2. Hyperactive bowel sounds 3. Cramping *Multiple liquid or semiliquid stools in a 24 h period with hyperactive bowel sounds with cramping are the criteria for diarrhea. Fever is not a diagnostic criteria for diarrhea, and a single loose stool is merely documented as such
The nurse is caring for a patient immediately following a liver biopsy. Which actions are appropriate for the nurse to take? (select all that apply) A. Position the patient on the right side B. Assess the patient's pain C. Monitor vital signs every 15 minutes for the first hour D. Instruct patient to cough and deep-breathe E. Assess for hematoma at puncture site
1. Position the patient on the right side 2. Assess the patient's pain 3. Monitor vital signs every 15 minutes for the first hour 4. Assess for hematoma at puncture site The liver biopsy is performed under local or general anesthesia. Post-procedural care will include positioning on the right side for the first 2 h, and assessing pain, vital signs and the puncture site. The patient should not cough as it increased intra-abdominal pressure and may stimulate bleeding
Which factor(s) increase the risk for developing pancreatic cancer? (select all that apply) A. obesity B. Jewish ethnicity C. Diabetes mellitus (DM) D. Hepatitis A E. smoking
1. obesity 2. Diabetes mellitus (DM) 3. smoking *Pancreatic cancer rises steadily with age. Although the cause of pancreatic cancer is not known, the incidence is higher in cigarette smokers. Obesity, chronic pancreatitis, and DM are also risk factors for this cancer. Hewish ethnicity and hepatitis are not contributory to the disease
A patient who is dehydrated because of vomiting and diarrhea needs IV fluid therapy. The health care provider orders 1000 mL normal saline to infuse over 6 hours. The drop factor is 10 gtt/mL. You calculate the rate to infuse per gravity at _______ drops per minute
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The nurse is reviewing a student nurse's charting and notes that the student has documented absent bowel sounds. The nurse reminds the student that in order to document absent bowel sounds, one must auscultate each quadrant at what period of time? A. 30 seconds B. 1 minute C. 2 minutes D. 5 minutes
5 minutes *The criterion for the documentation of absent bowel sounds is that each quadrant is auscultated for 5 minutes
The nurse is caring for multiple patients. The nurse determines that which patient has the highest risk for developing gallstones? A. A 37-year-old white man of normal weight on long-term corticosteroids for asthma B. A 42-year-old African American man of normal weight who has smoked for 25 years C. A 46-year-old Indonesian woman who is under weight and has recently had radiation treatments D. A 50-year-old obese Mexican American woman who has type 1 diabetes
A 50-year-old obese Mexican American woman who has type 1 diabetes *Obesity, diabetes mellitus (DM), rapid weight loss, and Crohn disease increase the risk for the development of gallstones. Native American and Mexican Americans have an ethnic predisposition to gallstones
Which laboratory values would you use to assess liver function? A. CBC, BUN, creatinine B. Lipase, amylase, WBC C. Troponin, CPK, myoglobin D. ALT, ammonia, INR
ALT, ammonia, INR *ALT, ammonia, and INR all assess the liver and its functions. (1) These labs would be done to assess kidney function. (2) Elevation in these labs would indicate pancreatitis. (3) These labs evaluate the heart.
Transfer nutrients into smaller molecules
Absorption
The nurse is caring for a patient who returns to the floor at lunch time after undergoing an upper GI (UGI series). Which action is most important for the nurse to perform first? A. Administer a laxative B. Educate the patient about the possibility of white stools C. Offer the patient a small snack D. Provide oral care
Administer a laxative *The contrast media used in the series features barium that can harden and lead to an impaction. Patients should have a bowel movement quickly after the procedure to eliminate the medium from the body. While fluids and snacks or meal trays should be given as quickly as possible, patients should be educated about the possibility of white stools for several days post-procedure, and oral care should be provided, these interventions are of lesser importance since they do not directly work to quickly prevent a post-procedure complication
Repair of body tissue
Anabolism
The nurse is caring for a patient who has been experiencing severe diarrhea and can now resume solid foods. The nurse educates the patient about appropriate food choices. Which food choice indicates that the nurse's teaching has been successful? A. Whole-grain rice B. Wheat toast C. Applesauce D. Grapes
Applesauce *When a patient has severe diarrhea and is allowed to resume solid foods, the foods should be slowly introduced in order to help thicken the stool. Foods such as applesauce, pretzels, bananas, white rice, white toast, and yogurt are beneficial
The nurse is caring for a patient who is complaining of postoperative gas pain. What intervention should the nurse implement? A. Assist the patient with ambulation B. Apply a cold compress on the abdomen C. Offer a cup of coffee or tea D. Offer chilled vegetable juice
Assist the patient with ambulation *Ambulation is the most effective method for helping a patient expel gas. Hot or cold beverages and cold compresses will increase gas
The nurse is assessing the stooling patterns of an assigned patient. The patient reports stools as being clay colored. The nurse knows this may indicate which condition? A. The patient is experiencing upper gastrointestinal (GI) bleeding. B. Bile is not reaching the intestines. C. The stool contains undigested fat. D. The stool has an excessive amount of bilirubin.
Bile is not reaching the intestines. *The clay-colored stool indicates the bile is not reaching the patient's intestines due to an obstruction in the bile ducts. Intestinal bleeding will present as black or red stools. Stools containing undigested fat will float in the toilet.
Breaking down larger molecules into smaller molecules
Catabolism
The nurse is preparing to administer liquid laxative to a patient in preparation for a colonoscopy. Which action should the nurse take? A. Offer a small snack B. Take the patient's temperature C. Mix the laxative with orange juice D. Chill the laxative and pour it over ice
Chill the laxative and pour it over ice *Chilling the laxative or pouring it over ice makes the drink more palatable and easier to swallow. The nurse should not offer any food, as the accuracy of the test depends on adequate bowel prep. The laxative does not affect the patient's temperature. Mixing the laxative with another substance can make it difficult to judge how much the patient actually consumed if any liquid is remaining
The nurse is reviewing the laboratory results of an assigned patient. The serum bilirubin is 2.8 mg/dL. The nurse anticipates that the patient's urine will display which finding? A. Dark color B. Low specific gravity C. Very scant amount D. Foul odor
Dark color *Normal serum bilirubin is 0.1 to 1.2 mg/dL. Jaundice is present at readings above 2.5 mg/dL. The patient who is jaundiced will have dark, tea-colored urine. Specific gravity refers to the concentration of the urine. The amount and odor of urine will not be directly influenced by the bilirubin level
A 30-year-old woman is admitted with complains of severe nausea and vomiting over the past 2 days. On admission she is hypotensive and extremely weak. What is the priority problem? A. Altered breathing pattern B. Altered activity intolerance C. Deficient fluid volume D. Altered cardiac output
Deficient fluid volume *Deficient fluid volume is the priority since symptoms and the condition are related to excessive fluid loss. (1) Nothing in the history suggests that the patient is having trouble breathing. (2, 4) These are not priority nursing diagnoses. The patient is likely to have activity intolerance, and her hypotension suggests a decreased cardiac output, but both problems should readily resolve if the fluid deficit is corrected.
The older adult patient presents to the emergency department complaining of severe vomiting for 3 days. The nurse knows which is the major complication of continuous vomiting? A. Dehydration B. Aspiration of vomitus C. Cardiac dysrhythmias D. Weight loss
Dehydration *Older adult patients experiencing continuous vomiting are at particular risk for dehydration. Significant weight loss would not occur immediately; it is a sign of prolonged nutritional deficiency. If the vomiting were to continue, the resulting hypokalemia could result in dysrhythmias.
When assessing a patient's bowel sounds, the nurse auscultates loud bowel sounds in each quadrant every 3 seconds. The nurse understands that these findings could indicate that the patient is experiencing which condition? A. Diarrhea B. Paralytic ileus C. Vomiting D. Constipation
Diarrhea *Loud, rapid bowel sounds are indicative of hypermobility, which could result in diarrhea. Absent bowel sounds are associated with paralytic ileus. Normal bowel sounds present as soft gurgles and clicks every 5 to 15 seconds. Hypoactive bowel sounds indicate decreased motility and could indicate that the patient is constipated
A decreased secretion of intrinsic factor is a physiologic change associated with the aging process; therefore, you suspect decreased intrinsic factor should assess for which behavior? A. A refusal to eat salty or sweet foods B. A change in stools after eating fatty foods C. Fatigue and activity intolerance D. Difficulties with mastication
Fatigue and activity intolerance *A lack of intrinsic factor may cause pernicious anemia, which can manifest as fatigue and activity intolerance. (1) Atrophy of taste buds results in difficulty in distinguishing between salty and sweet flavors. (2) Change in stool quality can be related to many disorders or bodily functions but not to lack of intrinsic factor; however, changes in lipase or bile will change the stool characteristics. (4) Difficulties with mastication can be related to poor dentition or ill-fitting dentures.
The nurse is talking with a patient who has been experiencing nausea and vomiting. The patient indicates an interest in using alternative therapies for the condition. Which product may aid in nausea management? A. Ginger B. Ginseng C. Chamomile D. Soy
Ginger *Ginger has been used for centuries in Asia to combat nausea and vomiting, motion sickness, and dyspepsia. It is available candied in capsules, fluid extract, and tablets, and tincture or as fresh ginger root that can be grated and used to make tea. Ginger may decrease the action of histamine (H2) receptor antagonists and proton pump inhibitors and may increase absorption of medications taken orally. Ginger may decrease the effect of antidiabetic medications. It should not be used during pregnancy or lactation
A patient questions the use of herbal remedies to manage motion sickness on an upcoming trip. Which has been used with success to manage this health complaint? A. Ginkgo B. Goldenrod C. Ginseng D. Ginger
Ginger *Ginger has been used for centuries in Asia to combat nausea and vomiting, motion sickness, and dyspepsia. It is available candied, in capsules, fluid extract, and tablets, and tincture or as fresh ginger root that can be grated and used to make tea. Gingko biloba, ginseng, and goldenrod are not used for motion sickness.
The nurse is assessing a patient's bowel sounds. After auscultating each quadrant for 30 seconds, the nurse fails to hear any sounds. How should the nurse document this finding? A. Absent bowel sounds B. Hypoactive bowel sounds C. Active bowel sounds D. Hyperactive bowel sounds
Hypoactive bowel sounds *Hypoactive bowel sounds can be noted in the medical record when no sounds are heard after listening in each of the four quadrants for 30 seconds. For bowel sounds to be considered absent, it is necessary to verify that no sounds are heard after listening in each of the four quadrants for 5 minutes. If hyperactive, high-pitched sounds are heard in one quadrant, and decreased sounds are heard in another quadrant, assess for nausea and vomiting, as the patient may have an intestinal obstruction
The nurse is caring for an older adult patient who reports continued problems with constipation. What intervention can be implemented to promote timely bowel movements? A. Administration of an oil retention enema weekly. B. Take a mild over-the-counter laxative each evening. C. Increase fiber intake. D. Limit fluid intake to 1.5 L daily.
Increase fiber intake. *Fiber intake will promote defecation. The current recommendation for daily total water intake is 3.7 L for males and 2.7 L for women unless contraindicated by medical conditions. Laxative and enema use should be avoided if possible. Too frequent use of these aids may result in reliance on them to have a bowel movement.
The nurse cautions that constant stress can cause which alteration to the gastrointestinal (GI) system? A. Slowed GI mobility resulting in constipation B. Reversed peristalsis resulting in projectile vomiting C. Increased digestive juices resulting in a gastric ulcer D. Decreased digestive juices resulting in ineffective metabolism
Increased digestive juices resulting in a gastric ulcer *Stress increase the gastric secretions, which irritate and finally ulcerate the gastric mucosal
The home health nurse is caring for the caring for the patient with tuberculosis who is taking rifampin and isoniazid (INH). The nurse should carefully monitor the patient for which potential side effect? A. Gallstones B. Liver disorders C. bleeding ulcers D. esophagitis
Liver disorders *Rifampin and INH are both hepatotoxic
During a morning assessment, the nurse observes that a patient displays bulging flanks when supine with the knees flexed. Which action should the nurse take next? A. Measure the patient's abdominal girth B. Auscultate each quadrant of the abdomen for 5 minutes C. Document the finding D. Notify the charge nurse
Measure the patient's abdominal girth *The nurse's initial assessment indicates fluid accumulation. The nurse needs to obtain more information, first measuring abdominal girth. The nurse can then percuss from the umbilicus to the flanks to detect fluid shifts, and document all findings. The nurse will only auscultate bowel sounds for 5 minutes in each quadrant if bowel sounds are not heard before then. It is unnecessary to notify the charge nurse at this time
The nurse caring for an 80-year-old woman who is undergoing the extensive bowel preparation for a colonoscopy. The nurse should most closely monitor the patient for which potential complication? A. Diarrhea B. Metabolic acidosis C. Fatigue D. Dyspnea
Metabolic acidosis *The older patient is especially at risk for problems of electrolyte imbalance, fluid overload, or dehydration when undergoing preparation for diagnostic tests that require a fasting state and/or bowel cleansing. Metabolic acidosis can occur when there is a large volume loss of bowel content. Bowel preparation causes diarrhea and may cause fatigue; bowel preparation should not cause dyspnea
Chemical process to make substances needed by the body
Metabolism
You are planning care for several patients who had diagnostic testing. Which patient will require the most time for postprocedural care? A. Patient who had an ultrasound B. Patient who had hepatobiliary scintigraphy C. Patient who had a liver biopsy D. Patient who had a Helicobacter pylori antibody test
Patient who had a liver biopsy *(See Table 27.1 for specific nursing care related to diagnostic testing.) Patients who undergo liver biopsy are at risk for postprocedural bleeding or respiratory problems, such as dyspnea, cyanosis, or restlessness, which might indicate pneumothorax. They require frequent vital signs and close observation. (1) Ultrasound is a noninvasive procedure; routine monitoring is sufficient. (2) Patients who undergo hepatobiliary scintigraphy should be informed that there is little danger of radioactivity; routine monitoring is sufficient. (4) Helicobacter pylori antibody test requires a blood sample, so routine care of a venipuncture site is sufficient.
Rhythmic squeezing action of intestinal tract
Peristalsis
An elderly patient reports a loss of interest in eating. The patient's history indicates the patient's spouse died a few months ago. When providing information to the patient, which action by the nurse is likely to be most helpful in increasing the patient's intake? A. Having the patient keep a food diary B. Giving the patient a list of high-calorie foods C. Reminding the patient of the importance of eating D. Suggesting to the patient's family members that someone join the patient for meals
Suggesting to the patient's family members that someone join the patient for meals *Psychosocial factors have a significant impact on one's desire for food. Appetite depends on complex mental processes having to do with memory and mental associations that can be pleasant or extremely unpleasant. Appetite is stimulated by the sight, smell, and thought of food. The physical and social environment in which a person is eating stimulates appetite. It would not be helpful for the nurse to have the patient keep a food diary, to give the patient a list of high-calorie foods, or to remind the patient of the importance of eating.
A common cause of liver toxicity is A. Daily hydrochlorothiazide administration for hypertension B. Regular consumption of a high-fat diet throughout life C. Long-term smoking of a pack of cigarettes per day D. Taking extra-strength acetaminophen at doses of 4500 mg per day
Taking extra-strength acetaminophen at doses of 4500 mg per day *Excessive amounts of acetaminophen can cause liver toxicity and failure. (1) Patients need to be reminded to check other medications and over-the-counter medications for acetaminophen. . No more than 4000 mg per day of acetaminophen should be taken on a regular basis. (1) Hydrochlorothiazide can cause liver damage in some patients but a more common cause is too much acetaminophen. (2) Consumption of a high-fat diet may cause gallbladder problems, not liver toxicity. (3) Long-term smoking can damage the lungs and blood vessels and contribute to the formation of various cancers, but it does not cause liver toxicity.
The nurse is percussing a patient's abdomen and hears a dull thud in the right upper quadrant. This sound indicates that nurse is percussing over which location? A. The liver B. The small intestine C. The stomach D. The lungs
The liver *Percussion is performed by placing the middle finger of one hand on the abdomen and striking the finger lightly below the knuckle and listening for the pitch of sound produced. A dull thud would be heard over the liver. Tympany would be heard over the stomach and intestines, and resonance would be heard over lung tissue
A magnetic resonance imaging (MRI) test is scheduled. What should be included in the information provided to the patient? A. Dental bridges will need to be removed if the MRI is of the head. B. The test will take approximately 30 to 60 minutes. C. Solid foods are restricted for 6 to 8 h prior to the test. D. There is only a limited amount of radiation exposure associated with the test.
The test will take approximately 30 to 60 minutes. *The MRI will take approximately 30 to 90 minutes. There are no dietary restrictions. Due to the strong magnet, all metal objects, including dental bridges will need to be removed. There is no radiation exposure associated with the test.
The nurse is planning care for a patient who has experienced moderate diarrhea for 3 days. Which collaborative intervention is most important to include in the plan of care? A. Place the patient on NPO status B. limit the patient's diet to clear liquids C. Administer parenteral nutrition D. Restrict the patient's diet to soft food only
limit the patient's diet to clear liquids *If diarrhea is moderate, only clear liquids are permitted by mouth. If the diarrhea is severe, nothing is given by mouth until it subsides. Severe, long-term diarrhea may require the use of total parenteral nutrition. When diarrhea is caused by infection, stool cultures and antibiotics may be necessary. As the condition improves, the diet is advanced
Measures used to tech patients to prevent gastrointestinal ulcers include A. limiting the amount of routine alcohol consumption B. refraining from the use of aspirin for a headache C. takin an H2 inhibitor to decrease stomach acid daily D. eating hot, spicy food at least once each day
limiting the amount of routine alcohol consumption *Drinking excessive alcohol on a consistent basis may cause erosion of the gastric mucosa and predispose to ulcer formation. (2) Taking an occasional aspirin does not predispose to a gastrointestinal ulcer. (3) Taking an H2 inhibitor on a daily basis is not recommended for prevention of an ulcer. (4) Eating hot, spicy food at least once a day is not recommended for ulcer prevention.
