Med Surg. Chapter 44 Assessment of Digestive and Gastrointestinal Function

A patient tells the nurse that his stool was colored yellow. The nurse assesses for which of the following?

Recent foods ingested

After 20 seconds of auscultating for bowel sounds on a client recovering from abdominal surgery, the nurse hears nothing. Which of the following should the nurse do based on the assessment findings?

Listen longer for the sounds.

The nurse is performing an abdominal assessment. The nurse should perform the assessment in which of the following orders?

Inspection, auscultation, percussion, palpation

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?

Intrinsic factor

Which of the following terms describes a gastric secretion that combines with vitamin B12 so that it can be absorbed?

Intrinsic factor

A client has recently obtained a set of dentures. Which of the following will the nurse do during a complete physical examination?

Remove the plates to visualize the oral cavity.

A client frequently reports constipation. The nurse asks the client about his bowel habits. Which of the following would be the most likely contributing factor related to constipation?

Resisting the urge to defecate several times a day

Which of the following is the primary function of the small intestine?

Absorption

When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the physician?

"I really don't like to be in small, enclosed spaces."

A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?

"I'll avoid eating or drinking anything 6 to 8 hours before the test."

A nursing instructor tells the class that review of oral hygiene is an important component during assessment of the gastrointestinal system. One of the students questions this statement. Which of the following explanations from the nurse educator is most appropriate?

"Injury to oral mucosa or tooth decay can lead to difficulty in chewing food."

A patient asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers:

"It indicates if a cancer is present."

The nurse asks a client to point to where she feels pain. The client asks why this is important. The nurse's best response would be which of the following?

"Often the area of pain is referred from another area."

A patient is in the outpatient recovery area after having a colonoscopy and informs the nurse of abdominal cramping. What is the best response by the nurse?

"The cramping is caused by the air insufflated in the colon during the procedure."

Which of the following digestive enzymes aids in the digesting of starch?

Amylase

Upon hearing that his small intestine lining has thinned, an elderly client asks, "What can this lead to?" The nurse would most likely respond with which of the following comments?

"You may frequently experience constipation."

The nurse is caring for a patient after a gastroscopy for which the patient received sedation. The nurse should report which of the following findings to the physician?

Difficulty swallowing

The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment?

Abdominal distention

A patient is being prepared for esophageal manometry. The nurse should inform the patient to withhold what medication for 48 hours prior to the procedure?

Aspirin

A nurse assesses the abdomen of a newly admitted client. Which finding would necessitate further investigation?

Asymmetrical upper quadrants

A client, age 82, is admitted to an acute care facility for treatment of an acute flare-up of a chronic GI condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the GI tract. Which age-related change increases the risk of anemia?

Atrophy of the gastric mucosa

The nurse is to obtain a stool specimen from a client who reported that he is taking iron supplements. The nurse would expect the stool to be which color?

Black

During a colonoscopy with moderate sedation, the patient groans with obvious discomfort and begins bleeding from the rectum. The patient is diaphoretic and has an increase in abdominal girth from distention. What complication of this procedure is the nurse aware may be occurring?

Bowel perforation

The nurse is a preparing a patient for a barium enema. The nurse should place the patient on which of the following prior to the procedure?

Clear liquids day before

Cystic fibrosis, a genetic disorder characterized by pulmonary and pancreatic dysfunction, usually appears in young children but can also affect adults. If the pancreas was functioning correctly, where would the bile and pancreatic enzymes enter the GI system?

Duodenum

During a nursing assessment, the nurse knows that the most common symptom in patients with GI dysfunction is which of the following?

Dyspepsia

The nurse is teaching a patient scheduled for a colonoscopy. Which of the following should be included as part of the preparation for the procedure?

Follow the dietary and fluid restrictions and bowel preparation procedures.

The nurse is assessing a client who is stating gastrointestinal upset and a feeling of bloating. Which type of meal would the nurse anticipate causing these types of symptoms?

Hamburger and French fries

The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds?

Hyperactive

One or two bowel sounds in 2 minutes would be documented as which of the following?

Hypoactive

A client calls the nurse into her room and admits to peeking at her chart. She saw that she has borborygmi and is concerned. Which of the following explanations will the nurse give about this term?

Loud, prolonged stomach growling

If a client has abdominal surgery and a portion of the small intestine is removed, the client is at risk for which of the following?

Malabsorption syndrome

Which of the following would be most important to ensure that a client does not retain any barium after a barium swallow?

Monitoring the stool passage and its color.

The nurse is assessing a 50-year-old, dark-skinned African American man and has noted that he appears jaundice. Most likely, the nurse made this observation by assessing which part of his body?

Mucous membranes

The nurse is answering questions regarding fecal matter for a client who is scheduled for a colon resection. The client is asking questions regarding the composition of the fecal matter and when it becomes a formed mass. The nurse is most correct to state at which location?

Sigmoid colon

The nurse is providing care to a client who has had a percutaneous liver biopsy. The nurse would monitor the client for which of the following?

Signs and symptoms of bleeding

The nurse is preparing to examine the abdomen of a client complaining of a change in his bowel pattern. The nurse would place the client in which position?

Supine with knees flexed

Which patient teaching component is important for the nurse to communicate regarding pain management prior to or during diagnostic testing for a disorder of the GI system?

The patient should inform the test personnel if he or she experiences pressure or cramping during the instillation of test fluids.

A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor?

The ultrasonography should be scheduled before the GI procedure.

Which of the following is a true statement regarding older patients, considering the age-related effects on their gastrointestinal (GI) system?

They tend usually to have less control of the rectal sphincter.

Upon review of a client's chart, the nurse notes the client has been receiving antiemetics every 6 to 8 hours. What in this client's history may necessitate such frequency?

Treatment for cancer

Which of the following is an age-related change in the esophagus?

Weakened gag reflex

Which of the following is an age-related change of the GI system?

Weakened gag reflex

A patient asks the nurse which part of the GI tract absorbs the food and fluids. The nurse explains that the small intestine completes food digestion, but most of the water is absorbed by the:

large intestine

Lisa Bentley, a 32-year-old teacher, presents to the gastroenterology office where you work. She is known to have a history of Crohn's disease, and you have met with her several times to discuss the various health concerns that she has related to her diagnosis. When talking with the client, the nurse explains that having a GI disorder doesn't mean her problems are limited to the one area that is diseased but might also involve all of the following except ________.

metabolism

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are

normal.

A nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. The nurse tells the client that products of digestion are absorbed mainly in the:

small intestine.

A client is scheduled for magnetic resonance imaging (MRI). During the client teaching, the nurse will discuss which of the following?

"Do you experience any claustrophobia?"

During Mrs. Feldman's physical assessment, she informs you that her stools have been red lately. Which of the following will the nurse include in her assessment questioning?

"Have you been eating beets?"

The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following?

"Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact."

During assessment of a patient complaining of dyspepsia, the nurse is aware that abdominal pain associated with indigestion is usually which of the following?

Described as cramping or burning

A patient is complaining of abdominal pain associated with indigestion. What is characteristic of this type of pain?

Described as crampy or burning

When examining the abdomen of a client with complaints of nausea and vomiting, which of the following would the nurse do first?

Inspection

What part of the GI tract begins the digestion of food?

Mouth

The nurse is performing an initial assessment of a patient complaining of increased stomach acid related to stress. The nurse knows that the physician will want to consider the influence of what neuroregulator?

Norepinephrine

The nurse is assisting the physician with a gastric acid stimulation test for a patient. What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions?

Pentagastrin

A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?

Permit the client to drink only clear liquids.

Following ingestion of carrots or beets, the nurse would expect which alteration in stool color?

Red

A group of students are studying for an examination on the gastrointestinal (GI) system and are reviewing the structures of the esophagus and stomach. The students demonstrate understanding of the material when they identify which of the following as the opening between the stomach and duodenum?

Pyloric sphincter

A patient scheduled to undergo an abdominal ultrasonography is advised to do which of the following?

Restrict eating of solid food for 6 to 8 hours before the test.

A nurse is providing postprocedure instructions for a client who had an esophagogastroduodenoscopy. The nurse should perform which action?

Review the instructions with the person accompanying the client home.

The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?

Serum antibodies for H. pylori

Which of the following would indicate to the nurse that a client who has received three cleansing enemas in preparation for a barium enema is experiencing dehydration?

Signs of dizziness and confusion

A client receives a local anesthetic to suppress the gag reflex for a diagnostic procedure of the upper GI tract. Which of the following nursing interventions is advised for this patient?

The client should not be given any food and fluids until the gag reflex returns.

A client is scheduled for an esophagogastroduodenoscopy (EGD) to detect lesions in the gastrointestinal tract. The nurse would observe for which of the following while assessing the client during the procedure?

Client's tolerance for pain and discomfort

A client is scheduled for several diagnostic tests to evaluate her gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when she identifies which test as not requiring the use of a contrast medium?

Colonoscopy

After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected?

Stomach

The nurse has been directed to position a patient for an examination of the abdomen. What position should the nurse place the patient in for the examination?

Supine position with the knees flexed to relax the abdominal muscles

The nurses is assessing for blood in the stool due to an upper GI condition. The nurse understands that if there is blood in the stool, the stool will be which of the following colors?

Tarry black

What should the nurse advise a client who is scheduled for a proctosigmoidoscopy involving the lower GI structures?

The client should follow the dietary and fluid restrictions and bowel preparation procedures.

The patient is describing to the nurse a test that he underwent to detect a small bowel obstruction prior to admission to the hospital. The patient states that the test involved insertion of a tube through the nose and lasted over 6 hours. The nurse documents the name of the test as which of the following?

Upper GI enteroclysis