Chapter 55: Assessment of the Gastrointestinal System Nursing School Test Banks

Chapter 55: Assessment of the Gastrointestinal System

Test Bank

MULTIPLE CHOICE

1. The nurse is caring for a client who is receiving radiation treatment for oral cancer. Which problem does the nurse anticipate for this client?

a.

Failure to absorb nutrients from the stomach

b.

Inability to digest protein

c.

Impaired ability to soften and break down food

d.

Difficulty swallowing food

ANS: C

Saliva is responsible for the softening of food in the mouth and contains an enzyme, salivary amylase (ptyalin), which assists in the breakdown of carbohydrates. Radiation to the oral cavity can result in reduction of saliva production. Radiation to the mouth will not impair swallowing, ability to digest protein, or ability to absorb nutrients from the stomach.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)

MSC: Integrated Process: Nursing Process (Planning)

2. Which question best assists the nurse in assessing a client with acute diarrhea?

a.

Have you traveled outside the country recently?

b.

Have you had a colonoscopy lately?

c.

Do you have any trouble swallowing?

d.

Do you have any allergies?

ANS: A

A history of recent travel may help pinpoint an infectious source for the clients diarrhea. A colonoscopy will not cause acute diarrhea. Trouble swallowing is not related to diarrhea. Allergic reactions do not typically cause acute diarrhea.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

3. A client has been taking naproxen (Naprosyn) for several months. Which assessment question is important for the nurse to ask?

a.

Have you experienced any constipation?

b.

Have you had any stomach pain or indigestion?

c.

Have you had any difficulty swallowing?

d.

Have you noticed any weight loss lately?

ANS: B

Long-term use of NSAIDs for chronic pain can precipitate peptic ulcer formation through inhibition of prostaglandins, which normally protects the gastric mucosa. The client should be assessed for stomach pain or indigestion. This medication does not typically cause constipation or difficulty swallowing. Weight loss would not be related to this medication.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse is screening clients at a health fair. Which client is at highest risk for the development of colon cancer?

a.

Older white client with irritable bowel syndrome

b.

Middle-aged African-American client who smokes cigars

c.

Middle-aged Asian client who travels and eats out frequently

d.

Older American Indian client taking hormone replacement therapy

ANS: B

Colon cancer is more prevalent among African Americans and smokers. Irritable bowel syndrome, travel, and hormone replacement therapy do not increase the risk for colon cancer.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1181

TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Nursing Process (Assessment)

5. When performing an assessment, the nurse detects a fruity odor on the clients breath. What does the nurse do next?

a.

Assess the clients blood sugar level.

b.

Assess the clients stool for occult blood.

c.

Instruct the client in oral hygiene techniques.

d.

Assess the client for petechiae, itching, and jaundice.

ANS: A

A fruity odor to the breath may indicate uncontrolled or undiagnosed diabetes mellitus. The clients blood sugar level should be checked immediately for hyperglycemia. The nurse may perform the other assessment tests for the client, but they will not be helpful in determining the cause of the fruity breath.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

6. The nurse is preparing to perform an abdominal assessment on a client with suspected cholecystitis. In what sequence does the nurse palpate the clients abdomen?

a.

Palpate the lower quadrants only.

b.

Palpate the upper quadrants last.

c.

Palpate the upper quadrants only.

d.

Defer palpation and use percussion only.

ANS: B

The client with cholecystitis will report pain in the right upper quadrant of the abdomen. Tender or painful areas should be palpated last to prevent the client from tensing his or her abdominal muscles because of pain, thereby making the examination more difficult. All quadrants should be palpated. Palpation is an important assessment tool that should not be deferred for this client.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

7. The nurse is caring for a client who has just returned from abdominal surgery. When auscultating the clients abdomen, the nurse does not hear any bowel sounds. Which is the nurses best action?

a.

Notify the health care provider.

b.

Percuss the abdomen.

c.

Document the finding.

d.

Insert a nasogastric tube.

ANS: C

Absent bowel sounds are expected immediately following abdominal surgery. The finding should be noted in the clients record for later reference. The provider does not need to be notified at this time. The nurse should insert a nasogastric tube if ordered by the physician if the ileus persists. Percussion may be performed but may be uncomfortable for the client and will not reveal the cause of the ileus.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

8. The nurse assesses dullness at the left anterior axillary line. The nurse is concerned about which condition that the client may have?

a.

Cirrhosis

b.

Splenomegaly

c.

Bowel obstruction

d.

Abdominal aortic aneurysm

ANS: B

Dullness in front of the tenth intercostal space, at the left anterior axillary line, is indicative of splenomegaly, which is commonly seen with mononucleosis. Cirrhosis would be noted with percussion in the clients left upper quadrant, indicating hepatomegaly. The nurse may note tympanic sounds with bowel obstruction. Percussion would not be used to assess abdominal aortic aneurysm.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1184

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

9. The nurse finds a positive Blumbergs sign in a client with abdominal pain. Which action does the nurse plan?

a.

Have the client be NPO in preparation for surgery.

b.

Document this normal finding in the clients record.

c.

Immediately auscultate the clients abdomen for bowel sounds.

d.

Repeat the maneuver with the client in a supine position, with the knees flexed.

ANS: A

A positive Blumbergs sign (rebound tenderness), an abnormal sign, is indicative of peritoneal inflammation, which commonly accompanies appendicitis. The client should be made NPO in preparation for surgery to remove the appendix. The maneuver should not be repeated with the client in the supine position. The nurse should perform auscultation before percussion for the abdominal assessment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

10. Which laboratory finding does the nurse expect to find on assessment of a client with advanced cirrhosis?

a.

Amylase, 129 IU/L; alkaline phosphate, 45 U/L

b.

Reticulocyte count, 1%; magnesium, 1.5 mEq/L

c.

Hemoglobin, 14 g/dL; direct bilirubin, 0.2 mg/dL

d.

Prothrombin time (PT), 17.5 seconds; albumin, 1.6 g/dL

ANS: D

Cirrhosis frequently results in impaired production of clotting factors, with increased PT and partial thromboplastin time (PTT). Serum albumin is decreased with cirrhosis because protein formation within the liver is impaired. The other laboratory values are within normal limits and would not be expected with advanced cirrhosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

11. The nurse is caring for a client who just completed an upper GI radiographic series with oral barium contrast. Which instructions does the nurse provide to the client?

a.

Drink plenty of fluids over the next few days.

b.

Do not eat or drink anything for 6 hours after the test.

c.

You may not drive or operate heavy machinery today.

d.

Do not take any blood thinners for 24 hours after the test.

ANS: A

The client is encouraged to drink plenty of fluids after a barium swallow to help eliminate the barium from the colon. Limiting the diet as the barium is being cleared is not necessary. The test will not make the client drowsy, so driving should not be limited. Similarly, blood thinners will not affect the client.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1187

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Teaching/Learning

12. The client is scheduled for a colonoscopy. Which statement indicates that the client needs additional teaching about the procedure?

a.

I may have gas and abdominal cramps after the test.

b.

I will take strong laxatives the afternoon before the test.

c.

I will take my Coumadin with a sip of water tomorrow morning.

d.

I will take nothing by mouth after midnight on the day of the test.

ANS: C

Blood thinners should not be taken before colonoscopy because bleeding may occur if polyps are removed. The client should stop taking warfarin (Coumadin) approximately 2 weeks before the colonoscopy. The other answers describe accurate complications of the colonoscopy and preparation for the procedure.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Assessment)

13. The nurse is preparing the client for a computed tomography (CT) scan of the abdomen with IV contrast. Which question does the nurse ask the client before the examination?

a.

Are you allergic to shrimp, scallops, or shellfish?

b.

Have you had anything to eat or drink in the past 12 hours?

c.

Did you finish taking all the prescribed laxatives?

d.

Can you tolerate being tilted from side to side?

ANS: A

Allergies to iodine or seafood can cause a cross-allergic reaction to the contrast dye used for CT scans. Clients reporting such allergies should be scheduled for CT without contrast to avoid anaphylactic reactions. The client does not need to be NPO for this test and does need not to take laxatives. The client is not tilted during the CT scan.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlError Prevention) MSC: Integrated Process: Nursing Process (Assessment)

14. An abdominal ultrasound is scheduled for the client. Which statement by the client indicates that the nurses teaching about the procedure was effective?

a.

The IV contrast may burn when it is injected.

b.

I will drive myself home after the test is completed.

c.

I will empty my bladder completely before the test.

d.

I may have to take a laxative to pass the barium afterward.

ANS: B

Because sedation is not used for this test, clients may drive themselves home after the abdominal ultrasound is completed. Barium and IV contrast are not needed. The clients bladder should be full for accurate visualization.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

15. While a health history is obtained from a client with a new diagnosis of advanced pancreatic cancer, the client begins to cry. Which is the nurses best response?

a.

I am so sorry for making you cry!

b.

I will step out for a few minutes until you feel better.

c.

I can see that you are upset about this. It is all right to cry.

d.

I can see that I am upsetting you. Lets move on to something else.

ANS: C

The nurse should recognize the clients feelings and should allow the client to cry. Moving on to another topic shows disregard for the clients feelings. The nurse should not leave the room but should stay to offer support. Apologizing to the client does not place the focus on the client or acknowledge the clients feelings and emotions in this situation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Caring

16. The nurse is performing an abdominal assessment on an older client. Which assessment finding does the nurse expect as a normal consequence of aging?

a.

Increased salivation and drooling

b.

Hyperactive bowel sounds and loose stools

c.

Increased gastric acid production and heartburn

d.

Impaired sensation to defecate and constipation

ANS: D

Older adults may lose the sensation to defecate, resulting in constipation. Salivation decreases with aging, along with peristalsis and gastric acid production.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

17. The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) completed. The client tells the nurse that her mouth is very dry after the procedure. Which is the nurses best action?

a.

Keep the client NPO (nothing by mouth).

b.

Check the clients gag reflex.

c.

Offer the client sips of clear liquids.

d.

Provide the client with a few ice chips.

ANS: B

The back of the throat is numbed for the EGD, impairing the gag reflex. Therefore the client is initially NPO postoperatively. The nurse should check the gag reflex before offering any type of liquid to the client. The client may be given ice chips or sips of fluids once the gag reflex has returned.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention) MSC: Integrated Process: Nursing Process (Assessment)

18. A client has a family history of colon cancer. Which laboratory tests are ordered to rule out colon cancer?

a.

Cholesterol

b.

Serum lipase

c.

Carcinoembryonic antigen

d.

Xylose absorption

ANS: C

The carcinoembryonic antigen can indicate colorectal, stomach, or pancreatic cancer if elevated. Elevated cholesterol and serum lipase may indicate pancreatitis. Decreased xylose absorption may indicate malabsorption in the small intestine.

DIF: Cognitive Level: Comprehension/Understanding REF: Chart 55-3, p. 1186

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

MULTIPLE RESPONSE

1. The nurse performs percussion of a clients abdomen. Which findings may the nurse determine with this assessment technique? (Select all that apply.)

a.

Hepatomegaly

b.

Kidney stones

c.

Ascites

d.

Large mass below the liver

e.

Biliary colic

f.

Ileus

ANS: A, C, D, F

Percussion allows the nurse to identify the presence of masses, fluid, enlarged organs, and air in the abdomen. The nurse would not be able to identify biliary colic or kidney stones with percussion.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

2. A client reports that he has been passing black stools for the last few days. Which findings from the clients health history does the nurse consider as possible causes? (Select all that apply.)

a.

Cirrhosis

b.

Cholecystitis

c.

Hemorrhoids

d.

Diverticulitis

e.

Long-term use of NSAIDs

f.

Use of iron supplements

ANS: A, E, F

Cirrhosis may cause black stools when bleeding occurs from esophageal varices. Long-term NSAID use may lead to gastric ulcer development and bleeding. Iron supplements may turn the color of the stool black. Hemorrhoids or diverticulitis would result in stools that are streaked with red. Cholecystitis may result in pale-colored stools if bile flow is obstructed.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

3. A client has jaundice and ascites. Which laboratory values indicate hepatic disease? (Select all that apply.)

a.

Albumin, 2.0 g/dL

b.

Potassium, 3.0 mEq/L

c.

Alanine aminotransferase (ALT), 45 IU/L

d.

Aspartate aminotransferase (AST), 45 U/L

e.

Unconjugated (indirect) bilirubin, 1 mg/dL

f.

Ammonia, 120 mg/dL

ANS: A, C, D, E, F

Decreased albumin and increased ALT, AST, unconjugated bilirubin, and ammonia all indicate hepatic disease. When the liver is damaged, albumin is not produced by the hepatic cells. ALT and AST liver enzymes increase with liver disease. Bilirubin, the primary component of bile, can be measured as direct or indirect and, if elevated, can indicate impaired secretion. Elevated levels of ammonia indicate severe hepatocellular damage. Decreased potassium does not indicate possible liver involvement but can be reduced by vomiting and diarrhea.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

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