Assessment of Gastrointestinal System Lewis: Medical-Surgical Nursing, 10th Edition

1. Which information about an 80-yr-old male patient at the senior center is of most concern to the nurse? a. Decreased appetite c. Difficulty chewing food b. Unintended weight loss d. Complaints of indigestion ANS: B Unintentional weight loss is not a normal finding and may indicate a problem such as cancer or depression. Poor appetite, difficulty in chewing, and complaints of indigestion are common in older patients. These will need to be addressed but are not of as much concern as the weight loss. DIF: Cognitive Level: Analyze (analysis) REF: 839 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. An older patient reports chronic constipation. To promote bowel evacuation, the nurse will suggest that the patient attempt defecation a. in the mid-afternoon. b. after eating breakfast. c. right after getting up in the morning. d. immediately before the first daily meal. ANS: B The gastrocolic reflex is most active after the first daily meal. Arising in the morning, the anticipation of eating, and physical exercise do not stimulate these reflexes. DIF: Cognitive Level: Apply (application) REF: 836 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. When caring for a patient with a history of a total gastrectomy, the nurse will monitor for a. constipation. b. dehydration. c. elevated total serum cholesterol. d. cobalamin (vitamin B12) deficiency. ANS: D The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or constipation. DIF: Cognitive Level: Apply (application) REF: 835 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse will plan to monitor a patient with an obstructed common bile duct for a. melena. b. steatorrhea. c. decreased serum cholesterol level. d. increased serum indirect bilirubin level. ANS: B A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to fatty stools. Gastrointestinal bleeding is not caused by common bile duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with biliary obstruction. DIF: Cognitive Level: Apply (application) REF: 847 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 5. The nurse receives the following information about a 51-yr-old female patient who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient has a permanent pacemaker to prevent bradycardia. b. The patient is worried about discomfort during the examination. c. The patient has had an allergic reaction to both shellfish and iodine in the past. d. The patient declined to drink the prescribed polyethylene glycol (GoLYTELY). ANS: D If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure should be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient’s anxiety about discomfort. DIF: Cognitive Level: Apply (application) REF: 849 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 6. Which statement to the nurse from a patient with jaundice indicates a need for teaching? a. “I used cough syrup several times a day last week.” b. “I take a baby aspirin every day to prevent strokes.” c. “I use acetaminophen (Tylenol) every 4 hours for back pain.” d. “I need to take an antacid for indigestion several times a week” ANS: C Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patient’s jaundice. The other patient statements require further assessment by the nurse but do not indicate a need for patient education. DIF: Cognitive Level: Apply (application) REF: 840 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 7. To palpate the liver during a head-to-toe physical assessment, the nurse a. places one hand on the patient’s back and presses upward and inward with the other hand below the patient’s right costal margin. b. places one hand on top of the other and uses the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. c. presses slowly and firmly over the right costal margin with one hand and withdraws the fingers quickly after the liver edge is felt. d. places one hand under the patient’s lower ribs and presses the left lower rib cage forward, palpating below the costal margin with the other hand. ANS: A The liver is normally not palpable below the costal margin. The nurse needs to push inward below the right costal margin while lifting the patient’s back slightly with the left hand. The other methods will not allow palpation of the liver. DIF: Cognitive Level: Apply (application) REF: 844 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance