question

When assessing a patient's abdomen, what would be most appropriate for the nurse to do? 1. Palpate the abdomen before auscultation. 2. Percuss the abdomen before auscultation. 3. Auscultate the abdomen before palpation. 4. Perform deep palpation before light palpation.

answer

3 During examination of the abdomen, auscultation is done before percussion and palpation because these latter procedures may alter the bowel sounds.

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When preparing a patient for a capsule endoscopy study, what should the nurse do? 1. Ensure the patient understands the required bowel preparation. 2. Have the patient return to the procedure room for removal of the capsule. 3. Teach the patient to maintain a clear liquid diet throughout the procedure. 4. Explain to the patient that conscious sedation will be used during placement of the capsule.

answer

1 A capsule endoscopy study involves the patient performing a bowel prep to cleanse the bowel before swallowing the capsule. The patient will be on a clear liquid diet for 1 to 2 days before the procedure and will remain NPO for 4 to 6 hours after swallowing the capsule. The capsule is disposable and will pass naturally with the bowel movement, although the monitoring device will need to be removed.

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Inspection of an older patient's mouth reveals the presence of white, curd-like lesions on the patient's tongue. What is the most likely etiology for this abnormal assessment finding? 1. Herpesvirus 2. Candida albicans 3. Vitamin deficiency 4. Irritation from ill-fitting dentures

answer

2 White, curd-like lesions surrounded by erythematous mucosa are associated with oral candidiasis. Herpesvirus causes benign vesicular lesions in the mouth. Vitamin deficiencies may cause a reddened, ulcerated, swollen tongue. Irritation from ill-fitting dentures will cause friable, edematous, painful, bleeding gingivae.

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The nurse should recognize that the liver performs which functions (select all that apply)? 1. Bile storage 2. Detoxification 3. Protein metabolism 4. Steroid metabolism 5. Red blood cell (RBC) destruction

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2, 3, 4 The liver performs multiple major functions that aid in the maintenance of homeostasis. These include metabolism of proteins and steroids as well as detoxification of drugs and metabolic waste products. The Kupffer cells of the liver participate in the breakdown of old RBCs. The liver produces bile, but storage occurs in the gall bladder.

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The health care team is assessing a male patient for acute pancreatitis after he presented to the emergency department with severe abdominal pain. Which laboratory value is the best diagnostic indicator of acute pancreatitis? 1. Gastric pH 2. Blood glucose 3. Serum amylase 4. Serum potassium

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3 Elevated serum amylase levels indicate early pancreatic dysfunction and are used to diagnose acute pancreatitis. Serum lipase levels stay elevated longer than serum amylase in acute pancreatitis. Blood glucose, gastric pH, and potassium levels are not direct indicators of acute pancreatic dysfunction.

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The nurse is performing a focused abdominal assessment of a patient who has been recently admitted. In order to palpate the patient's liver, where should the nurse palpate the patient's abdomen? 1. Left lower quadrant 2. Left upper quadrant 3. Right lower quadrant 4. Right upper quadrant

answer

4 Although the left lobe of the liver is located in the left upper quadrant of the abdomen, the bulk of the liver is located in the right upper quadrant.

question

The patient had a car accident and was "scared to death." The patient is now reporting constipation. What affecting the gastrointestinal (GI) tract does the nurse know could be contributing to the constipation? 1. The patient is too nervous to eat or drink, so there is no stool. 2. The sympathetic nervous system was activated, so the GI tract was slowed. 3. The parasympathetic nervous system is now functioning to slow the GI tract. 4. The circulation in the GI system has been increased, so less waste is removed.

answer

2 The constipation is most likely related to the sympathetic nervous system activation from the stress related to the accident. SNS activation can decrease peristalsis. Even without oral intake for a short time, stool will be formed. The parasympathetic system stimulates peristalsis. The circulation to the GI system is decreased with stress.

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A 90-year-old healthy man is suffering from dysphagia. The nurse explains what age-related change of the GI tract is the most likely cause of his difficulty? 1. Xerostomia 2. Esophageal cancer 3. Decreased taste buds 4. Thinner abdominal wall

answer

1 Xerostomia, decreased volume of saliva, leads to dry oral mucosa and dysphagia. Esophageal cancer is not an age-related change. Decreased taste buds and a thinner abdominal wall do not contribute to difficulty swallowing.

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A patient had a stomach resection for stomach cancer. The nurse should teach the patient about the loss of the hormone that stimulates gastric acid secretion and motility and maintains lower esophageal sphincter tone. Which hormone will be decreased with a gastric resection? 1. Gastrin 2. Secretin 3. Cholecystokinin 4. Gastric inhibitory peptide

answer

1 Gastrin is the hormone activated in the stomach (and duodenal mucosa) by stomach distention that stimulates gastric acid secretion and motility and maintains lower esophageal sphincter tone. Secretin inhibits gastric motility and acid secretion and stimulates pancreatic bicarbonate secretion. Cholecystokinin allows increased flow of bile into the duodenum and release of pancreatic digestive enzymes. Gastric inhibitory peptide inhibits gastric acid secretion and motility.

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The patient tells the nurse she had a history of abdominal pain, so she had a surgery to make an opening into the common bile duct to remove stones. The nurse knows that this surgery is called a 1. colectomy 2. cholecystectomy 3. choledocholithotomy 4. choledochojejunostomy

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3 A choledocholithotomy is an opening into the common bile duct for the removal of stones. A colectomy is the removal of the colon. The cholecystectomy is the removal of the gallbladder. The choledochojejunostomy is an opening between the common bile duct and the jejunum.

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The ED nurse has inspected, auscultated, and palpated the abdomen with no obvious abnormalities, except pain. When the nurse palpates the abdomen for rebound tenderness, there is severe pain. The nurse should know that this could indicate what problem? 1. Hepatic cirrhosis 2. Hypersplenomegaly 3. Gall bladder distention 4. Peritoneal inflammation

answer

4 When palpating for rebound tenderness, the problem area of the abdomen will produce pain and severe muscle spasm when there is peritoneal inflammation. Hepatic cirrhosis, hypersplenomegaly, and gall bladder distention do not manifest with rebound tenderness.

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A patient who is scheduled for surgery with general anesthesia in 1 hour is observed with a moist, but empty water glass in his hand. Which assessment finding may indicate that the patient drank a glass of water? 1. Flat abdomen without movement upon inspection 2. Tenderness at left upper quadrant upon palpation 3. Easily heard, loud gurgling in the right upper quadrant 4. High-pitched, hollow sounds in the left upper quadrant

answer

3 If the patient drank water on an empty stomach, gurgling can be assessed without a stethoscope or assessed with auscultation. High-pitched, hollow sounds are tympanic and indicate an empty cavity. A flat abdomen and tenderness do not indicate that the patient drank a glass of water.

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When caring for the patient with heart failure, the nurse knows that which gastrointestinal process is most dependent on cardiac output and may affect the patient's nutritional status? 1. Ingestion 2. Digestion 3. Absorption 4. Elimination

answer

3 Substances that interface with the absorptive surfaces of the GI tract (primarily in the small intestine) diffuse across the intestinal membranes into intestinal capillaries and are then carried to other parts of the body for use in energy production. The cardiac output provides the blood flow for this absorption of nutrients to occur.

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An 85-year-old woman seen in the primary care provider's office for a well check complains of difficulty swallowing. What common effect of aging should the nurse assess for as a possible cause? 1. Anosmia 2. Xerostomia 3. Hypochlorhydria 4. Salivary gland tumor

answer

2 Xerostomia (decreased saliva production), or dry mouth, affects many older adults and may be associated with difficulty swallowing (dysphagia). Anosmia is loss of sense of smell. Hypochlorhydria, a decrease in stomach acid, does not affect swallowing. Salivary gland tumors are not common.

question

The nurse is reviewing the home medication list for a 44-year-old man admitted with suspected hepatic failure. Which medication could cause hepatotoxicity? 1. Nitroglycerin 2. Digoxin (Lanoxin) 3. Ciprofloxacin (Cipro) 4. Acetaminophen (Tylenol)

answer

4 Many chemicals and drugs are potentially hepatotoxic (see Table 39-6) and result in significant patient harm unless monitored closely. For example, chronic high doses of acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) may be hepatotoxic.

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The nurse is assessing a 50-year-old woman admitted with a possible bowel obstruction. Which assessment finding would be expected in this patient? 1. Tympany to abdominal percussion 2. Aortic pulsation visible in epigastric region 3. High-pitched sounds on abdominal auscultation 4. Liver border palpable 1 cm below the right costal margin

answer

3 The bowel sounds are more high pitched (rushes and tinkling) when the intestines are under tension, as in intestinal obstruction. Bowel sounds may also be diminished or absent with an intestinal obstruction. Normal findings include aortic pulsations on inspection and tympany with percussion, and the liver may be palpable 1 to 2 cm along the right costal margin.

question

A 62-year-old woman patient is scheduled for a percutaneous transhepatic cholangiography to restore biliary drainage. The nurse discusses the patient's health history and is most concerned if the patient makes which statement? 1. "I am allergic to bee stings." 2. "My tongue swells when I eat shrimp." 3. "I have had epigastric pain for 2 months." 4. "I have a pacemaker because my heart rate was slow."

answer

2 The percutaneous transhepatic cholangiography procedure will include the use of radiopaque contrast medium. Patients allergic to shellfish and iodine are also allergic to contrast medium. Having a pacemaker will not affect the patient during this procedure. It would be expected that the patient would have some epigastric pain given the patient's condition.

question

A 35-year-old man with a family history of adenomatous polyposis had a colonoscopy with removal of multiple polyps. Which signs and symptoms should the nurse teach the patient to report immediately? 1. Fever and abdominal pain 2. Flatulence and liquid stool 3. Loudly audible bowel sounds 4. Sleepiness and abdominal cramps

answer

1 The patient should be taught to observe for signs of rectal bleeding and peritonitis. Fever, malaise, and abdominal pain and distention could indicate a perforated bowel with peritonitis.

question

Bilirubin

answer

the orange-yellow pigment of bile, formed principally by the breakdown of hemoglobin in red blood cells after termination of their normal lifespan

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borborygmi

answer

audible abdominal sound produced by hyperactive intestinal peristalsis

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cheilosis

answer

a disorder of the lips and mouth characterized by bilateral scales and fissures, resulting from a deficiency of riboflavin in the diet

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deglutition

answer

swallowing;the mechanical component of ingestion. Organs involved are the mouth, pharynx, and esophagus.

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endoscopy

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the direct visualization of a body structure through a lighted instrument (scope)

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hematemesis

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vomiting of blood that indicates bleeding in the upper gastrointestinal tract; may be bright red or of "coffee ground" character

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hepatocyte

answer

a parenchymal liver cell that performs all the functions ascribed to the liver

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Kupffer cells

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a type of macrophage found in the liver that removes bacteria and toxins from the blood

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melena

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black, tarry stools that indicate slow bleeding from an upper gastrointestinal source

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pyorrhea

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a discharge of purulent material

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pyrosis

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burning in epigastric or substernal area; heartburn

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steatorrhea

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greater than normal amounts of fat in the feces, characterized by frothy foul-smelling fecal matter that floats, as in celiac disease; some malabsorption syndromes; and any condition in which fats are poorly absorbed by the small intestine

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tenesmus

answer

spasmodic contraction of the anal sphincter with pain and persistent desire to empty the bowel

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Valsalva maneuver

answer

a maneuver that involves contraction of the chest muscles on a closed glottis with simultaneous contraction of the abdominal muscles; may be contraindicated in the patient with a head injury, eye surgery, cardiac problems, hemorrhoids, abdominal surgery, or liver cirrhosis with portal hypertension.

question

The gastrointestinal (GI) system (also called the digestive system)

answer

The mouth, esophagus, stomach, small intestine, large intestine, rectum, and anus. The associated organs are the liver, pancreas, and gallbladder

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The GI is composed of four layers

answer

(1) mucosa, (2) submucosa, (3) muscle, and (4) serosa

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The GI tract is innervated by the parasympathetic and sympathetic branches of the autonomic nervous system.

answer

The parasympathetic (cholinergic) system is mainly excitatory, and the sympathetic (adrenergic) system is mainly inhibitory. For example, peristalsis is increased by parasympathetic stimulation and decreased by sympathetic stimulation.

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The GI tract has its own nervous system: the enteric (or intrinsic) nervous system.

answer

composed of two nerve layers that lie between the mucosa and the muscle layers. These neurons have receptors for pressure and movement.

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IMA

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Inferior mesenteric artery

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IMA

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Supplies blood to the distal large intestine through the anus

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portal vein

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Supplies blood to the liver

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celiac artery, SMA, and IMA

answer

Supplies blood to the GI tract

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celiac axis

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Supplies blood to the stomach and duodenum

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SMA

answer

superior mesenteric artery

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branches of the hepatic and SMA

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Supplies blood to the small intestine to mid large intestine

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The two folds of the peritoneum are

answer

The mesentery attaches the small intestine and part of the large intestine to the posterior abdominal wall and contains blood and lymph vessels. The omentum hangs like an apron from the stomach to the intestines and contains fat and lymph nodes

question

two layers of the peritoneum

answer

the parietal layer, which lines the abdominal cavity wall, and the visceral layer, which covers the abdominal organs

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The main function of the GI system is

answer

to supply nutrients to body cells. This is accomplished through the processes of (1) ingestion (taking in food), (2) digestion (breaking down food), and (3) absorption (transferring food products into circulation)

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appetite

answer

stimulated by hypoglycemia, an empty stomach, decrease in body temperature, and input from higher brain centers. The sight, smell, and taste of food frequently stimulate appetite. Appetite may be inhibited by stomach distention, illness (especially accompanied by fever), hyperglycemia, nausea and vomiting, and certain drugs (e.g., amphetamines).

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Ghrelin

answer

released from the stomach mucosa plays a role in appetite stimulation.

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Leptin

answer

involved in appetite suppression

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salivary glands

answer

parotid, submaxillary, and sublingual glands. These glands produce saliva, which consists of water, protein, mucin, inorganic salts, and salivary amylase.

question

The Stomach

answer

functions are to store food, mix food with gastric secretions, and empty contents in small boluses into the small intestine; absorbs only small amounts of water, alcohol, electrolytes, and certain drugs; always contains gastric fluid and mucus; serves as a reservoir for food, which is slowly released into the small intestine. The length of time that food remains in the stomach depends on the composition of the food, but average meals remain from 3 to 4 hours.

question

upper esophageal sphincter (UES)

answer

at the proximal end of the esophagus

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lower esophageal sphincter (LES)

answer

remains contracted except during swallowing, belching, or vomiting; is an important barrier that normally prevents reflux of acidic gastric contents into the esophagus.

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chief cells, located in the funds of the stomach

answer

which secrete pepsinogen, and parietal cells, which secrete hydrochloric (HCl) acid, water, and intrinsic factor. The secretion of HCl acid makes gastric juice acidic. This acidic pH aids in the protection against ingested organisms. Intrinsic factor promotes cobalamin (vitamin B12) absorption in the small intestine.

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Small intestine

answer

two primary functions are digestion and absorption (uptake of nutrients from the gut lumen to the bloodstream). It extends from the pylorus to the ileocecal valve. Composed of the duodenum, jejunum, and ileum; carbohydrates are broken down to monosaccharides, fats to glycerol and fatty acids, and proteins to amino acids

question

The ileocecal valve

answer

prevents reflux of large intestine contents into the small intestine.

question

amylase (ptyalin)

answer

breaks down starches to maltose

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digestion of proteins

answer

begins in the stomach with the release of pepsinogen from chief cells

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chyme

answer

food mixed with gastric secretions; stimulate motility and secretion. Secretions involved in digestion include enzymes from the pancreas, bile from the liver and enzymes from the small intestine. Enzymes on the brush border of the microvilli complete the digestion process. These enzymes break down disaccharides to monosaccharides and peptides to amino acids for absorption.

question

Large intestin

answer

absorption of water and electrolytes; forms feces and serves as a reservoir for the fecal mass until defecation occurs

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Liver

answer

largest internal organ in the body; It lies in the right epigastric region; it essential for life; It functions in the manufacture, storage, transformation, and excretion of a number of substances involved in metabolism.

question

The biliary tract

answer

consists of the gallbladder and the duct system.

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The gallbladder

answer

It function is to concentrate and store bile. It holds approximately 45 mL of bile. Bile is produced by the hepatic cells

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stercobilinogen

answer

accounts for the brown color of stool.

question

Functions of the Liver

answer

Carbohydrate metabolism; Glycogenesis (conversion of glucose to glycogen), glycogenolysis (process of breaking down glycogen to glucose), gluconeogenesis (formation of glucose from amino acids and fatty acids). Protein metabolism: Synthesis of nonessential amino acids, synthesis of plasma proteins (except gamma globulin), synthesis of clotting factors, urea formation from ammonia (NH3) (NH3 formed from deamination of amino acids by action of bacteria in colon). Fat metabolism: Synthesis of lipoproteins, breakdown of triglycerides into fatty acids and glycerol, formation of ketone bodies, synthesis of fatty acids from amino acids and glucose, synthesis and breakdown of cholesterol. Detoxification: Inactivation of drugs and harmful substances and excretion of their breakdown products. Steroid metabolism; Conjugation and excretion of gonadal and adrenal corticosteroid hormones. Bile Synthesis Bile production; Formation of bile, containing bile salts, bile pigments (mainly bilirubin), and cholesterol. Bile excretion: Bile excretion by liver about 1 L/day. Storage: Glucose in form of glycogen. Vitamins, including fat soluble (A, D, E, K) and water soluble (B1, B2, cobalamin, folic acid). Fatty acids. Minerals (iron, copper). Amino acids in form of albumin and beta-globulins. Kupffer cells: Breakdown of old RBCs, WBCs, bacteria, and other particles. Breakdown of hemoglobin from old RBCs to bilirubin and biliverdin.

question

The pancreas

answer

behind the stomach and in front of the first and second lumbar vertebrae; exocrine and endocrine functions. The exocrine function contributes to digestion through the production and release of enzymes. The endocrine function occurs in the islets of Langerhans, whose β cells secrete insulin and amylin; α cells secrete glucagon; δ cells secrete somatostatin; and F cells secrete pancreatic polypeptide.

question

Causes of constipation in older adults

answer

slower peristalsis, inactivity, decreased dietary fiber, decreased fluid intake, constipating medications, and laxative abuse; neurologic, cognitive, and metabolic disorders may also play a role.

question

Drug effect on the GI

answer

chronic high doses of acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) may be hepatotoxic. NSAIDs (including aspirin) may also predispose a patient to upper GI bleeding, with an increasing risk as the person ages. Other medications such as antibiotics may change the normal bacterial composition in the GI tract, resulting in diarrhea. Antacids and laxatives may affect the absorption of certain medications.

question

Appendectomy

answer

Removal of appendix

question

Cholecystectomy

answer

Removal of gallbladder

question

Vagotomy

answer

Resection of branch of vagus nerve

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Pyloroplasty

answer

Enlargement and repair of pyloric sphincter area

question

Mandibulectomy

answer

Removal of mandible

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lleostomy

answer

Opening into ileum

question

Herniorrhaphy

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Removal of a hernia

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Hemiglossectomy

answer

Removal of half of tongue

question

Glossectomy

answer

Removal of tongue

question

Gastrostomy

answer

Opening into stomach

question

Gastrectomy

answer

Removal of stomach

question

Esophagogastrostomy

answer

Removal of esophagus and anastomosis of remaining portion to stomach

question

Esophagoenterostomy

answer

Removal of portion of esophagus with segment of colon attached to remaining portion

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Colostomy

answer

Opening into colon

question

Colectomy

answer

Removal of colon

question

Choledochojejunostomy

answer

Opening between common bile duct and jejunum

question

Choledocholithotomy

answer

Opening into common bile duct for removal of stones

question

Right Upper Quadrant

answer

• Liver and gallbladder • Pylorus • Duodenum • Head of pancreas • Right adrenal gland • Portion of right kidney • Hepatic flexure of colon • Portion of ascending and transverse colon

question

Left Upper Quadrant

answer

• Left lobe of liver • Spleen • Stomach • Body of pancreas • Left adrenal gland • Portion of left kidney • Splenic flexure of colon • Portion of transverse and descending colon

question

Right Lower Quadrant

answer

• Lower pole of right kidney • Cecum and appendix • Portion of ascending colon • Bladder (if distended) • Right ovary and salpinx • Uterus (if enlarged) • Right spermatic cord • Right ureter

question

Left Lower Quadrant

answer

• Lower pole of left kidney • Sigmoid flexure • Portion of descending colon • Bladder (if distended) • Left ovary and salpinx • Uterus (if enlarged) • Left spermatic cord • Left ureter

question

tympany

answer

Air produces a higher-pitched, hollow sound

question

dullness

answer

Fluid or masses produce a short, high-pitched sound with little resonance

question

peritoneal inflammation

answer

indicates rebound tenderness

question

Palpate liver

answer

Right upper quadrant

question

Palpate Spleen

answer

Left upper quadrant; if palpable, do not continue because manual compression of an enlarged spleen may cause it to rupture.

question

An upper GI series with small bowel follow-through

answer

provides visualization of the oropharyngeal area, the esophagus, the stomach, and the small intestine via fluoroscopy and x-ray examination. The procedure consists of the patient swallowing contrast medium and then assuming different positions on the x-ray table.

question

lower GI series (barium enema)

answer

observe by means of fluoroscopy the colon filling with contrast medium and to observe by x-ray the filled colon. This procedure identifies polyps, tumors, and other lesions in the colon. It consists of administering an enema of contrast medium to the patient.

question

Esophagogastroduodenoscopy (EGD)

answer

Directly visualizes mucosal lining of esophagus, stomach, and duodenum with flexible endoscope. Before procedure: Keep patient NPO for 8 hr. Make sure signed consent is on chart. Give preoperative medication if ordered. Explain to patient that local anesthesia may be sprayed on throat before insertion of scope and that patient will be sedated during the procedure. After procedure: Keep patient NPO until gag reflex returns. Gently tickle back of throat to determine reflex. Use warm saline gargles for relief of sore throat. Check temperature q15-30min for 1-2 hr (sudden temperature spike is sign of perforation).

question

Colonoscopy

answer

Directly visualizes entire colon up to ileocecal valve with flexible fiberoptic scope. Before procedure: Bowel preparation is done. After procedure: Patient may experience abdominal cramps caused by stimulation of peristalsis because the bowel is constantly inflated with air during procedure. Observe for rectal bleeding and manifestations of perforation (e.g., malaise, abdominal distention, tenesmus). Check vital signs.

question

Video capsule endoscopy (VCE)

answer

Patient swallows a capsule with camera , which provides endoscopic visualization of GI tract . Instruct patient to fast overnight. Patient may have bowel preparation similar to colonoscopy. The video capsule is swallowed, and clear liquids resumed after 2 hr and food and medications after 4 hr. Eight hours after swallowing the capsule, the patient returns to have the monitoring device removed. Peristalsis causes passage of the disposable capsule with a bowel movement.

question

1.A patient is admitted to the hospital with a diagnosis of diarrhea with dehydration. The nurse recognizes that increased peristalsis resulting in diarrhea can be related to a.sympathetic inhibition. b.mixing and propulsion. c.sympathetic stimulation. d.parasympathetic stimulation.

answer

D

question

2.A patient has an elevated blood level of indirect (unconjugated) bilirubin. One cause of this finding is that a.the gallbladder is unable to contract to release stored bile. b.bilirubin is not being conjugated and excreted into the bile by the liver. c.the Kupffer cells in the liver are unable to remove bilirubin from the blood. d.there is an obstruction in the biliary tract preventing flow of bile into the small intestine.

answer

B Bilirubin is a pigment derived from the breakdown of hemoglobin and is insoluble in water. Bilirubin is bound to albumin for transport to the liver and is referred to as unconjugated. An indirect bilirubin determination is a measurement of unconjugated bilirubin, and the level may be elevated in hepatocellular and hemolytic conditions.

question

3.As gastric contents move into the small intestine, the bowel is normally protected from the acidity of gastric contents by the a.inhibition of secretin release. b.release of bicarbonate by the pancreas. c. release of pancreatic digestive enzymes. d. release of gastrin by the duodenal mucosa.

answer

B The hormone secretin stimulates the pancreas to secrete fluid with a high concentration of bicarbonate. This alkaline secretion enters the duodenum and neutralizes acid in the chyme.

question

4. A patient is jaundiced and her stools are clay colored (gray). This is most likely related to a.decreased bile flow into the intestine. b.increased production of urobilinogen. c.increased production of cholecystokinin. d.increased bile and bilirubin in the blood.

answer

A Bile is produced by the hepatocytes and is stored and concentrated in the gallbladder. When bile is released from the common bile duct, it enters the duodenum. In the intestines, bilirubin is reduced to stercobilinogen and urobilinogen by bacterial action. Stercobilinogen accounts for the brown color of stool. Stools may be clay-colored if bile is not released from the common bile duct into the duodenum. Jaundice may result if the bilirubin level in the blood is elevated.

question

5. An 80-year-old man states that, although he adds a lot of salt to his food, it still does not have much taste. The nurse's response is based on the knowledge that the older adult a.should not experience changes in taste. b.has a loss of taste buds, especially for sweet and salt. c.has some loss of taste but no difficulty chewing food. d.loses the sense of taste because the ability to smell is decreased.

answer

B Older adults have decreased numbers of taste buds and a decreased sense of smell. These age-related changes diminish the sense of taste (especially of salty and sweet substances).

question

6. When the nurse is assessing the health perception-health maintenance pattern as related to GI function, an appropriate question to ask is a."What is your usual bowel elimination pattern?" b."What percentage of your income is spent on food?" c."Have you traveled to a foreign country in the last year?" d."Do you have diarrhea when you are under a lot of stress?"

answer

C When assessing gastrointestinal function in relation to the health perception-health management pattern, the nurse should ask the patient about recent foreign travel with possible exposure to hepatitis, parasitic infestation, or bacterial infection.

question

7. During an examination of the abdomen the nurse should a.position the patient in the supine position with the bed flat and knees straight. b.listen in the epigastrium and all four quadrants for 2 minutes for bowel sounds. c.use the following order of techniques: inspection, palpation, percussion, auscultation. d.describe bowel sounds as absent if no sound is heard in the lower right quadrant after 2 minutes.

answer

B The nurse should listen in the epigastrium and all four quadrants for bowel sounds for at least 2 minutes. The patient should be in the supine position and should slightly flex the knees; the head of the bed should be raised slightly. During examination of the abdomen, the nurse auscultates before performing percussion and palpation because the latter procedures may alter the bowel sounds. Bowel sounds cannot be described as absent until no sound is heard for 5 minutes in each quadrant.

question

8. A normal physical assessment finding of the GI system is/are (select all that apply) a.nonpalpable liver and spleen. b.borborygmi in upper right quadrant. c.tympany on percussion of the abdomen. d.liver edge 2 to 4 cm below the costal margin. e. finding of a firm, nodular edge on the rectal examination.

answer

A, C Normal assessment findings for the gastrointestinal system include a nonpalpable liver and spleen and generalized tympany on percussion. Normally, bowel sounds are high pitched and gurgling; loud gurgles indicate hyperperistalsis and are called borborygmi (stomach growling). If the patient has chronic obstructive pulmonary disease, large lungs, or a low-set diaphragm, the liver may be palpated 0.4 to 0.8 inch (1 to 2 cm) below the right costal margin. On palpation, the rectal wall should be soft and smooth and should have no nodules.

question

9. In preparing a patient for a colonoscopy, the nurse explains that a.a signed permit is not necessary. b.sedation may be used during the procedure. c.only one cleansing enema is necessary for preparation. d.a light meal should be eaten the day before the procedure.

answer

B Sedation is induced during a colonoscopy. A signed consent form is necessary for a colonoscopy. A cathartic or enema is administered the night before the procedure, and more than one enema may be necessary. Patients may need to be kept on clear liquids 1 to 2 days before the procedure.

Chapter 39 Nursing Assessment: Gastrointestinal System – Flashcards

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