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LEWIS GI TEST BANK

LEWIS 10

th

Chapter 38: Assessment of Gastrointestinal System

Lewis: Medical-Surgical Nursing, 10th Edition

MULTIPLE CHOICE

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

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

8. Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal

assessment?

a. Loud gurgles c. Absent bowel sounds

b. High-pitched gurgles d. Frequent clicking

sounds

ANS: C

Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient

should be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening, laxative use,

or a gastrostomy tube will not affect the results of the study.

DIF: Cognitive Level: Apply (application) REF: 848

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

11. The nurse is assessing an alert and independent 78-yr-old patient for malnutrition risk. Which is the

most appropriate initial question?

a. “How do you get to the store to buy your

food?”

b. “Can you tell me the food that you ate

yesterday?”

c. “Do you have any difficulty in preparing or

eating food?”

d. “Are you taking any medications that alter

your taste for food?”

ANS: B

This question is the most open-ended and will provide the best overall information about the

patient’s daily intake and risk for poor nutrition. The other questions may be asked, depending on

the patient’s response to the first question.

DIF: Cognitive Level: Analyze (analysis) REF: 841

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

12. A patient has just arrived in the recovery area after an upper endoscopy. Which information collected

by the nurse is most important to communicate to the health care provider?

a. The patient is very drowsy.

b. The patient reports a sore throat.

c. The oral temperature is 101.4°F.

d. The apical pulse is 100 beats/minute.

ANS: C

A temperature elevation may indicate that an acute perforation has occurred. The other assessment

data are normal immediately after the procedure.

DIF: Cognitive Level: Analyze (analysis) REF: 850

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

13. A 30-yr-old male patient with a body mass index (BMI) of 22 kg/m^2 is being admitted to the hospital

for elective knee surgery. Which assessment finding is important to report to the health care

provider?

a. Tympany on percussion of the abdomen

b. Liver edge 3 cm below the costal margin

c. Bowel sounds of 20/minute in each quadrant

d. Aortic pulsations visible in the epigastric area

ANS: B

Normally the lower border of the liver is not palpable below the ribs, so this finding suggests

hepatomegaly. The other findings are within normal range for the physical assessment.

DIF: Cognitive Level: Apply (application) REF: 847

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

14. A 58-yr-old patient has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD).

Which action by unlicensed assistive personnel (UAP) requires that the registered nurse (RN)

intervene?

a. Offering the patient a pitcher of water

b. Positioning the patient on the right side

c. Checking the vital signs every 30 minutes

d. Swabbing the patient’s mouth with a wet

cloth

ANS: A

DIF: Cognitive Level: Apply (application) REF: 841

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

17. Which area of the abdomen shown in the accompanying figure will the nurse palpate to assess for

splenomegaly?

a. 1

b. 2

c. 3

d. 4

ANS: B

The spleen is usually not palpable, but when palpated, it is located in left upper quadrant of

abdomen.

Chapter 42: Lower Gastrointestinal Problems Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1.Which action will the nurse include in the plan of care for a patient who is being admitted with Clostridium difficile? a. Teach the patient about proper food storage. b. Order a diet without dairy products for the patient. c. Place the patient in a private room on contact isolation. d. Teach the patient about why antibiotics will not be used. ANS: C

Because C. difficile is highly contagious, the patient should be placed in a private room, and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile infections. Improper food handling and storage do not cause C. difficile. DIF: Cognitive Level: Apply (application) REF: 932 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 2.A 74-yr-old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first? a. Encourage the patient to increase oral fluid intake. b. Question the patient about risk factors for constipation. c. Suggest that the patient increase intake of high-fiber foods. d. Teach the patient that a daily bowel movement is unnecessary. ANS: B The nurse’s initial action should be further assessment of the patient for risk factors for constipation and for his usual bowel pattern. The other actions may be appropriate but will be based on the assessment. DIF: Cognitive Level: Analyze (analysis) REF: 933 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3.A patient who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? a. Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives. b. Dietary sources of fiber should be eliminated to prevent excessive gas formation. c. Use of this type of laxative to prevent constipation does not cause adverse effects. d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction. ANS: D A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat- soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives.

6.A 58-yr-old patient with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient’s oral temperature. d. Obtain information about the accident. ANS: B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery. DIF: Cognitive Level: Analyze (analysis) REF: 941 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 7.A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? a. Assist the patient to cough and deep breathe. b. Palpate the abdomen for rebound tenderness. c. Suggest the patient lie on the side, flexing the right leg. d. Encourage the patient to sip clear, noncarbonated liquids. ANS: C The patient’s clinical manifestations are consistent with appendicitis. Lying still with the right leg flexed is often the most comfortable position. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time. DIF: Cognitive Level: Apply (application) REF: 942 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8.Which nursing action will be included in the plan of care for a 25-yr-old male patient with a new diagnosis of irritable bowel syndrome (IBS)?

a. Encourage the patient to express concerns and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs). d. Teach the patient about the use of alosetron (Lotronex) to reduce IBS symptoms. ANS: A Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS. DIF: Cognitive Level: Apply (application) REF: 940 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 9.A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to a. administer IV metoclopramide (Reglan). b. discontinue the patient’s oral food intake. c. administer cobalamin (vitamin B 12 ) injections. d. teach the patient about total colectomy surgery. ANS: B An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B 12 ) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate. DIF: Cognitive Level: Apply (application) REF: 946 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 10.Which nursing action will the nurse include in the plan of care for a 35-yr-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. c. Ambulate six times daily. b. Monitor stools for blood. d. Increase dietary fiber intake.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 13.Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs c. Oatmeal with cream b. White toast and jam d. Pancakes with syrup ANS: C During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient. DIF: Cognitive Level: Apply (application) REF: 949 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 14.After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, “I cannot manage all these changes. I don’t want to look at the stoma.” What is the best action by the nurse? a. Reassure the patient that ileostomy care will become easier. b. Ask the patient about the concerns with stoma management. c. Postpone any teaching until the patient adjusts to the ileostomy. d. Develop a detailed written list of ostomy care tasks for the patient. ANS: B Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patient’s feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patient’s ability to manage the ostomy. Although detailed ostomy teaching may be postponed, the nurse should offer teaching about some aspects of living with an ostomy. DIF: Cognitive Level: Analyze (analysis) REF: 959 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 15.A patient has a new diagnosis of Crohn’s disease after having frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months. The nurse will plan to teach about a. medication use. c. enteral nutrition.

b. fluid restriction. d. activity restrictions. ANS: A Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings. DIF: Cognitive Level: Apply (application) REF: 947 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 16.A young woman who has Crohn’s disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? a. Bacteria in the perianal area can enter the urethra. b. Fistulas can form between the bowel and bladder. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse. ANS: B Fistulas between the bowel and bladder occur in Crohn’s disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse. DIF: Cognitive Level: Apply (application) REF: 963 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17.A patient with diverticulosis has a large bowel obstruction. The nurse will monitor for a. referred back pain. c. projectile vomiting. b. metabolic alkalosis. d. abdominal distention. ANS: D Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction.

a. identify any metastasis of the cancer. b. monitor the tumor status after surgery. c. confirm the diagnosis of a specific type of cancer. d. determine the need for postoperative chemotherapy. ANS: B CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help to determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA. DIF: Cognitive Level: Understand (comprehension) REF: 955 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 21.A 71-yr-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the perineal drainage and incision. d. Encourage acceptance of the colostomy stoma. ANS: C Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period. DIF: Cognitive Level: Analyze (analysis) REF: 956 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 22.A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should a. place ice packs around the stoma. b. notify the surgeon about the stoma. c. monitor the stoma every 30 minutes. d. document stoma assessment findings.

ANS: D

The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed. DIF: Cognitive Level: Apply (application) REF: 960 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 23.Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin. ANS: B High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible. DIF: Cognitive Level: Apply (application) REF: 962 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 24.A patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups daily. a. 2 c. 4 b. 3 d. 5 ANS: A After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. One cup is about 240 mL.