Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more
Download
Standard view
Full view
of .
Look up keyword
Like this
26Activity
0 of .
Results for:
No results containing your search query
P. 1
Silvestri Chapter 46 Ed#56A

Silvestri Chapter 46 Ed#56A

Ratings:

5.0

(2)
|Views: 7,147|Likes:
Published by Linda Kuglarz

More info:

Published by: Linda Kuglarz on Oct 14, 2008
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as RTF, PDF, TXT or read online from Scribd
See more
See less

02/02/2015

pdf

text

original

 
Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 046 (edited file)—"Gastrointestinal System"10/14/08, Page 1 of 31, 0 Figure(s), 0 Table(s), 12 Box(es)
46: Gastrointestinal System
PRACTICE QUESTIONS
1. A client presents to the emergency department with upper gastrointestinal (GI) bleeding and isin moderate distress. Which nursing action would be the priority for this client?1. Thorough investigation of the precipitating events2. Insertion of a nasogastric tube and Hematest the emesis3. Complete abdominal physical examination4. Determination of vital signsAnswer: 4Rationale: The determination of vital signs indicates whether the client is in shock from bloodloss and also provides a baseline blood pressure and pulse by which to monitor the progress of treatment. Signs and symptoms of shock include low blood pressure; rapid, weak pulse;increased thirst; cold, clammy skin; and restlessness. Vital signs should be monitored every 15to 30 minutes, and the physician should be informed of any significant changes. The client maynot be able to provide subjective data until the immediate physical needs are met. Althoughoptions 2 and 3 may be a component of care, they are not the priority.Test-Taking Strategy: Note the word,
 priority
, and use the ABCs—airway, breathing, andcirculation. A client with an acute upper GI bleed is at risk for shock. Monitoring vital signs isthe nursing action that will assess circulation, provide information about the client’s circulatingvolume status, and alert the nurse to early stages of shock. Review care of the client
 
with a GI bleed if you had difficulty with this question.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Adult Health/GastrointestinalReferences: Christensen, B., & Kockrow, E. (2003).
 Adult health nursing 
(4th ed).
 
St. Louis:Mosby, p. 192.Linton, A., & Maebius, N. (2003).
 Introduction to medical-surgical nursing 
(3rd ed.).Philadelphia: W.B. Saunders, p. 688.2. A nurse is caring for a client with possible cholelithiasis who is being prepared for acholangiogram and provides instructions to the client about the procedure. Which clientstatement indicates that the client understands the purpose of this test?1. “They are going to look at my gallbladder and ducts.”2. “This procedure will drain my gallbladder.”3. “My gallbladder will be irrigated.”4. “They will put medication in my gallbladder.”Answer: 1Rationale: A cholangiogram is for diagnostic purposes. It outlines both the gallbladder and theducts, so gallstones that have moved into the ductal system can be detected. X-rays are used tovisualize the biliary duct system after an IV injection of radiopaque dye. Options 2, 3, and 4 areincorrect.Test-Taking Strategy: Use the process of elimination. Eliminate options 2, 3 and 4 because they
 
Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 046 (edited file)—"Gastrointestinal System"10/14/08, Page 2 of 31, 0 Figure(s), 0 Table(s), 12 Box(es)
are similar. Review this procedure if you had difficulty with this question.Level of Cognitive Ability: ComprehensionClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/EvaluationContent Area: Adult Health/GastrointestinalReferences: Linton, A., & Maebius, N. (2003).
 Introduction to medical-surgical nursing 
(3rded.). Philadelphia: W.B. Saunders, p. 718.Thompson, J., McFarland, G., Hirsch, J., & Tucker, S. (2002).
Mosby’s clinical nursing 
(5thed.). St. Louis: Mosby, pp. 1378-1379.3. A nurse is caring for a client with acute pancreatitis and a history of alcoholism and ismonitoring the client for complications. Which of the following data would be a sign of  paralytic ileus?1. Firm, nontender mass palpable at the lower right costal margin2. Severe, constant pain with rapid onset3. Inability to pass flatus4. Loss of anal sphincter controlAnswer: 3Rationale: An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, themost common form of nonmechanical obstruction. Inability to pass flatus is a clinicalmanifestation of paralytic ileus. Option 1 is the description of the physical finding of liver enlargement. The liver is usually enlarged in cases of cirrhosis or hepatitis. Although this clientmay have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinalobstruction. Pain is associated with paralytic ileus, but the pain usually presents as a moreconstant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likelycaused by strangulation of the bowel. Loss of sphincter control is not a sign of paralytic ileus.Test-Taking Strategy: Use the process of elimination. Note the relationship between the words“paralytic ileus” and option 3. Review these clinical manifestations if you had difficulty withthis question.Level of Cognitive Ability: ComprehensionClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Adult Health/GastrointestinalReference: Linton, A., & Maebius, N. (2003).
 Introduction to medical-surgical nursing 
(3rded.). Philadelphia: W.B. Saunders, p. 223.4. A nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tubein place. The client has tolerated the tube being clamped every 2 hours for 1 hour and the physician has now ordered the nasogastric tube to be discontinued. To determine the client’sreadiness for discontinuation of the nasogastric tube, the nurse should check for:1. Proper nasogastric tube placement2. The client’s serum electrolyte levels3. Presence of bowel sounds in all four quadrants4. The pH of the gastric aspirateAnswer: 3Rationale: Distention, vomiting, and abdominal pain are a few of the symptoms associated with
 
Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 046 (edited file)—"Gastrointestinal System"10/14/08, Page 3 of 31, 0 Figure(s), 0 Table(s), 12 Box(es)
intestinal obstruction and a nasogastric tube may be used to empty the stomach and relievedistention and vomiting. Bowel sounds return to normal as the obstruction is relieved andnormal bowel function is restored. Discontinuing the nasogastric tube before normal bowelfunction returns may result in a return of the symptoms necessitating reinsertion of thenasogastric tube. Serum electrolyte levels, tube placement, and pH of gastric aspirate areimportant assessments for the client with a nasogastric tube in place, but would not assist indetermining the readiness for removing the nasogastric tube.Test-Taking Strategy: Use the process of elimination and focus on the issue, removing thenasogastric tube. Recalling the pathophysiology for intestinal obstruction and purpose of anasogastric tube as a therapy will direct you to option 3. Review care of the client
 
with anintestinal obstruction if you had difficulty with this question.Level of Cognitive Ability: ComprehensionClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Adult Health/GastrointestinalReferences: Linton, A., & Maebius, N. (2003).
 Introduction to medical-surgical nursing 
(3rded.). Philadelphia: W.B. Saunders, pp. 660, 662.Potter, P., & Perry, A. (2005).
 Fundamentals of nursing 
(6th ed.). St. Louis: Mosby, pp.762,1183.5. A sexually active 20-year-old client has developed viral hepatitis. Which of the followingstatements if made by the client would indicate a need for teaching?1. “A condom should be used for sexual intercourse.”2. “I can never drink alcohol again.”3. “I won’t go back to work right away.”4. “My close friends should get the vaccine.”Answer:
 
2Rationale:
 
To prevent transmission of hepatitis, a condom is advised during sexual intercourse aswell as vaccination of the partner or close friends. Alcohol should be avoided for 1 year, becauseit is detoxified in the liver and may interfere with recovery. Rest is especially important untillaboratory studies show that the liver function has returned to normal. The client’s activity isincreased gradually.Test-Taking Strategy: Use the process of elimination and note the key words,
need for teaching 
.These words indicate a false response question and that you need to select the incorrect clientstatement. Recalling the pathophysiology related to hepatitis and the key word
never 
in option 2will direct you to this option. Review client instructions regarding hepatitis if you had difficultywith this question.Level of Cognitive Ability: ComprehensionClient Needs: Safe, Effective Care EnvironmentIntegrated Process: Nursing Process/EvaluationContent Area: Adult Health/GastrointestinalReference: Linton, A., & Maebius, N. (2003).
 Introduction to medical-surgical nursing 
(3rded.). Philadelphia: W.B. Saunders, p. 731.6. A client is admitted to the hospital with severe jaundice and is having diagnostic testing.Because the client has no complaints of fatigue, the client is encouraged to ambulate in the hall

Activity (26)

You've already reviewed this. Edit your review.
arudolph48 liked this
bwoodard22 liked this
ambinioni liked this
1 thousand reads
1 hundred reads
Zachari Jules liked this
dgressak liked this
Ty Gingrich liked this
Manol Manal liked this

You're Reading a Free Preview

Download
scribd
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->