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Chapter 39: Nursing Assessment: Gastrointestinal System

Test Bank

MULTIPLE CHOICE

1. Which information about an 80-year-old man at the senior center is of most concern to the
nurse?
a. Decreased appetite
b. Unintended weight loss
c. Difficulty chewing food
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: Apply (application) REF: 871


OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

2. A 62- year-old man 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: 869


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: 867-868


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 levels.
d. increased serum indirect bilirubin levels.
ANS: B
A common bile duct obstruction will reduce the absorption of fat in the small intestine,
leading to fatty stools. Gastrointestinal (GI) 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: 878


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

5. The nurse receives the following information about a 51-year-old woman 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 shellfish and iodine in the past.
d. The patient refused to drink the ordered 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 (MRI), but not to colonoscopy. The nurse should instruct the patient about the
sedation used during the examination to decrease the patients anxiety about discomfort.

DIF: Cognitive Level: Apply (application) REF: 881


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
patients 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: 872


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 patients back and presses upward and inward with the
other hand below the patients 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 patients 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 patients back slightly with the left hand. The
other methods will not allow palpation of the liver.

DIF: Cognitive Level: Apply (application) REF: 876


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
b. High-pitched gurgles
c. Absent bowel sounds
d. Frequent clicking sounds
ANS: C
Absent bowel sounds are abnormal and require further assessment by the nurse. The other
sounds may be heard normally.

DIF: Cognitive Level: Apply (application) REF: 875


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

9. After assisting with a needle biopsy of the liver at a patients bedside, the nurse should
a. put pressure on the biopsy site using a sandbag.
b. elevate the head of the bed to facilitate breathing.
c. place the patient on the right side with the bed flat.
d. check the patients postbiopsy coagulation studies.
ANS: C
After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site.
Coagulation studies are checked before the biopsy. A sandbag does not exert adequate
pressure to splint the site.

DIF: Cognitive Level: Apply (application) REF: 882


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

10. A 42-year-old woman is admitted to the outpatient testing area for an ultrasound of the
gallbladder. Which information obtained by the nurse indicates that the ultrasound may need
to be rescheduled?
a. The patient took a laxative the previous evening.
b. The patient had a high-fat meal the previous evening.
c. The patient has a permanent gastrostomy tube in place.
d. The patient ate a low-fat bagel 4 hours ago for breakfast.
ANS: D
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: 880


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

11. The nurse is assessing an alert and independent 78-year-old woman for malnutrition risk. The
most appropriate initial question is which of the following?
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
patients daily intake and risk for poor nutrition. The other questions may be asked, depending
on the patients response to the first question.

DIF: Cognitive Level: Apply (application) REF: 873


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

12. A 54-year-old man 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 101.6 F.
d. The apical pulse is 104 beats/minute.
ANS: C
A temperature elevation may indicate that a perforation has occurred. The other assessment
data are normal immediately after the procedure.

DIF: Cognitive Level: Apply (application) REF: 881


OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

13. A 30-year-old man is being admitted to the hospital for elective knee surgery. Which
assessment finding is most 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: 878


OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
14. A 58-year-old woman 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 drink of water
b. Positioning the patient on the right side
c. Checking the vital signs every 30 minutes
d. Swabbing the patients mouth with cold water
ANS: A
Immediately after EGD, the patient will have a decreased gag reflex and is at risk for
aspiration. Assessment for return of the gag reflex should be done by the RN. The other
actions by the UAP are appropriate.

DIF: Cognitive Level: Apply (application) REF: 15-16


OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment

15. A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as


soon as possible. Which actions from the agency policy for ERCP should the nurse take first?
a. Place the patient on NPO status.
b. Administer sedative medications.
c. Ensure the consent form is signed.
d. Teach the patient about the procedure.
ANS: A
The patient will need to be NPO for 8 hours before the ERCP is done, so the nurses initial
action should be to place the patient on NPO status. The other actions can be done after the
patient is NPO.

DIF: Cognitive Level: Apply (application) REF: 881


OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity

16. While interviewing a 30-year-old man, the nurse learns that the patient has a family history of
familial adenomatous polyposis (FAP). The nurse will plan to assess the patients knowledge
about
a. preventing noninfectious hepatitis.
b. treating inflammatory bowel disease.
c. risk for developing colorectal cancer.
d. using antacids and proton pump inhibitors.
ANS: C
Familial adenomatous polyposis is a genetic condition that greatly increases the risk for
colorectal cancer. Noninfectious hepatitis, use of medications that treat increased gastric pH,
and inflammatory bowel disease are not related to FAP.

DIF: Cognitive Level: Apply (application) REF: 872


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.

DIF: Cognitive Level: Understand (comprehension) REF: 875


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

OTHER

1. In the video, the examiner is

Click here to view the video clip


a. percussing for liver size.
b. percussing for splenomegaly.
c. palpating for abdominal distention.
d. palpating for abdominal tenderness.

ANS:
A
The video demonstrates percussion of the right anterior chest and right abdomen to determine
liver height.

DIF: Cognitive Level: Understand (comprehension) REF: 875-876


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