Exam (elaborations)
test bank bundle
- Course
- Health Sciences
- Institution
- AQE Private College, Pretoria, Gauteng
Exam of 185 pages for the course Health Sciences at AQE Private College, Pretoria, Gauteng (bundle test bank)
[Show more]
Seller
Follow
Content preview
abirb.com/testChapter 38: Assessment: Gastrointestinal System
abirb.com/test
Harding: Lewis’s Medical-Surgical Nursing, 11th Edition
MULTIPLE CHOICE abirb.com/test
1. Which information about an 80-yr-old male patient at the senior center is of most concern to
the nurse?
a. Decreased appetite abirb.com/test
b. Occasional indigestion
c. Unintended weight loss
d. Difficulty chewing food
abirb.com/test
ANS: C
Unintentional weight loss is not a normal finding and may indicate a problem such as cancer
or depression. Poor appetite, difficulty in chewing, and indigestion are common in older
abirb.com/test
patients. These will need to be addressed but are not of as much concern as the weight loss.
DIF: Cognitive Level: Analyze (analysis)
abirb.com/test
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
2. An older patient reports chronic constipation. To promote bowel evacuation, when should the
abirb.com/test
nurse suggest that the patient attempt defecation?
a. In the mid-afternoon
b. After eating breakfast
c. Right after awakening in the morning
abirb.com/test
d. Immediately before the first daily meal
ANS: B
The gastrocolic reflex is most active after the first daily meal. Awakening, the anticipation of
abirb.com/test
eating, and mid-afternoon timing do not stimulate these reflexes.
DIF: Cognitive Level: Apply (application)
abirb.com/test
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
3. What condition should the nurse anticipate when caring for a patient with a history of a total
gastrectomy?
a. Constipation
abirb.com/test
b. Dehydration
c. Elevated total serum cholesterol
d. abirb.com/test
Cobalamin (vitamin B12) deficiency
ANS: D
The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for
abirb.com/test
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.
abirb.com/test
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
abirb.com/test
abirb.com/test
abirb.com/test
, abirb.com/test
4. The nurse is caring for a patient with an obstructed common bile duct. What condition should
the nurse expect? abirb.com/test
a. Melena
b. Steatorrhea
c. Decreased serum cholesterol level
abirb.com/test
d. Increased serum indirect bilirubin level
ANS: B
A common bile duct obstruction will reduce the absorption of fat in the small intestine,
abirb.com/test
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.
abirb.com/test
DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
abirb.com/test
5. The nurse receives the following information about a 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 declined to drink the prescribed laxative solution.
abirb.com/test
b. The patient has had an allergic reaction to shellfish and iodine.
c. The patient has a permanent pacemaker to prevent bradycardia.
d. The patient is worried about discomfort during the examination.
abirb.com/test
ANS: A
If the patient has had inadequate bowel preparation, the colon cannot be visualized and the
procedure would be rescheduled. Because contrast solution is not used during colonoscopy,
abirb.com/test
the iodine allergy is not pertinent. Apacem
akerisacontraindication 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.
abirb.com/test
DIF: Cognitive Level: Apply (application)
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?
abirb.com/test
a. “I used cough syrup several times a day last week.”
b. “I take a baby aspirin every day to prevent strokes.”
c. “I take an antacid for indigestion several times a week”
abirb.com/test
d. “I use acetaminophen (Tylenol) every 4 hours for pain.”
ANS: D
Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the
abirb.com/test
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)
abirb.com/test
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
7. Which is the correct technique for the nurse to palpate the liver during a head-to-toe physical
assessment? abirb.com/test
a. Place one hand on top of the other and use the upper fingers to apply pressure and
the bottom fingers to feel for the liver edge.
abirb.com/test
abirb.com/test
abirb.com/test
, abirb.com/test
b. Place one hand on the patient’s back and press upward and inward with the other
abirb.com/test
hand below the patient’s right costal margin.
c. Press slowly and firmly over the right costal margin with one hand and withdraw
the fingers quickly after the liver edge is felt.
d. Place one hand under the patient’s lower ribs and press the left lower rib cage
abirb.com/test
forward, palpating below the costal margin with the other hand.
ANS: B
The liver is normally not palpable below the costal margin. The nurse needs to push inward
abirb.com/test
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.
abirb.com/test
DIF: Cognitive Level: Understand (comprehension)
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? abirb.com/test
a. Loud gurgles
b. High-pitched gurgles
c. Absent bowel sounds abirb.com/test
d. Frequent clicking sounds
ANS: C
abirb.com/test
Absent bowel sounds are abnormal and require further assessment by the nurse. The other
sounds may be heard normally.
DIF: Cognitive Level: Apply (application)
abirb.com/test
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
9. What action should the nurse take after assisting with a needle biopsy of the liver at a patient’s
bedside? abirb.com/test
a. Elevate the head of the bed to facilitate breathing.
b. Place the patient on the right side with the bed flat.
c. Check the patient’s postbiopsy coagulation studies.
d. abirb.com/test
Position a sandbag over the liver to provide pressure.
ANS: B
After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site.
abirb.com/test
Coagulation studies are checked before the biopsy. A sandbag does not exert adequate
pressure to splint the site.
DIF: Cognitive Level: Apply (application)
abirb.com/test
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
10. A patient 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?
abirb.com/test
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. abirb.com/test
The patient ate a low-fat bagel 4 hours ago for breakfast.
ANS: D
abirb.com/test
abirb.com/test
abirb.com/test
, abirb.com/test
Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient
abirb.com/test
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)
abirb.com/test
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
11. The nurse is assessing an alert and independent older adult patient for malnutrition risk.
Which is the most appropriate initial question?
abirb.com/test
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. abirb.com/test
“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
abirb.com/test
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)
abirb.com/test
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
abirb.com/test
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.
abirb.com/test
d. The apical pulse is 100 beats/min.
ANS: C
A temperature elevation may indicate that an acute perforation has occurred. The other
abirb.com/test
assessment data are normal immediately after the procedure.
DIF: Cognitive Level: Analyze (analysis)
abirb.com/test
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
13. An adult with a body mass index (BMI) of 22 kg/m2 is being admitted to the hospital for
abirb.com/test
elective knee surgery. Which assessment finding should the nurse report to the health care
provider?
a. Tympany on percussion of the abdomen
b. Liver edge 3 cm below the costal margin
abirb.com/test
c. Bowel sounds of 20/min in each quadrant
d. Aortic pulsations visible in the epigastric area
ANS: B abirb.com/test
Normally the lower border of the liver is not palpable below the ribs, so this finding suggests
hepatomegaly. Visible aortic pulsations in the epigastrium, active bowel sounds, and
abdominal tympany are within normal findings for an adult of normal weight.
abirb.com/test
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
abirb.com/test
abirb.com/test
abirb.com/test
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through EFT, credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying this summary from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller beem. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy this summary for R193,00. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
81849 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy summaries for 14 years now