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Nursing Assessment:
168 Chapter 39 Nursing Assessment: Gastrointestinal System
2. Identify the structures in the following illustration using the terms listed below.
Terms
Ampulla of Vater Common bile duct Common hepatic duct Cystic duct
Duodenum Gallbladder Left hepatic duct Main pancreatic duct
Pancreas (body) Pancreas (head) Pancreas (tail) Right hepatic duct
a. ____________
b. ____________
c. ____________
d. ____________
e. ____________
f. ____________
g. ____________
h. ____________
i. ____________
j. ____________
k. ____________
l. ____________
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
3. A patient receives atropine, an anticholinergic drug, in preparation for surgery. The nurse expects this drug to affect the GI tract by doing what?
a. Increasing gastric emptying c. Decreasing secretions and peristaltic action b. Relaxing pyloric and ileocecal sphincters d. Stimulating the nervous system of the GI tract
4. After eating, a patient with an inflamed gallbladder experiences pain caused by contraction of the gallbladder. What is the mechanism responsible for this action?
a. Production of bile by the liver c. Release of gastrin from the stomach antrum b. Production of secretin by the duodenum d. Production of cholecystokinin by the duodenum 5. Priority Decision: When caring for a patient who has had most of the stomach surgically removed, what is important
for the nurse to teach the patient?
a. Extra iron will need to be taken to prevent anemia.
b. Avoid foods with lactose to prevent bloating and diarrhea.
c. Lifelong supplementation of cobalamin (vitamin B12) will be needed.
d. Because of the absence of digestive enzymes, protein malnutrition is likely.
Chapter 39 Nursing Assessment: Gastrointestinal System 169 6. A 68-year-old patient is in the office for a physical. She notes that she no longer has regular bowel movements.
Which suggestion by the nurse would be most helpful to the patient?
a. Take an additional laxative to stimulate defecation.
b. Eat less acidic foods to enable the gastrointestinal system to increase peristalsis.
c. Eat less food at each meal to prevent feces from backing up related to slowed peristalsis.
d. Attempt defecation after breakfast because gastrocolic reflexes increase colon peristalsis at that time.
7. Which digestive substances are active or activated in the stomach (select all that apply)?
a. Bile d. Maltase
b. Pepsin e. Secretin
c. Gastrin f. Amylase
8. What problem should the nurse assess the patient for if the patient was on prolonged antibiotic therapy?
a. Coagulation problems c. Impaired absorption of amino acids b. Elevated serum ammonia levels d. Increased mucus and bicarbonate secretion 9. How will an obstruction at the ampulla of Vater affect the digestion of all nutrients?
a. Bile is responsible for emulsification of all nutrients and vitamins.
b. Intestinal digestive enzymes are released through the ampulla of Vater.
c. Both bile and pancreatic enzymes enter the duodenum at the ampulla of Vater.
d. Gastric contents can only pass to the duodenum when the ampulla of Vater is open.
10. A patient experiences increased red blood cell (RBC) destruction from a mechanical heart valve prosthesis. Describe what happens to the bilirubin that is released from the breakdown of hemoglobin (Hgb) from the RBCs.
11. What is a clinical manifestation of age-related changes in the GI system that the nurse may find in an older patient?
a. Gastric hyperacidity c. Yellowish tinge to the skin
b. Intolerance to fatty foods d. Reflux of gastric contents into the esophagus
12. Identify one specific finding identified by the nurse during assessment of each of the patient’s functional health patterns that indicates a risk factor for GI problems or the response of the patient to a GI disorder.
Functional Health Pattern Risk Factor for or Response to GI Problem Health perception–health management
Nutritional-metabolic Elimination
Activity-exercise Sleep-rest
Cognitive-perceptual Self-perception–self-concept Role-relationship
Sexuality-reproductive Coping–stress tolerance Value-belief
13. What is a normal finding during physical assessment of the mouth?
a. A red, slick appearance of the tongue c. A thin, white coating of the dorsum of the tongue b. Uvular deviation to the side on saying “Ahh” d. Scattered red, smooth areas on the dorsum of the tongue 14. What is a normal finding on physical examination of the abdomen?
a. Auscultation of bruits c. Percussion of liver dullness in the left midclavicular line b. Observation of visible pulsations d. Palpation of the spleen 1 to 2 cm below the left costal margin
170 Chapter 39 Nursing Assessment: Gastrointestinal System
15. A patient is admitted to the hospital with left upper quadrant (LUQ) pain. What may be a possible source of the pain?
a. Liver c. Appendix
b. Pancreas d. Gallbladder
16. What characterizes auscultation of the abdomen?
a. The presence of borborygmi indicates hyperperistalsis.
b. The bell of the stethoscope is used to auscultate high-pitched sounds.
c. High-pitched, rushing, and tinkling bowel sounds are heard after eating.
d. Absence of bowel sounds for 1 minute in each quadrant is reported as abnormal.
17. Priority Decision: Following auscultation of the abdomen, what should the nurse’s next action be?
a. Lightly percuss over all four quadrants b. Have the patient empty his or her bladder
c. Inspect perianal and anal areas for color, masses, rashes, and scars d. Perform deep palpation to delineate abdominal organs and masses
18. Complete the table below by indicating with an X which preparations are required for each of the diagnostic procedures listed.
(1) NPO up to 8 or more hours
(2) Bowel emptying with laxatives, enemas, or both (3) Informed consent
(4) Allergy to iodine assessed
Procedure (1) NPO (2) Bowel (3) Consent (4) Allergy
Upper GI series Barium enema
Percutaneous transhepatic cholangiogram
Gallbladder ultrasound Hepatobiliary scintigraphy Upper GI endoscopy Colonoscopy
Endoscopic retrograde
cholangiopancreatography (ERCP)
19. A patient’s serum liver enzyme tests reveal an elevated aspartate aminotransferase (AST). The nurse recognizes what about the elevated AST?
a. It eliminates infection as a cause of liver damage.
b. It is diagnostic for liver inflammation and damage.
c. Tissue damage in organs other than the liver may be identified.
d. Nervous system symptoms related to hepatic encephalopathy may be the cause.
20. Which nursing actions are indicated for a liver biopsy (select all that apply)?
a. Observe for white stools d. Position to right side after test b. Monitor for rectal bleeding e. Ensure bowel preparation was done c. Monitor for internal bleeding f. Check coagulation status before test
21. Checking for the return of the gag reflex and monitoring for LUQ pain, nausea and vomiting are necessary nursing actions after which diagnostic procedure?
a. ERCP c. Barium swallow
b. Colonoscopy d. Esophagogastroduodenoscopy (EGD)
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40
1. A 30-year-old man’s diet consists of 3000 calories with 120 g of protein, 160 g of fat, and 270 g of carbohydrate. He weighs 176 lb and is 5 ft, 11 in tall.
a. In the table below, indicate what percentage of total calories each of the nutrients contributes to this man’s diet.
Nutrient Percentage of Total Calories from Nutrient Protein
Fat
Carbohydrates
b. How many calories would be recommended for him as an average adult?
c. Using MyPlate as a guide, what changes could the nurse suggest to bring the man’s diet more in line with nutrition recommendations?
2. Which statement accurately describes vitamin deficiencies?
a. The two nutrients most often lacking in the diet of a vegan are vitamin B6 and folic acid.
b. Vitamin imbalances occur frequently in the United States because of excessive fat intake.
c. Surgery on the GI tract may contribute to vitamin deficiencies because of impaired absorption.
d. Vitamin deficiencies in adults most commonly are clinically manifested by disorders of the skin.
3. What is the most common cause of secondary protein-calorie malnutrition in the United States?
a. The unavailability of foods high in protein b. A lack of knowledge about nutritional needs c. A lack of money to purchase high-protein foods
d. An alteration in ingestion, digestion, absorption, or metabolism
4. Describe the metabolism of nutrients used for energy during starvation within the given approximate time frames.
Time Frame Metabolism of Nutrients First 18 hours
18 hours to 5 to 9 days 9 days to 6 weeks Over 6 weeks
5. What may occur with failure of the sodium-potassium pump during severe protein depletion?
a. Ascites c. Hyperkalemia
b. Anemia d. Hypoalbuminemia
6. What contributes to increased protein-calorie needs?
a. Surgery c. Lowered temperature
b. Vegan diet d. Cultural or religious beliefs
7. During assessment of the patient with protein-calorie malnutrition, what should the nurse expect to find (select all that apply)?
a. Frequent cold symptoms d. A flat or concave abdomen
b. Decreased bowel sounds e. Prominent bony structures
c. Cool, rough, dry, scaly skin f. Decreased reflexes and lack of attention