Chapter 20 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 20

Question 1

Type: MCSA

A patient is diagnosed with esophageal reflux. The nurse explains to the patient that there is an impairment in which structure?

1. Fundus

2. Duct of Wirsung

3. Cardiac sphincter

4. Antrum

Correct Answer: 3

Rationale 1: The fundus is part of the stomach and is not involved in esophageal reflux.

Rationale 2: The Duct of Wirsung is the main pancreatic duct and is not involved in esophageal reflux.

Rationale 3: The lower esophageal sphincter, also known as the cardiac sphincter, has high resting muscle tone at the distal end, which prevents gastroesophageal reflux. The patient diagnosed with esophageal reflux would have an impairment of this sphincter.

Rationale 4: The antrum is part of the stomach and is not involved in esophageal reflux.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-1

Question 2

Type: MCSA

A patient is diagnosed with a gastric ulcer located on the antrum. The nurse is aware that the ulcer may also affect the function of which adjacent structure?

1. Sphincter of Oddi

2. Acinus

3. Pyloric sphincter

4. Lower esophageal sphincter

Correct Answer: 3

Rationale 1: The Sphincter of Oddi is located in the pancreas and is not anatomically close to the antrum.

Rationale 2: The acinus is the functional unit of the pancreas and is not anatomically close to the antrum.

Rationale 3: The antrum is located at the base of the stomach, ending at the pyloric sphincter. Depending upon the extent of the ulcer, the function of the pyloric sphincter may be affected.

Rationale 4: The lower esophageal sphincter is located at the gastroesophageal juncture and is not the structure closest to the antrum.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1

Question 3

Type: MCMA

A patient has been diagnosed with deficiency of the hormone cholecystokinin (CCK). The nurse would expect this patient to have difficulty digesting which nutrients?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Fats

2. Proteins

3. Carbohydrates

4. Vitamins

5. Minerals

Correct Answer: 1,2

Rationale 1: CCK is secreted in response to the presence of fat in the duodenum.

Rationale 2: CCK is secreted in response to the presence of protein in the duodenum.

Rationale 3: Gastric inhibitory peptide (GIP) is secreted in response to the presence of carbohydrates.

Rationale 4: Vitamins are not digested, but are absorbed from or synthesized by the GI tract.

Rationale 5: Minerals are not digested, but are absorbed from the GI tract.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-4

Question 4

Type: MCSA

A patient is demonstrating hepatic encephalopathy due to buildup of ammonia. The nurse anticipates intervention to support which function of the liver?

1. Protein metabolism

2. Vitamin synthesis

3. Fat metabolism

4. Carbohydrate metabolism

Correct Answer: 1

Rationale 1: The liver is responsible for synthesis of the majority of the bodys proteins and for degrading amino acids for energy use through the process of deamination. The major by-product of deamination is ammonia, which is toxic to tissues. The liver is responsible for converting ammonia into urea, a nontoxic substance. Urea diffuses from the liver into the circulation for urinary excretion. When liver failure occurs, ammonia cannot be converted to urea and levels rapidly build in the blood.

Rationale 2: If the liver is not synthesizing vitamins, the patient would demonstrate findings related to vitamin A, D, E, and K deficiency.

Rationale 3: Fat metabolism is not related to the development of hepatic encephalopathy or a buildup of ammonia.

Rationale 4: Alterations in ability to metabolize carbohydrates would not result in hepatic encephalopathy, but rather in changes such as serum glucose levels.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-3

Question 5

Type: MCSA

A patient is diagnosed with duodenal ulcers caused by a highly acidic gastrointestinal environment. The nurse explains that this condition may be related to deficiency in which hormone?

1. Secretin

2. Lipase

3. Elastase

4. Amylase

Correct Answer: 1

Rationale 1: The release of secretin is stimulated by a drop in the intestinal mucosa pH to less than 4.5. When intestinal pH becomes too acidic, secretin stimulates the pancreas to secrete large quantities of bicarbonate and water. Bicarbonate raises the intestinal pH, which protects the mucosa.

Rationale 2: Lipase is a pancreatic enzyme that helps break down fats.

Rationale 3: Elastase is a pancreatic enzyme that helps to break down proteins.

Rationale 4: Amylase is a pancreatic enzyme that splits glycogen into disaccharides.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-2

Question 6

Type: MCMA

A patient is diagnosed with a splenic artery aneurysm. The nurse would assess for dysfunction in which organs?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Gallbladder

2. Stomach

3. Pancreas

4. Transverse colon

5. Spleen

Correct Answer: 2,3,5

Rationale 1: The gallbladder is supplied by the cystic artery.

Rationale 2: The splenic artery supplies the stomach, so disruption would possibly result in dysfunction of the stomach.

Rationale 3: The splenic artery supplies the pancreas, so disruption would possibly result in dysfunction of the pancreas.

Rationale 4: The superior and inferior mesenteric arteries supply the transverse colon.

Rationale 5: The spleen is supplied by the splenic artery, so disruption would possibly affect splenic function.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1

Question 7

Type: MCSA

The nurse is caring for a patient with an injury to cranial nerve X. Which assessment finding would the nurse attribute to that injury?

1. Rectal bleeding

2. Dry mouth

3. A metallic taste in the mouth

4. Decreased bowel sounds

Correct Answer: 4

Rationale 1: Rectal bleeding is not associated with cranial nerve X dysfunction.

Rationale 2: Salivary secretion is not controlled by cranial nerve X.

Rationale 3: Ability to taste is not controlled by cranial nerve X.

Rationale 4: Parasympathetic innervation to the gastrointestinal tract comes from cranial nerve X, the vagus nerve. Parasympathetic stimulation of the organs within the gastrointestinal system is responsible for stimulating the normal functions of the gastrointestinal system, such as processing of food, propulsion of contents through the gastrointestinal tract, and absorption of nutrients. Injury to cranial nerve X may result in decreased bowel sounds.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1

Question 8

Type: MCSA

A patient tells the nurse that after eating some food that tasted off he experienced a severe stomachache. However, after a few hours the discomfort was gone and he felt fine. Which information should the nurse consider when formulating a response to this report?

1. Decreased production of mucous in the duodenum likely propelled the organism through the system in a few hours.

2. The duodenal pH of 4.0 killed the offending organism.

3. The acidic stomach environment likely killed any offending organisms in the ingested food.

4. Chyme blocked the offending organism from attaching to the walls of the GI tract.

Correct Answer: 3

Rationale 1: The production of mucus provides a protective barrier, which prevents potential pathogens from adhering to the epithelial surface.

Rationale 2: The pH of the small intestine must remain at 7.0 or greater to allow the pancreatic proteolytic enzymes to be active.

Rationale 3: The acidic environment of the stomach (pH lower than 4.0) is hostile to most pathogens.

Rationale 4: Chyme is partially digested food. The presence of chyme does not block pathogens from adhering to the walls of the GI tract.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-2

Question 9

Type: MCSA

A patient with a history of tonsillectomy and appendectomy is admitted with a possible infection. Which etiological factor would the nurse select for the nursing diagnosis Infection, Risk for?

1. Decreased prostaglandin production

2. Impairment of gut-associated lymphoid tissue

3. Decrease in mucosa-associated lymphoid tissue

4. Degradation of superficial epithelial cells

Correct Answer: 2

Rationale 1: Prostaglandins protect the mucosal barrier of the GI tract by stimulating secretion of bicarbonate, increasing blood flow to the mucosa, and stimulating mucus secretion. Removal of the tonsils and appendix would not affect production of prostaglandins.

Rationale 2: Immunologic defense is provided by the gut-associated lymphoid tissue. This tissue includes the tonsils, lymph tissue within the intestinal wall, and the appendix and produce immunoglobulins and immunocytes that migrate to the gastrointestinal tract, tear ducts, and salivary glands to defend against pathogen penetration of epithelial surfaces.

Rationale 3: Mucosa-associated lymphoid tissue is found in the respiratory system, urogenital system, and conjunctiva but are primarily located in the digestive system and the small bowel. Removal of the tonsils and appendix would not decrease the amount of these tissues.

Rationale 4: Superficial epithelial cells secrete mucous and bicarbonate, which helps to protect the lining of the GI tract, but removal of the tonsils and adenoids would not affect these cells.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 20-2

Question 10

Type: MCSA

The nurse is planning care for a patient at risk for developing an infection because of an interruption in the intestinal mucosa. Which patient history would the nurse evaluate as most likely to exacerbate this risk?

1. The patient has a history of type 2 diabetes mellitus.

2. The patient was hospitalized 2 months ago for congestive heart failure.

3. The patient was hospitalized for treatment of severe trauma sustained in a motor vehicle accident.

4. The patient has been treated for hypertension for the last 10 years.

Correct Answer: 3

Rationale 1: A history of type 2 diabetes mellitus is not the most significant factor to consider in this patients history.

Rationale 2: Congestive heart failure is not known to cause interruption in the intestinal mucosa.

Rationale 3: Risk factors for disruption of intestinal mucosa include shock, trauma, intestinal obstruction, protein malnutrition, and total parenteral nutrition.

Rationale 4: History of treatment for hypertension is not a significant risk factor for the development of mucosal disruption.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 20-2

Question 11

Type: MCSA

A male patient admitted with a gastrointestinal bleed and a hematocrit level of 40% receives fluid resuscitation. In a few hours, the hematocrit level drops to 32%. How should the nurse evaluate this finding?

1. It is very likely that this patient has underlying renal disease.

2. There must be an undiagnosed second site of bleeding.

3. The patient is experiencing hemodilution caused by fluid resuscitation.

4. Efforts to stop the bleeding have not been successful.

Correct Answer: 3

Rationale 1: Alterations in the blood urea nitrogen level could indicate underlying renal disease.

Rationale 2: This drop is hematocrit level is not unexpected, so a secondary source of bleeding is not a likely causative factor.

Rationale 3: During acute hemorrhage, the hematocrit may not reflect the volume of blood loss. Prior to fluid resuscitation, the hematocrit may be higher than expected as a result of hemoconcentration from volume loss. The hematocrit may fall precipitously after aggressive fluid resuscitation because of hemodilution effects. It takes up to 72 hours for the hematocrit to equilibrate following a sudden loss of blood.

Rationale 4: This change in hematocrit is not unexpected, so continued bleeding is not a likely reason for the result.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 20-5

Question 12

Type: MCSA

A patient with liver disease has a decline in his previously elevated urobilinogen levels. The nurse would anticipate further testing for which condition?

1. Overhydration

2. Gastrointestinal bleeding

3. Worsening of the liver failure

4. Protein catabolism

Correct Answer: 3

Rationale 1: Overhydration will not result in dropping urobilinogen levels.

Rationale 2: Decrease in a previously increased urobilinogen level does not indicate gastrointestinal bleeding.

Rationale 3: Urobilinogen is measured as a sensitive test for hepatic damage. It may increase before serum bilirubin levels increase. In early hepatitis or mild liver cell damage, the urine urobilinogen level will increase despite an unchanged serum bilirubin level. However, with severe liver failure, the urine urobilinogen level may start to decrease because less bile will be produced.

Rationale 4: A drop in the level of a previously increased urobilinogen does not infer that protein catabolism is occurring.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-5

Question 13

Type: MCMA

A patient was admitted with acute abdominal and back pain. Which test results would the nurse evaluate as indicating additional testing for acute pancreatitis is likely?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Secretin stimulation test

2. Hematocrit level

3. Hemoglobin level

4. Serum lipase level

5. Amylase

Correct Answer: 4,5

Rationale 1: The secretin stimulation test helps determine pancreatic activity but will not necessarily aid in the diagnosis of acute pancreatitis.

Rationale 2: Hematocrit level is not used to help diagnose the presence of acute pancreatitis.

Rationale 3: Hemoglobin level is not used to help diagnose the presence of acute pancreatitis.

Rationale 4: Lipase levels in the serum will be elevated if pancreatic inflammation is present. Lipase is currently the best enzyme to identify acute pancreatitis.

Rationale 5: Amylase is often used as a screening test for pancreatitis. Elevated amylase levels indicate the need for additional testing as they can be elevated for multiple reasons.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-5

Question 14

Type: MCSA

A patient has just received an upper GI series diagnostic test. What nursing intervention is indicated?

1. Keep on bed rest for 6 hours postprocedure.

2. Monitor urine output.

3. Administer the prescribed cathartic.

4. Keep the patient on nothing by mouth status.

Correct Answer: 3

Rationale 1: It is not necessary to keep a patient on bed rest after an upper GI series.

Rationale 2: Monitoring urine output is not particularly indicated after this diagnostic test.

Rationale 3: An upper GI series with contrast medium is a type of x-ray that allows visualization of the GI tract in order to diagnose tumors, masses, hernias, obstructions, ulcers, fistulas, or diverticular disease. Because the patient ingests a contrast material prior to the actual x-ray, it is important to assist the patient in expelling the contrast medium after the test. The nurse should administer the prescribed cathartic to aid in the expelling of the barium.

Rationale 4: Maintaining NPO status is not necessary unless findings from the examination indicate so.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-5

Question 15

Type: MCMA

A patient is admitted with acute abdominal pain. Which preexisting conditions would prevent this patient from having a nuclear scan to diagnose the cause of the abdominal pain?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient is being treated for congestive heart failure.

2. The patient has severe rheumatoid arthritis.

3. The patient had an appendectomy 6 months ago.

4. The patient has bilateral titanium hip replacements

5. The patient had a similar scan done last week.

Correct Answer: 4,5

Rationale 1: Congestive heart failure is not a contraindication for nuclear scanning.

Rationale 2: Rheumatoid arthritis is not a contraindication for a nuclear scan.

Rationale 3: History of appendectomy is not a contraindication for a nuclear scan.

Rationale 4: A nuclear scan allows visualization of organs, gastrointestinal motility, and bleeding. A nuclear scan is contraindicated in patients with metal implants.

Rationale 5: Recent nuclear exposure is a contraindication to nuclear scanning.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-5

Question 16

Type: MCMA

The nurse is assessing a patient admitted with acute abdominal pain. Which information would the nurse associate with changes in the gastrointestinal system?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient is taking more of the proton pump inhibitor than is typically indicated for gastroesophageal reflux.

2. The patient reports that his mother was just diagnosed with renal failure.

3. The patient reports an itchy red rash over his thigh that has been present for several weeks.

4. The patient works as an insurance agent.

5. The patient often repeats himself and seems confused at times.

Correct Answer: 3,5

Rationale 1: Taking more or less of a medication associated with gastrointestinal symptoms may indicate that the patients symptoms are changing.

Rationale 2: There is not enough information to determine if the renal failure suffered by the patients mother is familial or if it is associated with gastrointestinal changes.

Rationale 3: Skin disturbances can be associated with gastrointestinal ailments.

Rationale 4: Occupation is not directly connected with gastrointestinal ailments.

Rationale 5: Lack of mental clarity is always an important consideration during assessment. If the patient is not able to answer questions correctly, information collection may not be valid.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-6

Question 17

Type: MCSA

The nurse has completed the focused history for a patient admitted with acute abdominal pain. How should the nurse continue with the assessment?

1. Palpate for abdominal masses or tenderness.

2. Auscultate for bowel sounds.

3. Inspect the abdomen.

4. Percuss for abdominal tones.

Correct Answer: 3

Rationale 1: Palpation should not be the first step of physical examination of the abdomen.

Rationale 2: Auscultation is not the first step of the physical examination of the abdomen.

Rationale 3: A focused abdominal assessment should begin with inspection, followed by auscultation, percussion, and palpation. During inspection, the abdomen should be examined for abnormal contour, alteration in skin, pulsations, and peristalsis.

Rationale 4: Percussion is not the first step of the physical examination of the abdomen.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-6

Question 18

Type: MCSA

A patient is in congestive heart failure due to damage from a myocardial infarction. Which gastrointestinal manifestation would the nurse expect on assessment?

1. Severe stomach cramping

2. Decreased bowel sounds

3. Enlargement of the liver

4. Esophageal reflux

Correct Answer: 3

Rationale 1: Stomach cramping is not an expected effect of congestive heart failure.

Rationale 2: Congestive heart failure does not result in decreased bowel sounds.

Rationale 3: The liver is a fluid reservoir. During periods of high fluid volume in the right heart, the liver is able to accept approximately one liter of excess volume by distending.

Rationale 4: Esophageal reflux is not directly correlated with congestive heart failure.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-3

Question 19

Type: MCSA

A patient will undergo an elastase test for pancreatic function. The nurse will collect which sample?

1. Stool

2. Serum

3. Saliva

4. Urine

Correct Answer: 1

Rationale 1: The elastase test requires a stool sample.

Rationale 2: The elastase test does not require a serum sample.

Rationale 3: The elastase test does not require a saliva sample.

Rationale 4: The elastase test does not require a urine sample.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-4

Question 20

Type: MCSA

A patient is scheduled to have sublingual capnometry. How would the nurse explain the purpose of this test?

1. This test will help us learn about the blood flow to your gastrointestinal organs.

2. This test will monitor the acidity of your gastric acids.

3. This test will determine if your pancreas if functioning.

4. This test will help us determine if you have an infection in your gastrointestinal tract.

Correct Answer: 1

Rationale 1: Sublingual capnometry uses a special probe to provide an alternative to invasive gastric tonometry monitoring of splanchnic perfusion.

Rationale 2: Sublingual capnometry is not associated with acidity of gastric acids.

Rationale 3: Sublingual capnometry is not associated with pancreatic function.

Rationale 4: Sublingual capnometry is not associated with discovering infections.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-5

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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