Chapter 47Assessment of Gastrointestinal Function My Nursing Test Banks

Chapter 47Assessment of Gastrointestinal Function

MULTIPLE CHOICE

1.A client asks the nurse what will happen to her digestion if she needs to have her appendix removed. The nurse should respond that the purpose of the appendix is:

1.

to digest food products and another organ will take over this function.

2.

to absorb nutrients and another organ will take over this function.

3.

to secrete enzymes and another organ will take over this function.

4.

nothing, so no other organ will need to take over this function.

ANS: 4

The appendix is a blind-ended, tube-like structure exiting from the cecum, and it has no function in humans. The appendix is not needed to digest food, absorb nutrients, or secrete enzymes.

PTS:1DIF:ApplyREF:Cecum and Appendix

2.Which of the following questions should the nurse ask while doing an assessment of a clients digestive system?

1.

Were you breastfed or bottle-fed as an infant?

2.

Do you have knowledge of the food pyramid?

3.

What medication have you taken, even over-the-counter drugs?

4.

Do you drink coffee or tea with meals?

ANS: 3

During the assessment, it is very important to discover what medications or over-the-counter drugs are being taken by the patient. Treatment and therapies may change because of this information. How the client was fed as an infant is not a part of this assessment. Asking if the client has knowledge of the food pyramid is not part of this assessment. If the client drinks coffee or tea with meals is not a part of this assessment.

PTS: 1 DIF: Apply REF: Assessment

3.The nurse realizes that a client diagnosed with heartburn will most likely experiencing symptoms:

1.

1 hour before eating.

2.

while eating a meal.

3.

1 hour after eating.

4.

first thing in the morning.

ANS: 3

Heartburn is a substernal burning sensation that is experienced within 1 hour after eating or 1 to 2 hours after reclining. Heartburn is not experienced before eating, while eating, or the first thing in the morning.

PTS: 1 DIF: Analyze REF: Heartburn

4.A client is experiencing straining at stool with the production of hard stools. The nurse realizes this client might be diagnosed with constipation if the client also has:

1.

fewer than six bowel movements per week.

2.

fewer than five bowel movements per week.

3.

fewer than four bowel movements per week.

4.

fewer than three bowel movements per week.

ANS: 4

The number of bowel movements a client has is very individual, but if a client has fewer than three bowel movements per week or must vigorously strain when passing stool, the client is considered to have constipation. The other choices do not fit the criteria for the diagnosis of constipation.

PTS: 1 DIF: Analyze REF: Constipation

5.The nurse is preparing to conduct an abdominal assessment on a client and realizes that this assessment should be performed in the order of:

1.

inspection, palpation, auscultation, and percussion.

2.

inspection, auscultation, percussion, and palpation.

3.

auscultation, palpation, percussion, and inspection.

4.

percussion, palpation, inspection, and auscultation.

ANS: 2

The order of abdominal assessment is inspection, auscultation, percussion, and palpation. Auscultation is performed second because palpation and percussion can alter bowel sounds. The other choices list the incorrect order for conducting this assessment.

PTS: 1 DIF: Apply REF: Assessment

6.The nurse has determined a client has absent bowel sounds because no sounds have been heard in all four quadrants for :

1.

1 minute.

2.

2 minutes.

3.

30 seconds.

4.

5 minutes.

ANS: 4

The nurse must listen for 3 to 5 minutes before concluding the patient has absent bowel sounds. Auscultating for 30 seconds or 1 or 2 minutes is not adequate to determine the absence of bowel sounds.

PTS:1DIF:Analyze

REF:Table 47-1 Assessment of Abdomen: Normal and Key Findings

7.A client scheduled for a colonoscopy should be instructed regarding the need for:

1.

serum blood specimens.

2.

a bowel preparation.

3.

pain medications prior to the test.

4.

eating a full meal prior to the test.

ANS: 2

Bowel cleansing is necessary for all colonoscopy procedures. The bowel preparation selected depends on the reasons for the procedure. Serum blood specimens are not needed for a colonoscopy. Pain medication is not typically needed prior to a colonoscopy. The client should take nothing by mouth for at least 6 hours before the colonoscopy.

PTS:1DIF:ApplyREF:Colonoscopy

8.A client, scheduled for a colonoscopy, is provided with a polyethylene glycol solution to ingest the day before the test. Which of the following should the nurse instruct the client about this solution?

1.

Keep the solution at room temperature.

2.

Sip the solution throughout the day until bowel movements begin.

3.

Drink 8 ounces of the solution every 10 minutes until totally consumed.

4.

Drink 8 ounces of the solution every hour until bowel movements begin.

ANS: 3

The nurse should instruct the client to refrigerate the solution and drink 8 ounces of the solution every 10 minutes until totally consumed. The solution should not be sipped throughout the day or only taken until bowel movements begin.

PTS:1DIF:ApplyREF:Colonoscopy

9.When instructing a client on the three steps of a proctosigmoidoscopy, which of the following would not be included?

1.

Placement of a nasogastric (NG) tube for gastric deflation

2.

Digital examination to dilate the anal sphincters to detect obstruction

3.

Sigmoidoscope to examine the distal sigmoid colon and rectum

4.

Proctoscope to examine the lower rectum and anal canal

ANS: 1

This is a diagnostic test that takes three steps: first, a digital examination; second, a sigmoidoscope; and third, a proctoscope. An NG tube is not needed for this examination.

PTS:1DIF:ApplyREFroctosigmoidoscopy

10.The nurse, planning care for a client diagnosed with severe facial trauma, realizes that which of the following will not be used when caring for this client?

1.

Blood pressure cuff

2.

Nasogastric tube

3.

Indwelling urinary catheter

4.

Doppler

ANS: 2

NG tube placement is contraindicated in facial trauma. Blood pressure cuffs are used for most, if not all, clients. An indwelling urinary catheter and Doppler may or may not need to be used when caring for this client.

PTS:1DIF:AnalyzeREF:Nasogastric Tubes

11.A client is prescribed to receive a nasogastric (NG) tube feeding. The nurse realizes that:

1.

placement does not need to be checked before the feeding.

2.

an NG tube is for long-term uses.

3.

the head of the bed must be 30 degrees or greater.

4.

feeding the client is not a reason for an NG tube.

ANS: 3

The head of the clients bed must be at least 30 degrees to decrease the risk of aspiration during feeding. Placement must be checked prior to feeding, and NG tubes are not for long-term use.

PTS: 1 DIF: Apply REF: Feeding Tubes: Patient Preparation

12.A client is diagnosed with insufficient hydrochloric acid in the stomach. The nurse realizes this client will most likely need which of the following vitamin supplements?

1.

A

2.

B-12

3.

C

4.

D

ANS: 2

Hydrochloric acid in the stomach triggers pepsinogen, which generates pepsin. Pepsin begins the digestion of proteins in the food and allows for the absorption of vitamin B-12. This is the vitamin supplement that the client will most likely need. Vitamins A, C, and D are not affected by a lack of hydrochloric acid in the stomach.

PTS: 1 DIF: Analyze REF: Stomach

13.A client is scheduled for an abdominal paracentesis. Which of the following should the nurse instruct the client to do before the procedure?

1.

Empty the bladder.

2.

Drink a large glass of water.

3.

Eat a full meal.

4.

Sleep for several hours.

ANS: 1

Prior to an abdominal paracentesis, the nurse should instruct the client to empty the bladder. The client should not drink a large glass of water or eat a full meal before the procedure. Sleeping before the procedure is not helpful.

PTS: 1 DIF: Apply REF: Paracentesis

MULTIPLE RESPONSE

1.A client is being assessed for gastrointestinal system dysfunction. The nurse realizes an impairment of this function could affect which of the following? (Select all that apply.)

1.

Absorption of food

2.

Digestion of food

3.

Metabolism of food

4.

Utilization of oxygen

5.

Synthesis of red blood cells

6.

Filtering of water

ANS: 1, 2, 3

An impairment in a clients gastrointestinal system functioning could affect the absorption of food, the digestion of food, and the metabolism of food. An impairment in this system will not affect the utilization of oxygen, synthesis of red blood cells, or the filtering of water.

PTS: 1 DIF: Analyze REF: Anatomy and Physiology

2.While palpating the abdominal organs during a physical assessment of a client, which of the following organs will the nurse most likely not be able to assess? (Select all that apply.)

1.

Liver

2.

Gallbladder

3.

Pancreas

4.

Kidney

5.

Spleen

6.

Colon

ANS: 3, 5

The pancreas is not palpable, and the spleen is not normally palpable during an assessment. The other organs can be palpated during the physical assessment of the abdomen.

PTS: 1 DIF: Apply REF: Assessment

3.During the eating habits portion of an assessment of a clients gastrointestinal system, the nurse should assess which of the following? (Select all that apply.)

1.

Fluid intake

2.

Urine output

3.

Blood pressure

4.

Bowel habits

5.

Food intolerance

6.

Appetite

ANS: 4, 5, 6

When assessing a clients eating habits, the nurse should assess the clients appetite, food intolerances, and bowel habits. Fluid intake, urine output, and blood pressure are not a part of this assessment.

PTS: 1 DIF: Apply REF: Assessment

4.A client is experiencing excessive belching. Which of the following can the nurse instruct this client? (Select all that apply.)

1.

Eat slowly.

2.

Do not drink with a straw.

3.

Avoid carbonated beverages.

4.

Do not smoke.

5.

Do not chew gum.

6.

Avoid eating onions.

ANS: 1, 2, 3, 4, 5

Excessive belching can be resolved by instructing the client to eat slowly, do not drink with a straw, avoid carbonated beverages, do not smoke, and do not chew gum. Not eating onions might help with flatus.

PTS:1DIF:ApplyREF:Gastrointestinal Gas

5.The nurse is assessing a client for acute appendicitis. Which of the following can be done to help diagnose this disorder? (Select all that apply.)

1.

Assess for Blumbergs sign.

2.

Assess bowel sounds.

3.

Perform the iliopsoas muscle test.

4.

Auscultate for bowel sounds in the right lower quadrant.

5.

Perform the obturator muscle test.

6.

Assess for referred pain to the right shoulder.

ANS: 1, 3, 5

Assessment for acute appendicitis includes the use of the Blumbergs sign, iliopsoas muscle test, and the obturator muscle test. Bowel sounds are not affected by acute appendicitis. Referred pain to the right shoulder would indicate a liver dysfunction.

PTS: 1 DIF: Apply REF: Red Flag: Assessments for Acute Appendicitis

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