Question 1

Which information about an 80-year-old man at the senior center is of most concern to the nurse?

Accepted Answer

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.

Question 2

Which area of the abdomen shown in the accompanying figure will the nurse palpate to assess for splenomegaly?

Accepted Answer

The spleen is usually not palpable,but when palpated,it is located in left upper quadrant of abdomen.

Question 3

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?

Accepted Answer

This question is the most open-ended,and will provide the best overall information about the 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.

Question 4

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?

Accepted Answer

The patient will need to be NPO for 8 hours before the ERCP is done,so the nurse's initial action should be to place the patient on NPO status.The other actions can be done after the patient is NPO.

Question 5

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?

Accepted Answer

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.

Question 6

When caring for a patient with a history of a total gastrectomy,the nurse will monitor for

Accepted Answer

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.

Question 7

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?

Accepted Answer

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.

Question 8

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?

Accepted Answer

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 patient's anxiety about discomfort.

Question 9

A 62- year-old man reports chronic constipation.To promote bowel evacuation,the nurse will suggest that the patient attempt defecation

Accepted Answer

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.

Question 10

Which statement to the nurse from a patient with jaundice indicates a need for teaching?

Accepted Answer

Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patient's jaundice.The other patient statements require further assessment by the nurse,but do not indicate a need for patient education.

Question 11

In the video,the examiner is

Accepted Answer

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

Question 12

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?

Accepted Answer

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.

Question 13

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 patient's knowledge about

Accepted Answer

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.

Question 14

Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment?

Accepted Answer

Absent bowel sounds are abnormal and require further assessment by the nurse.The other sounds may be heard normally.

Question 15

To palpate the liver during a head-to-toe physical assessment,the nurse

Accepted Answer

The liver is normally not palpable below the costal margin.The nurse needs to push inward 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.

Question 16

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?

Accepted Answer

A temperature elevation may indicate that a perforation has occurred.The other assessment data are normal immediately after the procedure.

Question 17

After assisting with a needle biopsy of the liver at a patient's bedside,the nurse should

Accepted Answer

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.

Question 18

The nurse will plan to monitor a patient with an obstructed common bile duct for

Accepted Answer

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.

Quiz 39: Nursing Assessment: Gastrointestinal System