Deck 55: Assessment of the Gastrointestinal System

Question 1

The nurse finds a positive Blumberg's sign in a client with abdominal pain.Which action does the nurse plan?

A) Have the client be NPO in preparation for surgery.
B) Document this normal finding in the client's record.
C) Immediately auscultate the client's abdomen for bowel sounds.
D) Repeat the maneuver with the client in a supine position, with the knees flexed.

Answer 1

Have the client be NPO in preparation for surgery.

Question 2

The nurse assesses dullness at the left anterior axillary line.The nurse is concerned about which condition that the client may have?

A) Cirrhosis
B) Splenomegaly
C) Bowel obstruction
D) Abdominal aortic aneurysm

Answer 2

Splenomegaly

Question 3

A client has been taking naproxen (Naprosyn)for several months.Which assessment question is important for the nurse to ask?

A) "Have you experienced any constipation?"
B) "Have you had any stomach pain or indigestion?"
C) "Have you had any difficulty swallowing?"
D) "Have you noticed any weight loss lately?"

Answer 3

"Have you had any stomach pain or indigestion?"

Question 4

The nurse is caring for a client who has just returned from abdominal surgery.When auscultating the client's abdomen,the nurse does not hear any bowel sounds.Which is the nurse's best action?

A) Notify the health care provider.
B) Percuss the abdomen.
C) Document the finding.
D) Insert a nasogastric tube.

Question 5

The client is scheduled for a colonoscopy.Which statement indicates that the client needs additional teaching about the procedure?

A) "I may have gas and abdominal cramps after the test."
B) "I will take strong laxatives the afternoon before the test."
C) "I will take my Coumadin with a sip of water tomorrow morning."
D) "I will take nothing by mouth after midnight on the day of the test."

Question 6

When performing an assessment,the nurse detects a fruity odor on the client's breath.What does the nurse do next?

A) Assess the client's blood sugar level.
B) Assess the client's stool for occult blood.
C) Instruct the client in oral hygiene techniques.
D) Assess the client for petechiae, itching, and jaundice.

Question 7

The nurse is screening clients at a health fair.Which client is at highest risk for the development of colon cancer?

A) Older white client with irritable bowel syndrome
B) Middle-aged African-American client who smokes cigars
C) Middle-aged Asian client who travels and eats out frequently
D) Older American Indian client taking hormone replacement therapy

Question 8

Which laboratory finding does the nurse expect to find on assessment of a client with advanced cirrhosis?

A) Amylase, 129 IU/L; alkaline phosphate, 45 U/L
B) Reticulocyte count, 1%; magnesium, 1.5 mEq/L
C) Hemoglobin, 14 g/dL; direct bilirubin, 0.2 mg/dL
D) Prothrombin time (PT), 17.5 seconds; albumin, 1.6 g/dL

Question 9

The nurse is caring for a client who just completed an upper GI radiographic series with oral barium contrast.Which instructions does the nurse provide to the client?

A) "Drink plenty of fluids over the next few days."
B) "Do not eat or drink anything for 6 hours after the test."
C) "You may not drive or operate heavy machinery today."
D) "Do not take any blood thinners for 24 hours after the test."

Question 10

The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD)completed.The client tells the nurse that her mouth is very dry after the procedure.Which is the nurse's best action?

A) Keep the client NPO (nothing by mouth).
B) Check the client's gag reflex.
C) Offer the client sips of clear liquids.
D) Provide the client with a few ice chips.

Question 11

Which question best assists the nurse in assessing a client with acute diarrhea?

A) "Have you traveled outside the country recently?"
B) "Have you had a colonoscopy lately?"
C) "Do you have any trouble swallowing?"
D) "Do you have any allergies?"

Question 12

A client reports that he has been passing black stools for the last few days.Which findings from the client's health history does the nurse consider as possible causes?

A) Cirrhosis
B) Cholecystitis
C) Hemorrhoids
D) Diverticulitis
E) Long-term use of NSAIDs
F) Use of iron supplements

Question 13

The nurse is performing an abdominal assessment on an older client.Which assessment finding does the nurse expect as a normal consequence of aging?

A) Increased salivation and drooling
B) Hyperactive bowel sounds and loose stools
C) Increased gastric acid production and heartburn
D) Impaired sensation to defecate and constipation

Question 14

The nurse is preparing the client for a computed tomography (CT)scan of the abdomen with IV contrast.Which question does the nurse ask the client before the examination?

A) "Are you allergic to shrimp, scallops, or shellfish?"
B) "Have you had anything to eat or drink in the past 12 hours?"
C) "Did you finish taking all the prescribed laxatives?"
D) "Can you tolerate being tilted from side to side?"

Question 15

While a health history is obtained from a client with a new diagnosis of advanced pancreatic cancer,the client begins to cry.Which is the nurse's best response?

A) "I am so sorry for making you cry!"
B) "I will step out for a few minutes until you feel better."
C) "I can see that you are upset about this. It is all right to cry."
D) "I can see that I am upsetting you. Let's move on to something else."

Question 16

The nurse is preparing to perform an abdominal assessment on a client with suspected cholecystitis.In what sequence does the nurse palpate the client's abdomen?

A) Palpate the lower quadrants only.
B) Palpate the upper quadrants last.
C) Palpate the upper quadrants only.
D) Defer palpation and use percussion only.

Question 17

A client has a family history of colon cancer.Which laboratory tests are ordered to rule out colon cancer?

A) Cholesterol
B) Serum lipase
C) Carcinoembryonic antigen
D) Xylose absorption

Question 18

The nurse is caring for a client who is receiving radiation treatment for oral cancer.Which problem does the nurse anticipate for this client?

A) Failure to absorb nutrients from the stomach
B) Inability to digest protein
C) Impaired ability to soften and break down food
D) Difficulty swallowing food

Question 19

The nurse performs percussion of a client's abdomen.Which findings may the nurse determine with this assessment technique?

A) Hepatomegaly
B) Kidney stones
C) Ascites
D) Large mass below the liver
E) Biliary colic
F) Ileus

Question 20

An abdominal ultrasound is scheduled for the client.Which statement by the client indicates that the nurse's teaching about the procedure was effective?

A) "The IV contrast may burn when it is injected."
B) "I will drive myself home after the test is completed."
C) "I will empty my bladder completely before the test."
D) "I may have to take a laxative to pass the barium afterward."

Question 21

A client has jaundice and ascites.Which laboratory values indicate hepatic disease?

A) Albumin, 2.0 g/dL
B) Potassium, 3.0 mEq/L
C) Alanine aminotransferase (ALT), 45 IU/L
D) Aspartate aminotransferase (AST), 45 U/L
E) Unconjugated (indirect) bilirubin, 1 mg/dL
F) Ammonia, 120 mg/dL