Med Surg - ed 9 - Chapter 39: Nursing Assessment: Gastrointestinal System

med-surg-ed-9-chapter-39-nursing-assessment-gastrointestinal-system

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Question 1 of 1

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

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Explanation

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

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

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Explanation

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.

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

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Explanation

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, eleva

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

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Explanation

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

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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?

Select the correct answer(s).

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Explanation

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 t

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

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Explanation

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.

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

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Explanation

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.

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

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Explanation

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

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

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Explanation

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.

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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?

Select the correct answer(s).

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Explanation

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 s

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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?

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Explanation

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.

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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?

Select the correct answer(s).

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Explanation

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

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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?

Select the correct answer(s).

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Explanation

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.

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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?

Select the correct answer(s).

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Explanation

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.

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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?

Select the correct answer(s).

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Explanation

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.

Med Surg - ed 9 - Chapter 39: Nursing Assessment: Gastrointestinal System

Question 1 of 1

Time Left

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

Select the correct answer(s).

(0/0)

Explanation

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

Select the correct answer(s).

(0/0)

Explanation

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

Select the correct answer(s).

(0/0)

Explanation

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

Select the correct answer(s).

(0/0)

Explanation

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?

Select the correct answer(s).

(0/0)

Explanation

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

Select the correct answer(s).

(0/0)

Explanation

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

Select the correct answer(s).

(0/0)

Explanation

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

Select the correct answer(s).

(0/0)

Explanation

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

Select the correct answer(s).

(0/0)

Explanation

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?

Select the correct answer(s).

(0/0)

Explanation

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?

Select the correct answer(s).

(0/0)

Explanation

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?

Select the correct answer(s).

(0/0)

Explanation

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?

Select the correct answer(s).

(0/0)

Explanation

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?

Select the correct answer(s).

(0/0)

Explanation

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?

Select the correct answer(s).

(0/0)

Explanation

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