Hogan Chapter 59 - Comprehensive Review NCLEX-RN PDF

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Comprehensive Review NCLEX-RN...

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Chapter 59 Gastrointestinal Disorders 1. A client has a total gastrectomy. The nurse explains to the client the need for long-term injections of which vitamin? 1. Thiamine 2. Folic acid 3. Cyanocobalamin 4. Niacin Rationale: The loss of parietal cells that secrete intrinsic factor results in vitamin B1 2 (cyanocobalamin) deficiency post-gastrectomy because intrinsic factor is needed for absorption of vitamin B1 2 . For this reason, clients require vitamin B1 2 injections for life. Thiamine, folic acid, and niacin are other B-complex vitamins. 2. A client with diverticular disease undergoes a colonoscopy. During an abdominal assessment, the nurse looks for which sign to indicate a possible complication of the procedure? 1. Diarrhea 2. Nausea and vomiting 3. Guarding and rebound tenderness 4. Redness and warmth of the abdominal skin Rationale: Bowel perforation is a possible result of colonoscopy if the colonoscope accidentally pierces the bowel wall. Perforation could lead to symptoms of peritonitis, such as guarding and rebound tenderness. Diarrhea is not considered to be a complication of colonoscopy. Nausea and vomiting could be signs of many GI disorders but are not complications of colonoscopy. Redness and warmth of abdominal skin would suggest a skin irritation or infection but is not a complication of colonoscopy. 3. The client who has ulcerative colitis is scheduled for an ileostomy. When the client asks the nurse what to expect related to bowel function and care after surgery, what response should the nurse make? 1. “You will be able to have some control over your bowel movements.” 2. “The stoma will require that you wear a collection device all the time.” 3. “After the stoma heals, you can irrigate your bowel so you will not have to wear a pouch.” 4. “The drainage will gradually become semisolid and formed.” Rationale: A client with an ileostomy must always wear a collection device. The client has no control over bowel movements. Bowel irrigation is not performed to eliminate the need to wear a drainage pouch. The drainage tends to be liquid but can become paste like with intake of specific foods 4. The nurse is conducting dietary teaching with a client who has dumping syndrome. The nurse encourages the client to avoid which foods that the client usually enjoys? Select all that apply. 1. Eggs 2. Cheese 3. Fruit 4. Pork 5. Cookies Rationale: Dumping syndrome, in which gastric contents rapidly enter the bowel, can occur following gastrectomy. Fruits and cookies containing simple carbohydrates will attract fluid into the GI tract, leading to symptoms of dumping syndrome. Eggs are higher in protein and fat (cholesterol), which will slow GI transit time, avoiding dumping syndrome. Cheese has variable amounts of protein and fat, and these are less likely to trigger dumping syndrome. Pork is high in protein, which slows GI transit time to reduce episodes of dumping syndrome.

5. A client is being evaluated for possible duodenal ulcer. The nurse assesses the client for which manifestation that would support this diagnosis? 1. Epigastric pain relieved by food 2. History of chronic aspirin use 3. Distended abdomen 4. Positive fluid wave Rationale: The pain of a gastric ulcer is dull and aching, occurs after eating, and is not relieved by food as is the pain from a duodenal ulcer. The pancreatic juices that are high in bicarbonate are released with food intake and relieve duodenal ulcer pain when the client eats. Chronic aspirin use is irritating to the stomach. Distended abdomen is a vague sign and is unrelated. A positive fluid wave is consistent with ascites and is unrelated. 6. The client returning from a colonoscopy has been given a diagnosis of Crohn’s disease. The oncoming shift nurse expects to note which manifestations in the client? Select all that apply. 1. Steatorrhea 2. Firm, rigid abdomen 3. Constipation 4. Enlarged hemorrhoids 5. Diarrhea Rationale: Steatorrhea is often present in the client with Crohn’s disease. Diarrhea is also a key feature, but unlike ulcerative colitis, the loose stool usually does not contain blood and is usually less frequent in number of episodes. A firm rigid abdomen is not a manifestation of Crohn’s disease. Constipation is not a manifestation of Crohn’s disease. Hemorrhoids are not a manifestation of Crohn’s disease. 7. A client is scheduled for a fecal fat exam. In planning client education, the nurse includes that which dietary modification is necessary before the test? 1. Eat a fat-free diet the day before the exam. 2. Eat a high-fat meal right before the exam. 3. Eat a diet containing 35 grams of fat for 36 hours before the test. 4. Eat at least 100 grams of fat for 3 days before and during the test. Rationale: It is suggested that adults consume at least 100 grams of fat per day for 3 days before the test and throughout specimen collection. The client is supposed to take in a high-fat diet, not a fat-free diet, for a specified amount of time before the test. Eating a high-fat meal right before the exam is not a sufficient time frame to ensure valid test results. Eating a diet containing 35 grams of fat for 36 hours before the test is insufficient in amount and time. 8. The Client with diverticular disease is scheduled for a sigmoidoscopy and suddenly reports severe abdominal pain. On examination, the nurse notes a rigid abdomen with guarding. What action should the nurse take next? 1. Notify the healthcare provider. 2. Place the client in a more comfortable position. 3. Keep the client distracted until the procedure begins. 4. Tell the client that the test will show what is causing his problem Rationale: Perforation of an obstructed diverticulum can cause abscess formation or generalized peritonitis. The manifestations of peritonitis are abdominal guarding and rigidity and pain. Because treatment of this complication is beyond the scope of independent nursing practice, the healthcare provider must be notified. Placing the client in a position of comfort could be attempted after notifying the healthcare provider of the complication. Providing a distraction is not the priority nursing action. Sigmoidoscopy is contraindicated in cases of perforation.

9. The nurse is educating the client with gastroesophageal reflux disease (GERD) about ways to minimize symptoms. Which information in the client’s history should the nurse address as indicators that need to be changed? Select all that apply. 1. Lifting weights for exercise 2. Being a vegetarian 3. Having a body mass index of 26 4. Taking calcium carbonate tablets 5. Drinking 2–4 cups of coffee daily Rationale: Lifestyle modifications can minimize symptoms of GERD. Anything that increases intra-abdominal pressure should be avoided, such as lifting weights. Obesity or being overweight (body mass index of 26) also aggravates symptoms. Coffee, cola, other sources of caffeine, and chocolate decrease lower esophageal sphincter tone and can increase symptoms of GERD. Being a vegetarian does not increase risk of GERD. Calcium carbonate tablets often aid in symptom relief. 10. The client with a duodenal ulcer asks the nurse why an antibiotic is part of the treatment regimen. Which information should the nurse include in the response? 1. Antibiotics decrease the likelihood of a secondary infection. 2. Many duodenal ulcers are caused by the Helicobacter pylori organism. 3. Antibiotics are used in an attempt to sterilize the stomach. 4. Many people have Clostridium difficile, which can lead to ulcer formation Rationale: Helicobacter pylori infection is a major cause of peptic ulcers, so treatment includes antibiotic therapy to eradicate the microorganisms. Antibiotics do not reduce the likelihood of a secondary infection; they treat the primary infection. Antibiotics are not used to sterilize the bowel, which would upset the normal flora of the GI tract. Clostridium difficile is a contagious microorganism that can lead to severe diarrhea. 11. The nurse should evaluate the results of which laboratory tests while caring for a client who has cirrhosis of the liver? Select all that apply. 1. Prothrombin time 2. Urinalysis 3. Serum lipase 4. Serum troponin 5. Serum albumin Rationale: Many clotting factors are produced in the liver, including fibrinogen (factor I), prothrombin (factor II), factor V, serum prothrombin conversion accelerator (factor VII), factor IX, and factor X. The client’s ability to form these factors may be impaired with cirrhosis, putting the client at risk for bleeding. The prothrombin time will evaluate blood-clotting ability. One function of the liver is to synthesize protein, which may be impaired with cirrhosis. Urinalysis is a general screening measure or can be used to diagnose problems with the urinary tract. Serum lipase is a useful indicator of disorders of the pancreas. Serum troponin is a common laboratory test used to diagnose myocardial infarction. 12. The nurse is caring for a client with a history of alcoholism. Which findings would indicate that the client has possibly developed chronic pancreatitis? Select all that apply. 1. Steady weight gain 2. Flank pain on left side only 3. Fatty stools 4. Excessive hunger 5. Constipation and flatulence

Rationale: Steatorrhea (fatty stools) result from a decrease in pancreatic enzyme secretion with pancreatitis. The client with chronic pancreatitis is likely to experience bouts of constipation and flatulence. The client with chronic pancreatitis is likely to experience weight loss rather than weight gain. The pain of pancreatitis is felt in the abdomen and is not limited to the left flank. Manifestations of chronic pancreatitis include nausea and vomiting rather than excessive hunger. 13. The nurse caring for a client with hemolytic jaundice anticipates which findings on laboratory test results? 1. Elevated serum indirect bilirubin 2. Decreased serum protein 3. Elevated urine bilirubin 4. Decreased urine pH Rationale: Hemolytic jaundice is caused by excessive breakdown of red blood cells, and the amount of bilirubin produced exceeds the ability of the liver to conjugate it, so there is an increase in indirect bilirubin. Serum protein is not measured to detect hemolytic jaundice. Unconjugated bilirubin is insoluble in water and is not found in the urine. Urine pH is not decreased by hemolytic jaundice. 14. A client was admitted to the hospital with cholelithiasis the previous day. Which new assessment finding indicates to the nurse that the stone has probably obstructed the common bile duct? 1. Nausea 2. Elevated cholesterol level 3. Right upper quadrant (RUQ) pain 4. Jaundice Rationale: Obstruction of the common bile duct results in reflux of bile into the liver, which produces jaundice. Nausea occurs with cholelithiasis and would not be a new symptom to signal obstruction. Alkaline phosphatase increases with biliary obstruction, but cholesterol level does not increase. RUQ pain occurs as a common symptom in cholelithiasis. 15. The nurse caring for a client with uncomplicated cholelithiasis anticipates that the client’s laboratory results will show an elevation in which test? 1. Serum amylase 2. Alkaline phosphatase 3. Mean corpuscular hemoglobin concentration (MCHC) 4. Indirect bilirubin Rationale: Obstructive biliary disease causes a significant elevation in alkaline phosphatase. Serum amylase would increase in pancreatic disorders. MCHC is one type of red blood cell index used to differentiate among different types of anemia. Obstruction in the biliary tract causes an elevation in direct bilirubin, not indirect bilirubin. 16. In caring for a client 4 days’ post-cholecystectomy, the nurse notices that drainage from the T-tube is 600 mL in 24 hours. Which is the most appropriate action by the nurse? 1. Clamp the tube q 2 hours for 30 minutes 2. Place the client in a supine position 3. Assess drainage characteristics and notify the healthcare provider 4. Encourage an increased fluid intake Rationale: The T-tube may drain up to 500 mL in the first 24 hours and decreases steadily thereafter. If there is excessive drainage, the nurse should further assess the drainage to be able to describe it accurately and notify the healthcare provider immediately. Clamping the T-tube after the first 24 hours would be contraindicated as it is too soon to do this. Placing the client in a supine position will not alter the flow of T-

tube drainage. While increased fluids in general would offset fluid loss from the T-tube, this does not address the significance of the excessive drainage. 17. The post-cholecystectomy client asks the nurse when the T-tube will be removed. Which response by the nurse would be appropriate? 1. “When your stool returns to a normal brown color, the tube can be removed.” 2. “The tube will be removed at the same time as your staples.” 3. “When the tube stops draining, it will be removed.” 4. “The tube is usually removed the day after surgery.” Rationale: When T-tube drainage subsides and stools return to a normal brown color, the tube can be clamped 1–2 hours before and after meals in preparation for tube removal. If the client tolerates clamping, the tube will then be removed. The tube is not removed at the same time as the incisional staples. It is not necessary for drainage to completely stop before tube removal. The client may not be ready for tube removal the day after surgery. 18. Which assessments made by the nurse could indicate the development of portal hypertension in a client with cirrhosis? Select all that apply. 1. Hemorrhoids 2. Bleeding gums 3. Muscle wasting 4. Splenomegaly 5. Ascites Rationale: Obstruction to portal blood flow causes a rise in portal venous pressure, which can lead to development of hemorrhoids. Splenomegaly can occur because of increased pressure in the portal system. Ascites occurs with portal blood flow obstruction because the increased pressure in the blood vessels leads to fluid accumulation in the abdomen because of pressure dynamics. Bleeding gums would indicate insufficient vitamin K production in the liver. Muscle wasting commonly accompanies the poor nutritional intake commonly seen in clients with cirrhosis. 19. The nurse is caring for a client who has ascites, and the healthcare provider prescribes spironolactone. When the client asks why this drug is being used, what is the best response by the nurse? 1. “This drug will help increase the level of protein in your blood.” 2. “The drug will cause an increase in the amount of the hormone aldosterone your body produces.” 3. “This medication is a diuretic but does not make the kidneys excrete potassium.” 4. “This will help you excrete larger amounts of ammonia.” Rationale: Spironolactone is used in clients with ascites who show no improvement with bedrest and fluid restriction. It inhibits sodium reabsorption in the distal tubule and promotes potassium retention by inhibiting aldosterone. Spironolactone does not increase protein levels in the blood. Spironolactone does not increase production of aldosterone. Spironolactone does not aid in excreting ammonia, although lactulose will have this effect. 20. When caring for a client who has cirrhosis, the nurse notices flapping tremors of the wrist and fingers. How should the nurse chart this finding? 1. “Trousseau’s sign noted.” 2. “Caput medusa noted.” 3. “Fetor hepaticus noted.” 4. “Asterixis noted.” Rationale: Asterixis is a flapping tremor of the hands when the arms are extended. Trousseau’s sign reflects hypocalcemia. Caput medusa refers to spiderlike abdominal veins that are also commonly found in clients

with cirrhosis who have portal hypertension as a complication. Fetor hepaticus is a specific odor noted in liver failure. 21. A mother arrives at the pediatric clinic with her 6-month-old infant. While the nurse assesses the child, the mother points to the umbilicus and says: “What am I going to do about this? When he cries, it looks like it’s going to burst.” What is the best response by the nurse? 1. “It’s best if you don’t let him cry.” 2. “It probably won’t rupture unless he gets excessively upset. I wouldn’t worry about it at this time.” 3. “I know it looks frightening, but it really won’t burst.” 4. “Put a binder around it, and that will keep it from bursting when he gets upset.” Rationale: It is a common finding that when the infant with an umbilical hernia cries, the hernia protrudes but will not rupture. It is unnecessary to try to prevent the infant from crying. An umbilical hernia will not rupture because the infant gets upset and this response does not reassure the parent. The family is instructed not to apply tape, straps, or coins to the umbilicus to reduce the hernia. 22. A 9-year-old male client with severe esophagitis is 12 hours’ status/post-Nissen fundoplication for gastroesophageal reflux. What action by the nurse would be appropriate while providing nursing care? 1. Encourage him to take small amounts of clear liquids every 4 hours. 2. Administer nasogastric or gastrostomy feedings every 4 hours. 3. Ask him to choose a face on the Wong FACES pain rating scale. 4. Insert a pH probe to monitor esophageal acidity Rationale: Pain management is a high priority following gastric surgery, and the nurse should use ageappropriate tools to assess for pain. A gastrostomy tube or nasogastric tube placed during surgery is kept in place to maintain gastric decompression, so drinking is not allowed. The child is kept NPO until bowel function returns. The use of a pH probe to measure gastric acidity is not necessary. 23. A 10-month-old female infant with biliary atresia is being discharged after a Kasai procedure. Which statement, if made by the parents, indicates that teaching with regard to prognosis has been understood? 1. “We are glad this problem was found so early; now everything will be fine.” 2. “We will stop her liver medicine now that she is being discharged.” 3. “We are happy to be able to stop that special formula and many of those vitamins.” 4. “We know that even though surgery is over, she will likely need a liver transplant.” Rationale: Because the Kasai procedure is palliative, a liver transplant is required in a majority of cases. The Kasai procedure is not curative, and prognosis is best if performed before 10 weeks of age. Its purpose is to achieve biliary drainage and avoid early liver failure. Medications need to be continued after discharge as prescribed. Formula and vitamins need to be continued after the procedure. 24. Which laboratory test would the nurse expect to be prescribed for a child with dehydration caused by vomiting and diarrhea? Select all that apply. 1. Serum sodium 2. Urine specific gravity 3. Serum ammonia 4. Serum amylase 5. Blood urea nitrogen (BUN) Rationale: Serum sodium would be expected to increase in a client with dehydration because of hemoconcentration. Measuring urine specific gravity provides data about the concentration of urine and provides information regarding hydration. The BUN rises with dehydration and is therefore a general

indicator of hydration status, although it also reflects kidney function. Serum ammonia could be elevated in liver disease. Serum amylase could be elevated in pancreatic disorders. 25. The nurse is caring for a child with a history of severe diarrhea. Which notation about acid–base imbalance would the nurse expect to find in the medical record? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis Rationale: In severe diarrhea, excess bicarbonate (base) is lost, which predisposes to metabolic acidosis. There is also carbohydrate malabsorption and depletion of glycogen stores, resulting in fat metabolism. Ketoacids are the by-products of fat metabolism, which adds to the metabolic acidosis. Diarrhea is not a respiratory problem, although diarrhea can lead to acidosis. Diarrhea is not a respiratory problem, and it does not lead to alkalosis. Diarrhea is a metabolic problem but does not lead to alkalosis. 26. A nurse who floats to the infant and toddlers nursing unit asks the pediatric nurse about the notation “ESSR” on the care plan of a client. The nurse explains that this documentation refers to which item? 1. The feeding method for children with gastroesophageal reflux 2. The feeding method for children with cleft lip or palate 3. The procedure for repair of pyloric stenosis 4. The proc...