GI

90問 • 1年前

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Carl, a 56-year-old traveling salesman, has recently been diagnosed with acute pancreatitis. Combined with clinical manifestations, what is the laboratory finding that is most commonly used to diagnose acute pancreatitis within 12 hours after onset of pain?

Increased serum amylase

Carl, a 56-year-old traveling salesman, has recently been diagnosed with acute pancreatitis. To prevent painful attacks, Carl will be on NPO (nothing per Orem) until

he is pain free.

Carl, a 56-year-old traveling salesman, has recently been diagnosed with acute pancreatitis. The nurse determines that further discharge instruction is needed when the patient with acute pancreatitis makes which statement?

"I shouldn't eat any salty foods or foods with high amounts of sodium."

Rory, an 18-year-old girl, is admitted to the hospital with a possible diagnosis of appendicitis. She had been symptomatic for several days before admission. During assessment, the nurse is looking for positive indicators of appendicitis, which include all of the following, ЕХСЕРТ:

thrombocytopenia.

Rory, an 18-year-old girl, is admitted to the hospital with a possible diagnosis of appendicitis. She had been symptomatic for several days before admission. A positive Rovsing's sign is indicative of appendicitis. The nurse knows to assess for this indicator by palpating the:

left lower quadrant.

Rory, an 18-year-old girl, is admitted to the hospital with a possible diagnosis of appendicitis. She had been symptomatic for several days before admission. Which complication is most likely the cause of appendicitis?

A fecalith

Rory, an 18-year-old girl, is admitted to the hospital with a possible diagnosis of appendicitis. She had been symptomatic for several days before admission. Preparation for an appendectomy includes all of the following measures, EXCEPT:

a bowel cleansing enema

Rory, an 18-year-old girl, is admitted to the hospital with a possible diagnosis of appendicitis. She had been symptomatic for several days before admission. The patient has peritonitis, which is a major complication of appendicitis. What treatment will the nurse plan to include?

Peritoneal lavage

The following questions ask about how the nurse should manage cases of inflammatory bowel disorders. Crohn's disease can be described as a chronic relapsing disease. Which area of the GI system may be involved with this disease?

The small intestine and colon, affecting the entire thickness of the bowel

The following questions ask about how the nurse should manage cases of inflammatory bowel disorders. A client with Crohn's disease experiences 20 watery stools per day. Which sign would indicate dehydration?

Poor skin turgor

The following questions ask about how the nurse should manage cases of inflammatory bowel disorders. Which intervention should be included in the medical management of Crohn's disease?

Using long-term steroid therapy

The following questions ask about how the nurse should manage cases of inflammatory bowel disorders. A nurse is reviewing the causes of ulcerative colitis with a client. Which factor is believed to cause ulcerative colitis?

Altered immunity

The following questions ask about how the nurse should manage cases of inflammatory bowel disorders. Which diet would be most appropriate for a client with ulcerative colitis?

Low-residue, high protein

A client with a chief complaint of vomiting and abdominal pain due to a swollen liver is diagnosed with cirrhosis of the liver. Aside from the vomiting and pain, the patient was also exhibiting 'flapping" tremors in the wrists and fingers. The nurse correctly identifies this as:

asterixis

A client with a chief complaint of vomiting and abdominal pain due to a swollen liver is diagnosed with cirrhosis of the liver. The client also has a large protruding abdomen positively identified by the doctor as ascites. The nurse knows the following are rationales for patients with liver cirrhosis having ascites, EXCEPT:

hyperlipidemia

A client with a chief complaint of vomiting and abdominal pain due to a swollen liver is diagnosed with cirrhosis of the liver. What laboratory test results should the nurse expect to find in a patient with cirrhosis?

Aspartate aminotransferase (AST): 6.0 U/L (0.1 mkat/L)

Malnutrition can be a big problem for patients with cirrhosis. Which nursing Intervention can help to improve nutrient intake?

Oral hygiene before meals and snacks

In discussing long-term management with the patient with alcoholic cirrhosis, what should the nurse advise the patient?

Abstinence from alcohol is the most important factor in improvement of the patient's condition.

A 45-year-old obese client with a history of hypertension is admitted to the medical-surgical unit with complaints of excruciating upper right abdominal pain that radiates to the back. She moves about restlessly, unable to find a comfortable position. She has been taking oral contraceptives for the past 3 months. A diagnosis of cholelithlasis with obstructive jaundice is made. While taking history, the nurse notes that the client has which of the following risk factors for development of gallstones, EXCEPT: 1. Age of 45 years old 2. Female gender 3. Obesity 4. History of hypertension 5. Use of oral contraceptives

4 only

A diagnosis of cholelithlasis with obstructive jaundice is made. The client experiences discomfort after ingesting fatty foods because:

Bile flow into the intestine is obstructed

A diagnosis of cholelithlasis with obstructive jaundice is made. The nurse is aware that the client would be likely to exhibit which of the following signs and symptoms? 1. Ecchymosis 2. Icteric Sclera 3. Dark brown stool 4. Straw-colored urine 5. Pain in right upper quadrant

1, 2 and 5

A diagnosis of cholelithlasis with obstructive jaundice is made. The client is scheduled for extracorporeal shock wave lithotripsy. The nurse should tell the client about which of these symptoms that may occur after this procedure?

Colic-type pain

Which outcome statement best indicates the effectiveness of treatment to reduce the aggravating factors of cholelithiasis?

The client reports no pain following Ingestion of low-fat meal

A 53 years old client has a seven-year history of hepatic cirrhosis. He was brought to the emergency room because he began vomiting large amounts of dark-red blood. The physician suspects bleeding esophageal varices. When caring for the client, with esophageal varices, the nurse knows that bleeding in this disorder usually stems from:

Portal hypertension

A 53 years old client has a seven-year history of hepatic cirrhosis. He was brought to the emergency room because he began vomiting large amounts of dark-red blood. The physician suspects bleeding esophageal varices. A Sengstaken-Blakemore tube was inserted to tamponade the bleeding esophageal varices. While the balloon tamponade is in place, the nurse who is caring for the client gives the highest priority to:

Auscultating breath sounds

The nurse is caring for the client, who has a Sengstaken-Blakemore tube in place to stop the bleeding. Which of the following actions should the nurse take first if the client suddenly experiences difficulty breathing?

Cut and remove the tube

Which rationale supports explaining the placement of an esophageal tamponade tube in the client, who is hemorrhaging?

Obtaining cooperation and reducing fear

The client Is receiving a vasopressin infusion. Which of these findings would indicate a complication of this therapy?

Chest pain

Crucial to the management of gastrointestinal conditions is an astute assessment of the gastrointestinal tract including its structure and the functions of each The nurse is performing a focused abdominal assessment of a patient who has been recently admitted. In order to palpate the patient's liver, where should the nurse palpate the patient's abdomen?

Right upper quadrant

The ED nurse has inspected, auscultated, and palpated the abdomen with no obvious abnormalities, except pain. When the nurse palpates the abdomen for rebound tenderness, there is severe pain. The nurse should know that this could indicate what problem?

Peritoneal inflammation

The health care team is assessing a male patient for acute pancreatitis after he presented to the emergency department with severe abdominal pain. Which laboratory value is the best diagnostic indicator of acute pancreatitis?

Serum amylase

A patient who is scheduled for surgery with general anesthesia in 1 hour is observed with a moist, but empty water glass in his hand. Which assessment finding may indicate that the patient drank a glass of water?

Easily heard, loud gurgling in the right upper quadrant

The patient tells the nurse she had a history of abdominal pain, so she had a surgery to make an opening into the common bile duct to remove stones. The nurse knows that this surgery is called a

choledocholithotomy

A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. The nurse should do which of the following first?

Notify the physician.

When obtaining a nursing history from a client with a suspected gastric ulcer, which signs and symptoms should the nurse assess? Select all that apply. 1) Epigastric pain at night. 2) Relief of epigastric pain after eating. 3) Vomiting. 4) Weight loss. 5) Melena.

3, 4 & 5 ONLY

The nurse is caring for a client who has had a gastroscopy. Which of the following may indicate that the client Is developing a complication related to the procedure? Select all that apply. 1) The client has a sore throat. 2) The client has a temperature of 100°F (37.8°C), • 3) The client appears drowsy following the procedure. 4) The client has epigastric pain. 5) The client experiences hematemesis.

2, 4 & 5 ONLY

A client admitted to the hospital with peptic ulcer disease tells the nurse about having black, tarry stools. The nurse should

Report the finding to the health care provider.

A client with peptic ulcer disease is taking ranitidine. What Is the expected outcome of this drug?

Limit gastric acid secretion.

A client with a peptic ulcer reports epigastric pain that frequently causes the client to wake up during the night. The nurse should instruct the client to do which activities? Select all that apply. 1)Obtain adequate rest to reduce stimulation. 2)Eat small, frequent meals throughout the day. 3)Take all medications on time as prescribed. 4)Sit up for 1 hour when awakened at night. 5)Stay away from crowded areas.

ALL EXCEPT 5

The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the client should eat which of the following?

Any foods that are tolerated.

A client with peptic ulcer disease reports being nauseated most of the day and now feeling light-headed and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? Select all that apply. 1) Administering an antacid hourly until nausea subsides. 2)Monitoring the client's vital signs. 3) Notifying the physician of the client's symptoms. 4) Initiating oxygen therapy. 5) Reassessing the client in an hour.

2&3 ONLY

The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers from a briefcase and arguing on the telephone with a coworker. The nurse's response to observing these actions should be based on knowledge that:

A relaxed environment will promote ulcer healing.

A client with a peptic ulcer has been Instructed to avoid intense physical activity and stress. Which strategy should the client incorporate into the home care plan?

Incorporate periods of physical and mental rest in the daily schedule.

Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing gastrosophageal reflux disease (GERD)?

Do not lie down for 2 hours after eating.

The client Is scheduled to have an upper gastrointestinal tract series of x-rays. Following the x-rays, the nurse should instruct the client to:

Take a laxative.

A client who has been diagnosed with gastroesophageal reflux disease (GERD) has heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet?

Hot chocolate.

The client with gastroesophageal reflux disease (GERD) has a chronic cough. This symptom may be indicative of which of the following?

Aspiration of gastric contents.

Bethanechol has been prescribed for a client with gastrosophageal reflux disease (GERD). The nurse should assess the client for which of the following adverse effects?

Urinary urgency.

The client attends two sessions with the dietitian to learn about diet modifications to minimize gastrosophageal reflux. The teaching would be considered successful if the client decreases the intake of which of the following foods?

Fats.

The nurse is obtaining a health history from a client who has a sliding hiatal hernia associated with reflux. The nurse should ask the client about the presence of which of the following symptoms?

Heartburn.

Which of the following factors would most likely contribute to the development of a client's hiatal hernia?

Being 5 feet, 3 inches tall (160 cm) and weighing 190 Ib (86.2 kg).

Which of the following nursing interventions would most likely promote self-care behaviors in the client with a hiatal hernia?

Ask the client to identify other situations in which the client changed health care habits.

When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistant? Select all that apply. 1) Assessing the client's bowel sounds. 2)Providing skin care following bowel movements. 3) Evaluating the client's response to antidiarrheal medications. 4)Maintaining intake and output records. 5.) Obtaining the client's weight.

2, 4 & 5 ONLY

Which goal for the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis?

Managing diarrhea.

The client with ulcerative colitis is to be on bed rest with bathroom privileges. When evaluating the effectiveness of this level of activity, the nurse should determine if the client has:

Reduced intestinal peristalsis.

A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which of the following complications?

Hypokalemia.

A client who has ulcerative colitis says to the nurse, "I can't take this anymore; I'm constantly in pain, and I can't leave my room because I need to stay by the toilet. I don't know how to deal with this." Based on these comments, the nurse should determine the client is experiencing:

Difficulty coping.

A nurse Is providing wound care to a client 1 day following an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care?

Clean the area around the drain moving away from the drain.

The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should:

Place the client on nothing-by-mouth (NPO) status.

A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these findings, the nurse should further assess the client for which of the following complications?

Peritonitis.

Postoperative nursing care for a client after an nursing appendectomy should include which of the following?

Noting the first bowel movement after surgery.

A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to:

Promote drainage of wound exudates.

A client has undergone a laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the discharge teaching?

Report bile-colored drainage from any incision.

A 40-year-old client is admitted to the hospital with a ' diagnosis of acute cholecystitis. The nurse should contact the physician to question which of the following prescriptions?

Administer morphine sulfate 10 mg IM every 4 hours as needed for severe abdominal pain.

A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis. The client has severe abdominal pain and nausea, and has vomited several times. Based on these data, which nursing action would have the highest priority for intervention at this time?

Manage the pain.

A client has an open cholecystectomy with bile duct exploration. Following surgery, the client has a t-tube. To evaluate the effectiveness of the t-tube, the nurse should:

Assess the color and amount of drainage every shift.

The nurse measures the amount of bile drainage from a t-tube and records it by which one of the following methods?

Charting it separately on the output record.

The client who has been hospitallzed with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:

There Is a strong link between alcohol use and acute pancreatitis.

The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions Is primarily responsible for making it difficult to manage shock in pancreatitis?

Vasodilating effects of kinin peptides.

A client with acute pancreatitis has a blood pressure of 88/40, heart rate of 128 bpm, respirations of 28/min, and Grey Turner's sign. What action should the nurse perform first?

Place an intravenous line.

A client is admitted with acute necrotizing pancreatitis. Lab results have been obtained, and a peripheral IV has been inserted. Which of the following prescriptions from a health care provider should the nurse question?

Total parenteral nutrition (TPN) at 72 mL/h.

The nurse should monitor the client with acute pancreatitis for which of the following complications?

Pneumonia.

A client with cirrhosis is receiving lactulose. During the assessment, the nurse notes increased confusion and asterixis. The nurse should:

Assess for gastrointestinal (GI) bleeding.

The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the physician of a decrease in which serum lab value that is a potential precipitating factor for hepatic encephalopathy?

Potassium.

A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process?

"Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels."

A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply. 1) Preventing constipation. 2) Administering lactulose to reduce blood ammonia levels. 3) Monitoring coordination while walking. 4) Checking the pupil reaction. 5)Providing food and fluids high in carbohydrate. 6) Encouraging physical activity,

ALL EXCEPT 6

The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment Is appropriate?

Anorexia.

A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?

Hyperkalemia.

What diet should be implemented for a client who is in the early stages of cirrhosis?

High-calorie, high-carbohydrate.

A client with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse discuss to prevent skin breakdown? Select all that apply. 1) Avoid lotions containing calamine. 2) Add baking soda to the water in a tub bath. 3)Keep nails short and clean. 4) Rub the skin when it itches with knuckles Instead of nails. 5) Massage skin with alcohol. 6) Increase sodium intake in diet.

2,3 & 4 ONLY

Which of the following health promotion activities would be appropriate for the nurse to suggest that the client with cirrhosis add to the daily routine at home?

Abstain from drinking alcohol.

Which of the following positions would be appropriate for a client with severe ascites?

Fowler's.

A member of the community who is schedule for a dental appointment after the program asked whether him having a history of mitral valve prolapse is significant. Which of the following replies is most appropriate?

"We will prescribe a prophylactic antibiotic for you to take before getting your teeth cleaned."

Arya is a community health nurse who has just finished organizing a program on oral health and smoking cessation. Which of the following lesions are commonly associated with oral cancer?

Red or white patches in the mouth or throat

A group of men who regularly chew tobacco have asked about warning signs that they need to report to their physicians. The following symptoms should be reported, EXCEPT:

Sensitive teeth

Sansa, a 34 year old lawyer, has been admitted to the hospital with complaints of stomach pain and suspected peptic ulcer disease. The nurse will now help prepare her for various investigations and treatment to help alleviate symptoms associated with this condition. Just as Sansa was about to be discharged, she starts vomiting bright red blood, develops a sudden sharp pain in the mid-epigastric region along with a rigid, board-like abdomen. These clinical manifestations suggest that the client has developed which of the following?

A perforated ulcer

Ned is a 65-year-old male who has been admitted to the hospital for a planned gastrectomy following a recent diagnosis of stomach cancer. The nurse knows that 90 to 95% of gastric cancers arise from which part of the stomach?

Mucus producing cells of the stomach

Ned is a 65-year-old male who has been admitted to the hospital for a planned gastrectomy following a recent diagnosis of stomach cancer. The surgeon has ordered an EGD to be done prior to surgery. The nurse would anticipate that the patient would most likely be in which position for the procedure?

Left lateral

Nurse Robb is caring for a 76-year old patient who has just returned to the unit following a subtotal gastrectomy. Nurse Robb is examining the drainage coming from the patient’s nasogastric tube. What color would be expected for about 12 to 24 hours after surgery?

Dark brown

Nurse Robb is caring for a 76-year old patient who has just returned to the unit following a subtotal gastrectomy. To reduce the risk of dumping syndrome following a gastrectomy, the nurse should teach the client to do which of the following?

Decrease the carbohydrate content of meals

Astignars random QS

Kyla Angelique Son · 19問 · 1年前

Astignars random QS