Gastrointestinal Clinical Assessment and Diagnostic Procedures
Gastrointestinal Clinical Assessment and Diagnostic Procedures
When assessing the
... [Show More] gastrointestinal system, the order of assessment progresses in which of the following?
a. Inspection, palpation, percussion, auscultation
b. Palpation, percussion, inspection, auscultation
c. Inspection, auscultation, percussion, palpation
d. Palpation, inspection, auscultation, percussion
ANS: C
To prevent stimulation of gastrointestinal activity, the order for the assessment should be inspection, auscultation, percussion, and palpation.
When assessing the abdomen, how long must the nurse listen to the abdomen to be able to accurately chart that bowel sounds are absent?
a. 30 seconds in each quadrant
b. 1 minute
c. 3 minutes
d. 5 minutes
ANS: D
Normal bowel sounds include high-pitched, gurgling sounds that occur approximately every 5 to 15 seconds or at a rate of 5 to 34 times per minute. Abnormal findings include the absence of bowel sounds throughout a 5-minute period, extremely soft and widely separated sounds, and increased sounds with a high-pitched, loud rushing sound (peristaltic rush).
Which assessment technique is most useful in detecting abdominal pathologic conditions? a. Percussion
b. Palpation
c. Inspection
d. Auscultation
ANS: B
Palpation is the assessment technique that is most useful in detecting abdominal pathologic conditions. Both light and deep palpation of each organ and quadrant should be completed. Deep palpation is most helpful in detecting abdominal masses. Areas in which the patient complains of tenderness should be palpated last.
Which of the following findings is considered an abnormal gastrointestinal assessment finding?
a. Visible peristaltic waves
b. Hyper-resonance of the intestine
c. High-pitched gurgling sounds in the small intestine
d. Dull sounds over the liver and spleen
ANS: A
Visible pulsations or peristaltic waves are considered an abnormal assessment finding.
Which of the following serum laboratory values is increased in acute pancreatitis? a. Bilirubin
b. Amylase
c. Lactate dehydrogenase
d. Ammonia
ANS: B
Serum amylase will rise with acute pancreatitis. The other values are affected by hepatocellular disease.
The best diagnostic test for the determination of upper gastrointestinal bleeding is a. endoscopic retrograde cholangiopancreatography (ERCP).
b. colonoscopy.
c. endoscopy.
d. angiography.
ANS: C
Endoscopy is the procedure of choice for the diagnosis of upper gastrointestinal (GI) bleeding. Colonoscopy permits viewing of the lower GI tract from the rectum to the distal ileum, and it is used to evaluate sources of lower GI bleeding. Angiography is used as a diagnostic and a therapeutic procedure. Diagnostically, it is used to evaluate the status of the GI circulation. Endoscopic retrograde cholangiopancreatography (ERCP) enables viewing of the biliary and pancreatic ducts, and it is used in the evaluation of pancreatitis.
Upon auscultation, the nurse hears borborygmi. This is a change in the patient's condition. The nurse suspects the patient maybe experiencing
a. a complete ileus.
b. early intestinal obstruction.
c. abnormality of blood flow.
d. peritonitis.
ANS: B
Hyperactive bowel sounds (borborygmi) that are loud and prolonged are caused by hunger, gastroenteritis, or early intestinal obstruction. Decreased (hypoactive) bowel sounds are symptoms of possible peritonitis or ileus. Bruits are caused by abnormality of blood flow.
Nursing management of the patient undergoing an angiogram includes
a. keeping the patient flat for 24 hours.
b. inserting a nasogastric tube before the procedure.
c. administering tap water enemas until clear.
d. checking the patient's pulse distal to the injection site every 15 minutes.
ANS: D
Postprocedural assessment involves monitoring vital signs, observing the injection site for bleeding, and assessing neurovascular integrity distal to the injection site every 15 minutes for the first 1 to 2 hours. Depending on how the puncture site is stabilized after the procedure, the patient may have to remain flat in bed for a specified length of time.
Which of the following diagnostic procedures is used to identify gallstones and hepatic abscesses?
a. Ultrasonography
b. Abdominal radiography
c. Angiography
d. Liver scan
ANS: A
Abdominal ultrasonography is useful in evaluating the status of the gallbladder and biliary system, the liver, the spleen, and the pancreas. It plays a key role in the diagnosis of many acute abdominal conditions, such as acute cholecystitis and biliary obstructions, because it is sensitive in detecting obstructive lesions, as well as ascites. Ultrasonography is used to identify gallstones and hepatic abscesses, candidiasis, and hematomas.
A 78-year-old patient was admitted to the critical care unit with cirrhosis of the liver. In cirrhosis of the liver, which of the following laboratory values is expected to drop?
a. Albumin
b. Total bilirubin
c. Alkaline phosphatase
d. Aspartate aminotransferase
ANS: A
In a patient with cirrhosis, total bilirubin, alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase values all show elevation, but albumin values drop as a result of the catabolism.
Signs and symptoms of which condition include nausea, localized right lower quadrant guarding and tenderness after 12 to 24 hours, fever, and an elevated white blood cell count? a. Appendicitis
b. Hepatitis
c. Cecal volvulus
d. Perforated duodenal ulcer
ANS: A
Signs and symptoms of appendicitis include anorexia, nausea, and vomiting; early vague epigastric, periumbilical, or generalized pain after 12 to 24 hours; RLQ at McBurney point; localized RLQ guarding and tenderness after 12 to 24 hours; a white blood cell count of 10,000/mm or left shift; and low-grade fever. Signs are highly variable.
A health care provider has ordered an MRI (magnetic resonance imaging) of the liver. The nurse's first action is to
a. prepare the patient psychologically and physically for the procedure.
b. monitor the patient's response to the procedure.
c. assess the patient after the procedure.
d. inform the patient's family of the results.
ANS: A
The nursing management of a patient undergoing a diagnostic procedure involves a variety of interventions. Nursing actions include preparing the patient psychologically and physically for the procedure, monitoring the patient's responses to the procedure, and assessing the patient after the procedure. Preparing the patient includes teaching the patient about the procedure, answering any questions, and transporting and positioning the patient for the procedure.
Steatorrhea is determined by which laboratory study? a. Gastric acid stimulation
b. Urea breath test
c. Culture and sensitivity
d. Stool studies
ANS: D
Steatorrhea (an increase of fat in the stool) results from malabsorption or pancreatic insufficiency and is determined with stool studies. The result of the urea breath test is positive if the patient has a Helicobacter pylori infection. Gastric acid stimulation is used for the detection of duodenal ulcers, gastric atrophy, and gastric carcinoma.
Which radiographic test would be used to identify pseudocysts of the pancreas? a. Plain film radiography
b. Abdominal ultrasonography
c. CT of abdomen
d. MRI of the abdomen
ANS: C
CT (Computed tomography) detects mass lesions more than 2 cm in diameter and allows visualization and evaluation of many different aspects of gastrointestinal (GI) disease. It is particularly useful in identifying pancreatic pseudocysts, abdominal abscesses, biliary obstructions, and a variety of GI neoplastic lesions.
The patient has just returned from a liver biopsy. The patient should be positioned on the
a. left side for 2 hours.
b. right side for 2 hours.
c. left side for 6 to 8 hours.
d. right side for 6 to 8 hours.
ANS: B
After the procedure, the patient is positioned on the right side for 2 hours and kept on complete bed rest for the next 6 to 8 hours.
Identify anatomic structures that are found in the right upper quadrant. (Select all that apply.) a. Duodenum
b. Portion of the transverse colon
c. Liver
d. Stomach e. Cecum
ANS: A, B, C
The right upper quadrant includes the liver and gallbladder, pylorus, duodenum, head of pancreas, right adrenal gland, portion of the right kidney, hepatic flexure of colon, and a portion of the ascending and transverse colon. The stomach is located in the left upper quadrant and the cecum is located in the right lower quadrant.
Identify anatomic structures that are found in the right lower quadrant. (Select all that apply.) a. Sigmoid colon
b. Portion of the ascending colon
c. Portion of the descending colon
d. Distended bladder
e. Enlarged uterus
ANS: B, D, E
The right lower quadrant includes the lower pole of the right kidney, cecum and appendix, portion of the ascending colon, bladder (if distended), ovary and salpinx, uterus (if enlarged), right spermatic cord, and right ureter. The sigmoid colon and portion of the descending colon are found in the left lower quadrant.
Identify anatomic structures that are found in the left upper quadrant. (Select all that apply.) a. Stomach
b. Spleen
c. Portion of the transverse and descending colon d. Head of the pancreas
e. Body of the pancreas
ANS: A, B, C, E
The left upper quadrant includes the left lobe of the liver, spleen, stomach, body of the pancreas, left adrenal gland, portion of the left kidney, splenic flexure of the colon, and portions of the transverse and descending colon. The head of the pancreas is found in the right upper quadrant.
Identify anatomic structures that are found in the left lower quadrant. (Select all that apply.) a. Distended uterus
b. Cecum and appendix
c. Left ureter
d. Portion of the descending colon
e. Sigmoid colon
ANS: A, C, D, E
The left lower quadrant includes the lower pole of the left kidney, sigmoid colon, portion of the descending colon, bladder (if distended), ovary and salpinx, uterus (if distended), left spermatic cord, and left ureter. The cecum and appendix is found in the right lower quadrant.
Potential complications of an endoscopy include (Select all that apply.) a. perforation of the GI tract.
b. hemorrhage.
c. oversedation.
d. constipation.
e. aspiration.
ANS: A, B, C, E
Fiberoptic endoscopy may present risks for the patient. Although rare, potential complications include perforation of the gastrointestinal (GI) tract, hemorrhage, aspiration, vasovagal stimulation, and oversedation. Signs of perforation include abdominal pain and distention, GI bleeding, and fever.
Inspection of the GI system should include the (Select all that apply.) a. mouth.
b. esophagus.
c. skin.
d. bladder.
e. abdomen.
ANS: A, C, E
Although assessment of the gastrointestinal system classically begins with inspection of the abdomen, the patient's oral cavity also must be inspected to determine any unusual findings. Abnormal findings of the mouth include temporomandibular joint tenderness, inflammation of gums, missing teeth, dental caries, ill-fitting dentures, and mouth odor. The skin should be observed for pigmentation, lesions, striae, scars, petechiae, signs of dehydration, and venous pattern. [Show Less]