Chapter 52: Assessment of the Gastrointestinal System Ignatavicius: Medical-Surgical Nursing, 8th Edition

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The student nurse studying the gastrointestinal system understands that chyme refers to what? Hormones that reduce gastric acidity Liquefied food ready for digestion Nutrients after being absorb... ed Secretions that help digest food ANS: B Before being digested, food must be broken down into a liquid form. This liquid is called chyme. Secretin is the hormone that inhibits acid production and decreases gastric motility. Absorption is carried out as the nutrients produced by digestion move from the lumen of the GI tract into the body’s circulatory system for uptake by individual cells. The secretions that help digest food include hydrochloric acid, bile, and digestive enzymes. DIF: Remembering/Knowledge REF: 1085 KEY: Gastrointestinal system MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best? a. Ask the client about shellfish allergies. Document this information on the chart. Ensure that the client has a ride home. Instruct the client on bowel preparation. ANS: A PTC uses iodinated dye, so the client should be asked about seafood allergies, specifically to shellfish. Documentation should occur, but this is not the priority. The client will need a ride home afterward if the procedure is done on an outpatient basis. There is no bowel preparation for PTC. DIF: Applying/Application REF: 1093 KEY: Gastrointestinal system| gastrointestinal assessment| allergies| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The client’s respiratory rate is 8 breaths/min. What action by the nurse is best? Administer naloxone (Narcan). Call the Rapid Response Team. Provide physical stimulation. Ventilate with a bag-valve-mask. ANS: C For an EGD, clients are given mild sedation but should still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse’s first action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for Versed. The Rapid Response Team is not needed at this point. The client does not need manual ventilation. DIF: Applying/Application REF: 1094 KEY: Gastrointestinal system| medication side effects| nursing implementation MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? a. “It’s a good thing I love orange and cherry gelatin.” “My spouse will be here to drive me home.” “I should refrigerate the GoLYTELY before use.” “I will buy a case of Gatorade before the prep.” ANS: A The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure. DIF: Evaluating/Synthesis REF: 1095 KEY: Gastrointestinal system| gastrointestinal assessment| patient education MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best? Ask the client to call back if this happens again today. Instruct the client to go to the emergency department. Remind the client that a small amount of bleeding is possible. Tell the client to come in to the clinic this afternoon. ANS: C After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse should remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness. DIF: Understanding/Comprehension REF: 1096 KEY: Gastrointestinal system| gastrointestinal assessment| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential An older client has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? “Changes in your liver cause drugs to be metabolized differently.” “Perhaps you don’t need as high a dose of the drug as before.” “Stomach muscles atrophy with age and you digest more slowly.” “Your body probably can’t tolerate as much medication anymore.” ANS: A Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugs—possibly to toxic levels. The other options do not accurately explain this age-related change. DIF: Understanding/Comprehension REF: 1088 KEY: Gastrointestinal system| older adult| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance [Show More]

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