Which information about an 80-yr-old male patient at the senior center is of most concern to the
nurse?
a. Decreased appetite c. Difficulty chewing
food
b. Unintended weight
loss
d. Complaints of
indigestion
ANS: B
Unintentional weight loss is not a normal finding and may indicate a proble...
LEWIS 10th
Chapter 38: Assessment of Gastrointestinal System
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. Which information about an 80-yr-old male patient at the senior center is of most concern to the
nurse?
a. Decreased appetite c. Difficulty chewing
food
b. Unintended weight d. Complaints of
loss indigestion
ANS: B
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 much concern as the weight loss.
DIF: Cognitive Level: Analyze (analysis) REF: 839
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
2. An older patient reports chronic constipation. To promote bowel evacuation, the nurse will suggest
that the patient attempt defecation
a. in the mid-afternoon.
b. after eating breakfast.
c. right after getting up in the morning.
d. immediately before the first daily meal.
ANS: B
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.
DIF: Cognitive Level: Apply (application) REF: 836
3. When caring for a patient with a history of a total gastrectomy, the nurse will monitor for
a. constipation.
b. dehydration.
c. elevated total serum cholesterol.
d. cobalamin (vitamin B12) deficiency.
ANS: D
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, elevated cholesterol, or
constipation.
DIF: Cognitive Level: Apply (application) REF: 835
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. The nurse will plan to monitor a patient with an obstructed common bile duct for
a. melena.
b. steatorrhea.
c. decreased serum cholesterol level.
d. increased serum indirect bilirubin level.
ANS: B
A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to
fatty stools. Gastrointestinal bleeding is not caused by common bile duct obstruction. Serum
cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with
biliary obstruction.
DIF: Cognitive Level: Apply (application) REF: 847
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
5. The nurse receives the following information about a 51-yr-old female patient who is scheduled for a
colonoscopy. Which information should be communicated to the health care provider before
sending the patient for the procedure?
a. The patient has a permanent pacemaker to
prevent bradycardia.
b. The patient is worried about discomfort
, during the examination.
c. The patient has had an allergic reaction to
both shellfish and iodine in the past.
d. The patient declined to drink the prescribed
polyethylene glycol (GoLYTELY).
ANS: D
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 to magnetic resonance imaging
but not to colonoscopy. The nurse should instruct the patient about the sedation used during the
examination to decrease the patient’s anxiety about discomfort.
DIF: Cognitive Level: Apply (application) REF: 849
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
6. Which statement to the nurse from a patient with jaundice indicates a need for teaching?
a. “I used cough syrup several times a day last
week.”
b. “I take a baby aspirin every day to prevent
strokes.”
c. “I use acetaminophen (Tylenol) every 4 hours
for back pain.”
d. “I need to take an antacid for indigestion
several times a week”
ANS: C
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.
DIF: Cognitive Level: Apply (application) REF: 840
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
7. To palpate the liver during a head-to-toe physical assessment, the nurse
a. places one hand on the patient’s back and
presses upward and inward with the other
hand below the patient’s right costal margin.
b. places one hand on top of the other and uses
, the upper fingers to apply pressure and the
bottom fingers to feel for the liver edge.
c. presses slowly and firmly over the right costal
margin with one hand and withdraws the
fingers quickly after the liver edge is felt.
d. places one hand under the patient’s lower ribs
and presses the left lower rib cage forward,
palpating below the costal margin with the
other hand.
ANS: A
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.
DIF: Cognitive Level: Apply (application) REF: 844
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
8. Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal
assessment?
a. Loud gurgles c. Absent bowel sounds
b. High-pitched gurgles d. Frequent clicking
sounds
ANS: C
Absent bowel sounds are abnormal and require further assessment by the nurse. The other sounds
may be heard normally.
DIF: Cognitive Level: Apply (application) REF: 844
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
9. After assisting with a needle biopsy of the liver at a patient’s bedside, the nurse should
a. put pressure on the biopsy site using a
sandbag.
b. elevate the head of the bed to facilitate
breathing.
c. place the patient on the right side with the bed
flat.
d. check the patient’s postbiopsy coagulation
studies.
ANS: C
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