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GI questions with Complete Answers
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GI questions with Complete Answers
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GI questions with Complete AnswersAn adolescent is being seen in the clinic for abdominal pain with a fever. In what order
should the nurse assess the abdomen?
1.Auscultate.
2.Inspect.
3.Palpate.
4.Percuss.
(70) - Answer-A: 2,1,4,3
R: The nurse should first inspect the abdomen for abnormalities. Auscultation should be
done before percussion and palpation as vigorous touching may disturb the intestines.
Percussion is next. Palpation is the last step as it is most likely to cause pain.
A child is admitted with a diagnosis of possible appendicitis. The child is in acute pain.
Which of the following nursing interventions would be appropriate prior to surgery to
decrease pain? Select all that apply.
1.Offer an ice pack.
2.Apply a heating pad.
3.Encourage the child to assume a position of comfort.
4.Limit the child's activity.
5.Request a prescription for a cathartic.
6. Administer pain medication
(71) - Answer-A: 1,3,4
R:Cold is a vasoconstrictor and supplies some degree of anesthesia. The child is
usually more comfortable on his side with his legs flexed to take the strain off the
inflamed appendix. Limiting the child's activity puts less stress on the inflamed appendix
and lessens the discomfort. Heat increases circulation to an area, causing more
engorgement and pain and, possibly, rupture of the appendix. Heat is contraindicated in
any situation where rupture or perforation is a possibility. A cathartic is contraindicated
when appendicitis is suspected. Increasing peristalsis can cause the appendix to
rupture. Pain medication masks symptoms of perforation.
A 10-year old male is 24 hours postappendectomy. He is awake, alert, and oriented. He
tells the nurse that he is experiencing pain. He has a prescription for morphine 1 to 2
mg PRN pain. What is the priority nursing action in managing the child's pain?
1.Change the child's position in bed.
2.Obtain vital signs with a pain score.
3.Administer 1 mg morphine as prescribed.
4.Perform a head to toe assessment.
(72) - Answer-A: 2
, R: The child is in pain and needs intervention but before the nurse can determine how
to proceed, it is essential to know the client's pain score to determine the appropriate
morphine dose. In addition, the nurse cannot evaluate the effectiveness of the pain
medication if there is no pain score prior to administering the medication. Changing the
child's position and administering pain medication may be helpful to relieve the child's
pain but the nurse must first know the severity of the pain before determining the
appropriate intervention. The nurse must perform a head to toe assessment however it
is not the priority in managing the child's pain.
A 5-year-old child is experiencing pain after an appendectomy. Which data collection
tool should the nurse use to assess the pain?
1.Visual analog scale.
2.FLACC scale.
3.Numerical pain scale.
4.FACES pain rating scale.
(73) - Answer-A: 4
R: The nurse should use the FACES pain rating scale for children aged three or older.
The visual analog and numerical scales are used with adults. The FLACC (faces-legs-
activity-cry-consolability) scale is a behavioral scale that is appropriate for very small
children or nonverbal children.
When obtaining the initial health history from a 10-year-old child with abdominal pain
and suspected appendicitis, which of the following questions would be most helpful in
eliciting data to help support the diagnosis?
1."Where did the pain start?"
2."What did you do for the pain?"
3."How often do you have a bowel movement?"
4."Is the pain continuous, or does it let up?"
(75) - Answer-A:1
R: The most helpful question would be to determine the location of the pain when it
started. The pain associated with appendicitis usually begins in the periumbilical area,
and then progresses to the right lower quadrant. After the nurse has determined the
location of the pain, asking about what was done for the pain would be appropriate.
Asking about the child's usual bowel movement pattern is a general question unrelated
to child's condition. Children with appendicitis may have diarrhea or constipation.
Additionally, knowledge about the child's usual pattern would not be a priority because
the child with appendicitis typically is not hospitalized long enough to reestablish the
normal pattern. Although the characteristics of the pain are important, asking if the pain
is continuous or intermittent is vague and general because the pain could be associated
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