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Science / Medicine / Surgery
Medical-Surgical Nursing Review
Terms in this set (138)
Chapter 39 - NCLEX ...
Review Questions
(GASTROINTESTINAL
SYSTEM)
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- Auscultate the abdomen before
When assessing a
palpation.
patient's
>During examination of the abdomen,
abdomen, what
auscultation is done before percussion
would be most
and palpation because these latter
appropriate for
procedures may alter the bowel
the nurse to do?
sounds.
A. Palpate the
abdomen before
auscultation.
B. Percuss the
abdomen before
auscultation.
C. Auscultate the
abdomen before
palpation.
D. Perform deep
palpation before
light palpation.
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- Ensure the patient understands the
When preparing
required bowel preparation.
a patient for a
>A capsule endoscopy study involves
capsule
the patient performing a bowel prep to
endoscopy study,
cleanse the bowel before swallowing
what should the
the capsule.
nurse do?
>The patient will be on a clear liquid
A. Ensure the
diet for 1 to 2 days before the
patient
procedure and will remain NPO for 4 to
understands the
6 hours after swallowing the capsule.
required bowel
>The capsule is disposable and will pass
preparation.
naturally with the bowel movement,
B. Have the
although the monitoring device will
patient return to
need to be removed.
the procedure
room for removal
of the capsule.
C. Teach the
patient to
maintain a clear
liquid diet
throughout the
procedure.
D. Explain to the
patient that
conscious
sedation will be
used during
placement of the
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Inspection of an - Candida albicans
older patient's >White, curd-like lesions surrounded by
mouth reveals erythematous mucosa are associated
the presence of with oral candidiasis. Herpesvirus
white, curd-like causes benign vesicular lesions in the
lesions on the mouth. Vitamin deficiencies may cause a
patient's tongue. reddened, ulcerated, swollen tongue.
What is the most Irritation from ill-fitting dentures will
likely etiology for cause friable, edematous, painful,
this abnormal bleeding gingivae.
assessment
finding?
A. Herpesvirus
B. Candida
albicans
C. Vitamin
deficiency
D. Irritation from
ill-fitting dentures
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The nurse should - Detoxification
recognize that - Protein metabolism
the liver - Steroid metabolism
performs which >The liver performs multiple major
functions (select functions that aid in the maintenance of
all that apply)? homeostasis. These include metabolism
A. Bile storage of proteins and steroids as well as
B. Detoxification detoxification of drugs and metabolic
C. Protein waste products. The Kupffer cells of the
metabolism liver participate in the breakdown of
D. Steroid old RBCs. The liver produces bile, but
metabolism storage occurs in the gall bladder.
E. Red blood cell
(RBC)
destruction
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The health care - Serum amylase
>Elevated serum amylase levels indicate
team is assessing
a male patient for early pancreatic dysfunction and are
acute pancreatitis used to diagnose acute pancreatitis.
after he Serum lipase levels stay elevated
longer than serum amylase in acute
presented to the
emergency pancreatitis. Blood glucose, gastric pH,
department with and potassium levels are not direct
severe abdominal indicators of acute pancreatic
dysfunction.
pain. Which
laboratory value
is the best
diagnostic
indicator of acute
pancreatitis?
A. Gastric pH
B. Blood glucose
C. Serum
amylase
D. Serum
potassium
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The nurse is - Right upper quadrant
performing a >Although the left lobe of the liver is
focused located in the left upper quadrant of
abdominal the abdomen, the bulk of the liver is
assessment of a located in the right upper quadrant.
patient who has
been recently
admitted. In
order to palpate
the patient's liver,
where should the
nurse palpate the
patient's
abdomen?
A. Left lower
quadrant
B. Left upper
quadrant
C. Right lower
quadrant
D. Right upper
quadrant
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-
The patient had a
>The constipation is most likely related
car accident and
to the sympathetic nervous system
was "scared to
activation from the stress related to the
death." The
accident. SNS activation can decrease
patient is now
peristalsis. Even without oral intake for a
reporting
short time, stool will be formed.
constipation.
>The parasympathetic system stimulates
What affecting
peristalsis.
the
>The circulation to the GI system is
gastrointestinal
decreased with stress
(GI) tract does
the nurse know
could be
contributing to
the constipation?
A. The patient is
too nervous to
eat or drink, so
there is no stool.
B. The
sympathetic
nervous system
was activated, so
the GI tract was
slowed. Correct
C. The
parasympathetic
nervous system is
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to slow the GI
tract.
D. The circulation
in the GI system
has been
increased, so less
waste is
removed.
A 90-year-old - Xerostomia
healthy man is >Xerostomia, decreased volume of
suffering from saliva, leads to dry oral mucosa and
dysphagia. The dysphagia.
nurse explains >Esophageal cancer is not an age-
what age-related related change.
change of the GI >Decreased taste buds and a thinner
tract is the most abdominal wall do not contribute to
likely cause of his difficulty swallowing.
difficulty?
A. Xerostomia
B. Esophageal
cancer
C. Decreased
taste buds
D. Thinner
abdominal wall
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- Gastrin
A patient had a
>Gastrin is the hormone activated in the
stomach
stomach (and duodenal mucosa) by
resection for
stomach distention that stimulates
stomach cancer.
gastric acid secretion and motility and
The nurse should
maintains lower esophageal sphincter
teach the patient
tone. >Secretin inhibits gastric motility
about the loss of
and acid secretion and stimulates
the hormone that
pancreatic bicarbonate secretion.
stimulates gastric
>Cholecystokinin allows increased flow
acid secretion
of bile into the duodenum and release
and motility and
of pancreatic digestive enzymes.
maintains lower
>Gastric inhibitory peptide inhibits
esophageal
gastric acid secretion and motility.
sphincter tone.
Which hormone
will be
decreased with a
gastric
resection?
A. Gastrin
B. Secretin
C.
Cholecystokinin
D. Gastric
inhibitory peptide
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- choledocholithotomy
The patient tells the
>A choledocholithotomy is an opening
nurse she had a history
into the common bile duct for the
of abdominal pain, so
removal of stones.
he had a surgery to
>A colectomy is the removal of the
make an opening into
colon. >The cholecystectomy is the
he common bile duct
removal of the gallbladder.
o remove stones. The
>The choledochojejunostomy is an
nurse knows that this
opening between the common bile
urgery is called a
duct and the jejunum.
A. colectomy
B. cholecystectomy
C. choledocholithotomy
D.
choledochojejunostomy
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- Peritoneal inflammation
The ED nurse has
>When palpating for rebound
inspected,
tenderness, the problem area of the
auscultated, and
abdomen will produce pain and severe
palpated the
muscle spasm when there is peritoneal
abdomen with no
inflammation. >Hepatic cirrhosis,
obvious
hypersplenomegaly, and gall bladder
abnormalities,
distention do not manifest with
except pain. When
rebound tenderness.
the nurse palpates
the abdomen for
rebound
tenderness, there is
severe pain. The
nurse should know
that this could
indicate what
problem?
A. Hepatic cirrhosis
B.
Hypersplenomegaly
C. Gall bladder
distention
D. Peritoneal
inflammation
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A patient who is - Easily heard, loud gurgling in the right
scheduled for upper quadrant
surgery with >If the patient drank water on an empty
general stomach, gurgling can be assessed
anesthesia in 1 without a stethoscope or assessed with
hour is observed auscultation.
with a moist, but >High-pitched, hollow sounds are
empty water tympanic and indicate an empty cavity.
glass in his hand. >A flat abdomen and tenderness do not
Which indicate that the patient drank a glass of
assessment water.
finding may
indicate that the
patient drank a
glass of water?
A. Flat abdomen
without
movement upon
inspection
B. Tenderness at
left upper
quadrant upon
palpation
C. Easily heard,
loud gurgling in
the right upper
quadrant
D. High-pitched,
hollow sounds in
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the left upper
quadrant
When caring for - Absorption
the patient with >Substances that interface with the
heart failure, the absorptive surfaces of the GI tract
nurse knows that (primarily in the small intestine) diffuse
which across the intestinal membranes into
gastrointestinal intestinal capillaries and are then
process is most carried to other parts of the body for
dependent on use in energy production.
cardiac output >The cardiac output provides the blood
and may affect flow for this absorption of nutrients to
the patient's occur.
nutritional status?
A. Ingestion
B. Digestion
C. Absorption
D. Elimination
Chapter 39 - Pre-Test ...
(GASTROINTESTINAL
SYSTEM)
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