Med Surg Nursing- GI Disorders Exam Prep Test

By touching the altered body part, the client recognizes the body change and establishes that the change is real. Closing the eyes, not looking at the abdomen when the colostomy is exposed, or avoiding talking about the surgery reflects denial.

The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis.

The nurse may not release any confidential information to unauthorized individuals, such as the client's boss. Options 1, 3, and 4 breech client confidentiality.

Hypertension, or high blood pressure, has the least important role in terms of peptic ulcer formation compared to the other options. Peptic ulcers are mainly caused by factors such as excessive acid production, the use of nonsteroidal anti-inflammatory drugs (NSAIDs), and the presence of Helicobacter pylori bacteria. Hypertension is not directly linked to peptic ulcers, although it may contribute to the overall health of the gastrointestinal system. However, it is not a primary factor in the formation of peptic ulcers.

For a colonoscopy, the nurse initially should position the client on the left side with knees bent to allow proper visualization of the large intestine.

When examining the oral cavity of a patient with candidiasis, a gown is unnecessary. Candidiasis is a fungal infection that primarily affects the mucous membranes, such as the mouth. It does not pose a risk of bodily fluid exposure, so there is no need for a gown. However, gloves are necessary to prevent the spread of infection, a penlight is useful for proper visualization, and a tongue blade can help to examine the tongue and oral tissues.

The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the client's vital signs.

A regular exercise regimen promotes peristalsis and contributes to regular bowel elimination patterns. A low-fiber diet, a sedentary lifestyle, and limited water intake would predispose the client to constipation.

Decreased abdominal strength, muscle tone of the intestinal wall, and motility all contribute to chronic constipation in the elderly.

Beta-blockers do not treat GERD (gastroesophageal reflux disease) because they primarily work to block the effects of adrenaline on the heart and blood vessels. They are commonly used to treat conditions such as high blood pressure and heart disease, but they do not have any direct effect on reducing stomach acid production or relieving the symptoms of GERD. Antacids, histamine receptor antagonists, and proton pump inhibitors are all commonly used to treat GERD by reducing stomach acid production or neutralizing the acid already present in the stomach.

Aspiration of gastric secretions with a pH less than 6 indicates placement in the stomach.

To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol.

Fiber supplements are usually recommended

Because the client had surgery three days ago, the nurse can safely delegate the task of helping the client walk down the hallway.

The graduate nurse and her preceptor should assess the new admission with acute abdominal pain first because he just arrived on the floor and might be unstable. Next, they should change the abdominal dressing for the postoperative client or measure the feeding tube residual in the client with continuous tube feedings.

Mc Burney's point is the correct answer for the location of pain in the lower, right abdominal quadrant in relation to appendicitis. This point is located approximately two-thirds of the distance between the umbilicus and the anterior superior iliac spine. It is a key landmark used by healthcare professionals to identify the potential presence of appendicitis.

Hypersalivation, aka water brash, occurs in response to reflux, not hyposalivation.

Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes on the blood.

Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks.

Disturbed body image is not an appropriate nursing diagnosis related to appendicitis because it refers to a person's perception of their own physical appearance, which is not directly affected by appendicitis. Appendicitis is characterized by symptoms such as acute pain, risk for infection due to rupture, and a potential lack of knowledge about the condition. Therefore, disturbed body image does not align with the specific physiological and psychological effects of appendicitis.

The length of endoscopies varies and it is also the least important education tool for the patient.

Ulcerative colitis and Crohn's disease are both inflammatory bowel diseases that can have similar symptoms. To definitively diagnose these conditions, a colonoscopy is often performed. During a colonoscopy, a long, flexible tube with a camera is inserted into the colon to examine the lining and detect any abnormalities or inflammation. This procedure allows for direct visualization and biopsy of the affected areas, providing a more accurate diagnosis compared to other tests such as EGD (esophagogastroduodenoscopy), CBC (complete blood count), or stool sample analysis. Therefore, colonoscopy is the preferred method for definitive diagnosis of ulcerative colitis and Crohn's disease.

The nursing diagnosis "Deficient fluid volume" is inappropriate for a client with malignant tumors of the oral cavity because it does not directly relate to the condition. Malignant tumors of the oral cavity primarily affect the tissues in the mouth, not the fluid volume in the body. Therefore, this diagnosis would not be relevant or helpful in addressing the client's needs.

High fiber intake is least likely to cause constipation because fiber adds bulk to the stool and helps to regulate bowel movements. It promotes regularity and prevents constipation by softening the stool and allowing it to pass through the digestive system more easily. On the other hand, being over 75, overuse of laxatives, and immobilization can all contribute to constipation.

Secondary stomatitis results from infection by opportunistic viruses or bacteria. In this case, the patient with AIDS is, most likely, immunosuppressed.

Of the choices listed, aspiration is the most serious potential complication of tube feedings. Dehydration — not fluid volume excess — is a concern because of decreased free water intake.

When an NG tube is no longer patent, stomach contents collect in the stomach giving the client a sensation of fullness

Patients with GERD should avoid peppermint, alcohol, caffeinated beverages, chocolate, tea, and coffee.

A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up

Periumbilical pain is the initial symptom, followed by nausea and vomiting.

The appropriate nursing diagnoses for patients with colorectal cancer include disturbed body image, deficient fluid volume, and acute/chronic pain. Colorectal cancer can have a significant impact on a patient's body image, causing distress and a negative self-perception. Deficient fluid volume may occur due to factors such as vomiting, diarrhea, or inadequate intake. Acute or chronic pain is common in colorectal cancer patients due to the disease itself or as a result of treatments such as surgery or radiation. These nursing diagnoses address important aspects of care for patients with colorectal cancer.

Hemoglobin and hematocrit are typically performed first in clients with upper GI bleeding to evaluate the extent of blood loss. Endoscopy is then performed to directly visualize the upper GI tract and locate the source of bleeding.

Toxic megacolon is a condition that occurs as a complication of ulcerative colitis. It is characterized by the dilation and paralysis of the colon, leading to a significant enlargement of the colon. This condition can be life-threatening and requires immediate medical intervention. It is not a fistula, which is an abnormal connection between two organs, and it is not a risk factor for pancreatitis, which is inflammation of the pancreas.

Patients should avoid red meat, animal fat, fatty foods, fried meats/ fish, and concentrated sweets.

All are goals

Pain is a symptom of PUD, not a complication

Corticosteroids, such as prednisone, reduce the signs and symptoms of diarrhea, pain, and bleeding by decreasing inflammation. Antidiarrheals, such as diphenoxylate (Lomotil), combat diarrhea by decreasing peristalsis.