Nursing Assessment: GI System (Test 2)

Question 1

What is part of ingestion and propulsion of food?

Answer 1

Mouth, pharynx, esophagus

Question 2

What is responsible for only digestion?

Answer 2

Mouth

Question 3

What does the mouth consist of?

Answer 3

Teeth, saliva/enzymes, mucosal layers, esophagus, lower esophageal sphincter

Question 4

What is responsible for both digestion and absorption?

Answer 4

Stomach

Question 5

What does the stomach consist of?

Answer 5

Mucosal layers, hydrochloric acid, enzymes, pyloric sphincter

Question 6

What is one of the side effects of chemo r/t GI system?

Answer 6

Sore mouth

Question 7

What can you use to help mouth soreness?

Answer 7

Give them magic mouthwash, it has Lidocaine, Malox, etc. in it

Question 8

Why are mucous membranes so important?

Answer 8

The entire GI system is lined with it and in order for the whole system to function we have to keep it healthy

Question 9

What helps with peristalsis?

Answer 9

Stomach and small intestines

Question 10

What is responsible for the absorption of nutrients?

Answer 10

Small intestine

Question 11

What does the small intestine consist of?

Answer 11

Mucosal layers, duodenum, Jejunum, ileum, and villi

Question 12

What is responsible for elimination?

Answer 12

Large intestine

Question 13

What does the large intestine consist of?

Answer 13

Ascending colon, transverse colon, descending colon, rectum, anus

Question 14

What else is part of the GI system besides mouth, stomach, small intestine, large intestine?

Answer 14

Liver, biliary tract, pancreas

Question 15

What are general effects of aging on the GI system?

Answer 15

Muscles weaken, decreased function- effect on valves, sphincters, and wall of colon; decreased production and secretion of enzymes- effect on digestive process

Question 16

What does the large intestine do besides elimination?

Answer 16

It absorbs water and is part of the immune system

Question 17

What do you need to ask when you find out a patient has a colostomy?

Answer 17

Where it is, know that it affects self concept and image and body integrity, and ask how it affects them

Question 18

How old should a child be before having nuts?

Answer 18

2, because of potential allergies

Question 19

How old should a child be before they have dairy?

Answer 19

1

Question 20

When assessing indigestion what should you ask?

Answer 20

What they have for lunch, how much they eat, do you ever have lunch without indigestion?, etc.

Question 21

What can sclerosis be caused by?

Answer 21

Chemicals or overuse of alcohol

Question 22

What parts of the GI system are affected by aging?

Answer 22

Mouth, esophagus, abdominal wall (all muscle basically), stomach (*ulcers), small intestines, liver, large intestine, anus, rectum

Question 23

What is subjective data needed for assessment of GI system?

Answer 23

Important health info: past health history, meds, surgery or other treatments

Question 24

Study the…

Answer 24

GFHP’s on younger and older adults about the GI system!!! :)

Question 25

What is the objective data needed for assessment of GI system?

Answer 25

Physical exam: mouth, abdomen, rectum and anus

Question 26

How long is the newborn "period?"

Answer 26

4 weeks old

Question 27

To help keep infants to keep food down what should you assess?

Answer 27

How they feed their baby, like burping, etc.

Question 28

How do you assess the abdomen?

Answer 28

First look, then listen, then start at RLQ because that's where the colon starts

Question 29

What are types of GI radiologic studies?

Answer 29

Upper GI Series (barium swallow), lower GI Series (barium enema), abdominal ultrasound, virtual colonoscopy

Question 30

Are barium swallows and enemas common?

Answer 30

No

Question 31

What is your job in preparing the patient for a barium swallow?

Answer 31

You need to teach them what's going to happen

Question 32

What is the most important follow up care for the barium swallow?

Answer 32

Increase fluids to get rid of barium and they may need a laxative because it becomes concrete eventually

Question 33

What part of the barium swallow and enema is radioactive?

Answer 33

The barium

Question 34

What is the purpose of the barium enema?

Answer 34

An effort to see the colon through the X-ray, the follow up is the same as swallow, esp. with laxative

Question 35

What is the most popular diagnostic study of the GI system?

Answer 35

Endoscopy

Question 36

What can the endoscope be used for?

Answer 36

EsophaGastroDuodenoscopy (EGD), sigmoidoscopy, colonoscopy

Question 37

What does ERCP stand for?

Answer 37

Endoscopic retrograde cholangio-pancreatography

Question 38

What does the ERCP look at?

Answer 38

Gallbladder and pancreas

Question 39

What is the other type of endoscopy besides the endoscope and ERCP?

Answer 39

Capsule endoscopy

Question 40

What is the capsule for the capsule endoscopy? What's the nurse's job?

Answer 40

A tiny camera is in it and the nurse's job is to recover the camera

Question 41

What is the prep for the EGD?

Answer 41

Maybe a few hours of NPO and help explain, they may put anesthesia on throat

Question 42

How do you prevent elders from losing potassium?

Answer 42

Go lightly

Question 43

``` The nurse observes that Mrs. Creighton's abdomen is firm and distended. WHat assessment is most important for the nurse to perform? A. Auscultate bowel sounds B. Measure abdominal girth C. Observe incisional staples D. Measure BP ```

Answer 43

A is correct. Her girth has nothing to do with anything at this point, staples aren't main source of pain, and you're probably already getting vitals

Question 44

``` The nurse auscultates for Joan's bowel sounds and hears faint gurgling sounds after three minutes. How will the nurse record this finding? A. Hypoactive bowel sounds B. Normal bowel sounds C. Paralytic ileus D. Reduced peristalsis ```

Answer 44

A is correct.

Question 45

In assessing bowel sounds, it is most important for the nurse to perform which action? A. Ask the client what she had her last BM B. Listen for up to 5 minutes when auscultating for bowel sounds C. Perform a rectal exam D. Place client in knee-chest position to expel excess gas prior to auscultation

Answer 45

B is correct.

Question 46

While the nurse is completing the assessment, Joan begins to cry and laments, "I just knew something would go wrong." What is the best response by the nurse? A. This is a minor problem. We'll have you better very soon. B. You have to expect that problems will occur after surgery. C. Tell me what is making you feel so upset. D. Why are you letting this upset you?

Answer 46

C is correct.

Question 47

Joan tells the nurse that she hates hospitals because she says "Nobody ever tells you what's happening, and you end up with all these things going wrong." Which response by the nurse will encourage continued verbalization by the patient? A. All the nurses are very busy here, and they are doing the best job they can. B. You should write down your questions so you can get some answers. C. I will be happy to tell you everything that's happening, so nothing else will go wrong. D. It sounds as if you have had another experience that did not go well.

Answer 47

D is correct.

Question 48

Joan responds, "I did everything my HCP told me to do. The surgery must have failed. It was supposed to make my intestines work better! How should the nurse respond? A. Refer the client to the surgeon to answer any questions about the surgical outcome. B. Advise the client that an incarcerated hernia is repaired to improve peristalsis so an error must have occurred during the surgery. C. Offer the client emotional support as she copes with this adverse outcome of surgery. D. Explain the the client the multiple factors that can decrease peristalsis postop, even when the desired surgical outcome is achieved.

Answer 48

D is correct. It is not C because it is a normal effect of surgery.

Question 49

Read the rest...

Answer 49

Of the quizzes on PP!!! :)

Question 50

What postop med is most likely to contribute to constipation?

Answer 50

Morphine sulfate, an opioid analgesic

Question 51

While performing the digital rectal exam, the nurse recognizes that the client may experience vagal nerve stimulation. This can result in which change in vital signs?

Answer 51

Decreased pulse rate

Question 52

Does a stool softener stimulate movement?

Answer 52

No

Question 53

Should a stool softener cause abdominal cramping?

Answer 53

No because it is inserted rectally

Question 54

What are hemorrhoids?

Answer 54

Blood vessels all stretch out because of pressure r/t pregnancy, varicose veins, strain

Question 55

What are hemorrhoids like?

Answer 55

Just like varicose veins in the rectum

Question 56

Do you need sterile gloves for a rectal examination?

Answer 56

No, just gloves to protect you

Question 57

What do we use D5O IVs for?

Answer 57

To bring diabetic's sugar up and it pulls potassium out of the circulating system

Question 58

When does the gut form in the neonate?

Answer 58

???

Question 59

When can we detect GI activity of the embryo?

Answer 59

???

Question 60

Is everything in the same spot of a child as an adult?

Answer 60

???

Question 61

When would you try to assess the pediatric abdomen?

Answer 61

???

Question 62

When is swallowing voluntary?

Answer 62

6 weeks

Question 63

How much saliva do infants have?

Answer 63

Minimal

Question 64

How does the stomach lie in infant's abdomen?

Answer 64

Stomach lies transversely and is horizontal

Question 65

Infants and children...

Answer 65

Have less stomach capacity

Question 66

What are gastric secretions like in an infant compared to older children and adults?

Answer 66

Less acidic

Question 67

How is hydrochloric acid concentration until school age?

Answer 67

Low concentration

Question 68

Human milk has properties that...?

Answer 68

Partially compensate for decreased digestive function and optimize nutrition

Question 69

What can milk or formula do to gastric secretions?

Answer 69

Increase alkalinity of them

Question 70

What part of the stomach in a baby is different? How does that affect them?

Answer 70

Cardiac sphincter is relaxed at birth, allowing mild, occasional regurgitation of stomach contents

Question 71

What does a baby's diarrhea look like?

Answer 71

A little solid with a water ring around it

Question 72

What are infants at risk for?

Answer 72

High risk for dehydration

Question 73

Common illnesses for babies?

Answer 73

Ears or upper respiratory infections

Question 74

Why is giving a baby a bottle when their ears are hurting and laying them to sleep a bad idea?

Answer 74

The milk may migrate to the Eustachian tubes and make the infection worse

Question 75

What is hydrocephalus?

Answer 75

Spinal fluid gets caught in the head

Question 76

How long is head circumference measured for? Why?

Answer 76

Until 18 months to 2 years for hydrocephalus

Question 77

What "arrest" type is more common in babies?

Answer 77

Respiratory more than cardiac

Question 78

What to know about peristaltic waves in infants?

Answer 78

They may reverse and cause regurgitation and vomiting

Question 79

Is peristalsis faster or slower for infants compared to adults?

Answer 79

Tends to be faster, with food remaining in the stomach for a shorter period

Question 80

What conditions can increase the rate of propulsion and peristalsis?

Answer 80

Fever and diarrhea

Question 81

What enzymes do infants have a deficiency of?

Answer 81

Amylase, lipase, and trypsin

Question 82

When are sufficient quantities of enzymes present to aid digestion?

Answer 82

Not until 4 to 6 months

Question 83

What kind of function is immature in the first year?

Answer 83

Liver function

Question 84

What are things to assess for a pediatric's GI tract?

Answer 84

History, vomiting episodes?, diarrhea?, daily weights, vital signs, intake and output, skin integrity, urine specific gravity, episodes of apnea or respiratory distress?, pain?, bowel sounds, abdominal circumference, calorie count, electrolyte status, hydration status

Question 85

If an infant has vomiting episodes, what should you know about them?

Answer 85

Amount, color, and consistency of emesis

Question 86

If an infant is having diarrhea, what should you know about it?

Answer 86

Frequency, amount, color, and consistency of stools

Question 87

What should you do with an infant's daily weights?

Answer 87

Plot progress on growth chart

Question 88

When taking an infant's vital signs, what should you add on top of normal vitals?

Answer 88

Quality of respirations

Question 89

When assessing skin integrity of infants, what areas are really important?

Answer 89

Perianal and rectal areas

Question 90

What diagnostic tests may be used for infants?

Answer 90

CBC, erythrocyte sedimentation rate, electrolytes, liver enzymes, absorption tests, stool reducing substances, pH, fat, trypsin, occult blood, stool culture, ova and parasites, upper GI tract, colonoscopy, small bowel follow through, barium enema, gastric emptying, pH probe

Question 91

Are those diagnostic tests for infants listed common?

Answer 91

Not unless there are indicators they are sick

Question 92

What is a standard tests for infants?

Answer 92

PKU for Phenylketonuria

Question 93

What is PKU?

Answer 93

Excretions of ketones, etc., that say baby can't digest protein

Question 94

What is testing/treatment for PKU?

Answer 94

They test for it by taking blood out of feet, and they can just manage it