Capstone: Gastrointestinal (NCLEX)
A nurse should plan to implement which interventions for a child admitted with
inorganicfailure to thrive? Select all that apply.
a. Observation of parent-child interactions
b. Assignment of different nurses to care for the child from day to day
c. Use of 28 calorie per ounce concentrated formulas
d. Administration of daily multivitamin supplements
e. Role modeling appropriate adult-child interactions - Answer ADE
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis
who is scheduled for surgery in 2 hours. The client begins to complain of increased
abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen
is distended and bowel sounds are diminished. Which is the most appropriate nursing
intervention?
A. Notify the health care provider (HCP).
B. Administer the prescribed pain medication.
C. Call and ask the operating room team to perform surgery as soon as possible.
D. Reposition the client and apply a heating pad on the warm setting to the client's
abdomen. - Answer A
On the basis of the signs and symptoms presented in the question, the nurse should
suspect peritonitis and notify the HCP. Administering pain medication is not an
appropriate intervention. Heat should never be applied to the abdomen of a client with
suspected appendicitis because of the risk of rupture. Scheduling surgical time is not
within the scope of nursing practice, although the HCP probably would perform the
surgery earlier than the prescheduled time.
The nurse is planning to teach a client with gastroesophageal reflux disease (GERD)
about substances to avoid. Which items should the nurse include on this list? Select all
that apply.
A. Coffee
B. Chocolate
C. Peppermint
D. Nonfat milk
E. Fried chicken
F. Scrambled eggs - Answer ABCE
Foods that decrease lower esophageal sphincter (LES) pressure and irritate the
esophagus will increase reflux and exacerbate the symptoms of GERD and therefore
should be avoided. Aggravating substances include coffee, chocolate, peppermint, fried
or fatty foods, carbonated beverages, and alcohol. Options 4 and 6 do not promote this
effect.
,A client has undergone esophagogastroduodenoscopy. The nurse should place highest
priority on which item as part of the client's care plan?
1. Monitoring the temperature
2. Monitoring complaints of heartburn
3. Giving warm gargles for a sore throat
4. Assessing for the return of the gag reflex - Answer 4
The nurse places highest priority on assessing for return of the gag reflex. This
assessment addresses the client's airway. The nurse also monitors the client's vital
signs and for a sudden increase in temperature, which could indicate perforation of the
gastrointestinal tract. This complication would be accompanied by other signs as well,
such as pain. Monitoring for sore throat and heartburn are also important; however, the
client's airway is the priority.
The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis.
The nurse instructs the client to include which foods rich in vitamin B12 in the diet?
Select all that apply.
A. Nuts
B. Corn
C. Liver
D. Apples
E. Lentils
F. Bananas - Answer ACE
Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading
to the loss of function of the parietal cells. The source of intrinsic factor is lost, which
results in an inability to absorb vitamin B12, leading to development of pernicious
anemia. Clients must increase their intake of vitamin B12 by increasing consumption of
foods rich in this vitamin, such as nuts, organ meats, dried beans, citrus fruits, green
leafy vegetables, and yeast.
The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment
finding would most likely indicate perforation of the ulcer?
A. Bradycardia
B. Numbness in the legs
C. Nausea and vomiting
D. A rigid, boardlike abdomen - Answer D
Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp,
intolerable severe pain beginning in the mid-epigastric area and spreading over the
abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur.
Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an
associated finding.
The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure).
Which postoperative prescription should the nurse question and verify?
,A. Leg exercises
B. Early ambulation
C. Irrigating the nasogastric tube
D. Coughing and deep-breathing exercises - Answer C
In a gastrojejunostomy (Billroth II procedure), the proximal remnant of the stomach is
anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for
preventing the retention of gastric secretions. The nurse should never irrigate or
reposition the gastric tube after gastric surgery, unless specifically prescribed by the
health care provider. In this situation, the nurse should clarify the prescription. Options
1, 2, and 4 are appropriate postoperative interventions.
The nurse is providing discharge instructions to a client following gastrectomy and
should instruct the client to take which measure to assist in preventing dumping
syndrome?
A. Ambulate following a meal.
B. Eat high-carbohydrate foods.
C. Limit the fluids taken with meals.
D. Sit in a high Fowler's position during meals. - Answer C
Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that
occurs after eating, especially following a gastrojejunostomy (Billroth II procedure).
Early manifestations usually occur within 30 minutes of eating and include vertigo,
tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The
nurse should instruct the client to decrease the amount of fluid taken at meals and to
avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low
Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric
emptying; and to take antispasmodics as prescribed.
The nurse is providing discharge teaching for a client with newly diagnosed Crohn's
disease about dietary measures to implement during exacerbation episodes. Which
statement made by the client indicates a need for further instruction?
A. "I should increase the fiber in my diet."
B. "I will need to avoid caffeinated beverages."
C. "I'm going to learn some stress reduction techniques."
D. "I can have exacerbations and remissions with Crohn's disease." - Answer A
Crohn's disease is an inflammatory disease that can occur anywhere in the
gastrointestinal tract but most often affects the terminal ileum and leads to thickening
and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized
by exacerbations and remissions. If stress increases the symptoms of the disease, the
client is taught stress management techniques and may require additional counseling.
The client is taught to avoid gastrointestinal stimulants containing caffeine and to follow
a high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially
during periods of exacerbation.
, The nurse is doing an admission assessment on a client with a history of duodenal
ulcer. To determine whether the problem is currently active, the nurse should assess
the client for which sign(s)/symptom(s) of duodenal ulcer?
A. Weight loss
B. Nausea and vomiting
C. Pain relieved by food intake
D. Pain radiating down the right arm - Answer C
A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These
clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that
often localizes in the mid-epigastric area. The client with duodenal ulcer usually does
not experience weight loss or nausea and vomiting. These symptoms are more typical
in the client with a gastric ulcer.
A client with hiatal hernia chronically experiences heartburn following meals. The nurse
should plan to teach the client to avoid which action because it is contraindicated with a
hiatal hernia?
A. Lying recumbent following meals
B. Consuming small, frequent, bland meals
C. Taking H2-receptor antagonist medication
D. Raising the head of the bed on 6-inch (15 cm) blocks - Answer A
Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm
where the esophagus usually is positioned. The client usually experiences pain from
reflux caused by ingestion of irritating foods, lying flat following meals or at night, and
eating large or fatty meals. Relief is obtained with the intake of small, frequent, and
bland meals; use of H2-receptor antagonists and antacids; and elevation of the thorax
following meals and during sleep.
A client has just had surgery to create an ileostomy. The nurse assesses the client in
the immediate postoperative period for which most frequent complication of this type of
surgery?
A. Folate deficiency
B. Malabsorption of fat
C. Intestinal obstruction
D. Fluid and electrolyte imbalance - Answer D
A frequent complication that occurs following ileostomy is fluid and electrolyte
imbalance. The client requires constant monitoring of intake and output to prevent this
from occurring. Losses require replacement by intravenous infusion until the client can
tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat
malabsorption and folate deficiency are complications that could occur later in the
postoperative period.
The nurse provides instructions to a client about measures to treat inflammatory bowel
syndrome (IBS). Which statement by the client indicates a need for further teaching?
A nurse should plan to implement which interventions for a child admitted with
inorganicfailure to thrive? Select all that apply.
a. Observation of parent-child interactions
b. Assignment of different nurses to care for the child from day to day
c. Use of 28 calorie per ounce concentrated formulas
d. Administration of daily multivitamin supplements
e. Role modeling appropriate adult-child interactions - Answer ADE
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis
who is scheduled for surgery in 2 hours. The client begins to complain of increased
abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen
is distended and bowel sounds are diminished. Which is the most appropriate nursing
intervention?
A. Notify the health care provider (HCP).
B. Administer the prescribed pain medication.
C. Call and ask the operating room team to perform surgery as soon as possible.
D. Reposition the client and apply a heating pad on the warm setting to the client's
abdomen. - Answer A
On the basis of the signs and symptoms presented in the question, the nurse should
suspect peritonitis and notify the HCP. Administering pain medication is not an
appropriate intervention. Heat should never be applied to the abdomen of a client with
suspected appendicitis because of the risk of rupture. Scheduling surgical time is not
within the scope of nursing practice, although the HCP probably would perform the
surgery earlier than the prescheduled time.
The nurse is planning to teach a client with gastroesophageal reflux disease (GERD)
about substances to avoid. Which items should the nurse include on this list? Select all
that apply.
A. Coffee
B. Chocolate
C. Peppermint
D. Nonfat milk
E. Fried chicken
F. Scrambled eggs - Answer ABCE
Foods that decrease lower esophageal sphincter (LES) pressure and irritate the
esophagus will increase reflux and exacerbate the symptoms of GERD and therefore
should be avoided. Aggravating substances include coffee, chocolate, peppermint, fried
or fatty foods, carbonated beverages, and alcohol. Options 4 and 6 do not promote this
effect.
,A client has undergone esophagogastroduodenoscopy. The nurse should place highest
priority on which item as part of the client's care plan?
1. Monitoring the temperature
2. Monitoring complaints of heartburn
3. Giving warm gargles for a sore throat
4. Assessing for the return of the gag reflex - Answer 4
The nurse places highest priority on assessing for return of the gag reflex. This
assessment addresses the client's airway. The nurse also monitors the client's vital
signs and for a sudden increase in temperature, which could indicate perforation of the
gastrointestinal tract. This complication would be accompanied by other signs as well,
such as pain. Monitoring for sore throat and heartburn are also important; however, the
client's airway is the priority.
The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis.
The nurse instructs the client to include which foods rich in vitamin B12 in the diet?
Select all that apply.
A. Nuts
B. Corn
C. Liver
D. Apples
E. Lentils
F. Bananas - Answer ACE
Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading
to the loss of function of the parietal cells. The source of intrinsic factor is lost, which
results in an inability to absorb vitamin B12, leading to development of pernicious
anemia. Clients must increase their intake of vitamin B12 by increasing consumption of
foods rich in this vitamin, such as nuts, organ meats, dried beans, citrus fruits, green
leafy vegetables, and yeast.
The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment
finding would most likely indicate perforation of the ulcer?
A. Bradycardia
B. Numbness in the legs
C. Nausea and vomiting
D. A rigid, boardlike abdomen - Answer D
Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp,
intolerable severe pain beginning in the mid-epigastric area and spreading over the
abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur.
Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an
associated finding.
The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure).
Which postoperative prescription should the nurse question and verify?
,A. Leg exercises
B. Early ambulation
C. Irrigating the nasogastric tube
D. Coughing and deep-breathing exercises - Answer C
In a gastrojejunostomy (Billroth II procedure), the proximal remnant of the stomach is
anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for
preventing the retention of gastric secretions. The nurse should never irrigate or
reposition the gastric tube after gastric surgery, unless specifically prescribed by the
health care provider. In this situation, the nurse should clarify the prescription. Options
1, 2, and 4 are appropriate postoperative interventions.
The nurse is providing discharge instructions to a client following gastrectomy and
should instruct the client to take which measure to assist in preventing dumping
syndrome?
A. Ambulate following a meal.
B. Eat high-carbohydrate foods.
C. Limit the fluids taken with meals.
D. Sit in a high Fowler's position during meals. - Answer C
Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that
occurs after eating, especially following a gastrojejunostomy (Billroth II procedure).
Early manifestations usually occur within 30 minutes of eating and include vertigo,
tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The
nurse should instruct the client to decrease the amount of fluid taken at meals and to
avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low
Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric
emptying; and to take antispasmodics as prescribed.
The nurse is providing discharge teaching for a client with newly diagnosed Crohn's
disease about dietary measures to implement during exacerbation episodes. Which
statement made by the client indicates a need for further instruction?
A. "I should increase the fiber in my diet."
B. "I will need to avoid caffeinated beverages."
C. "I'm going to learn some stress reduction techniques."
D. "I can have exacerbations and remissions with Crohn's disease." - Answer A
Crohn's disease is an inflammatory disease that can occur anywhere in the
gastrointestinal tract but most often affects the terminal ileum and leads to thickening
and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized
by exacerbations and remissions. If stress increases the symptoms of the disease, the
client is taught stress management techniques and may require additional counseling.
The client is taught to avoid gastrointestinal stimulants containing caffeine and to follow
a high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially
during periods of exacerbation.
, The nurse is doing an admission assessment on a client with a history of duodenal
ulcer. To determine whether the problem is currently active, the nurse should assess
the client for which sign(s)/symptom(s) of duodenal ulcer?
A. Weight loss
B. Nausea and vomiting
C. Pain relieved by food intake
D. Pain radiating down the right arm - Answer C
A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These
clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that
often localizes in the mid-epigastric area. The client with duodenal ulcer usually does
not experience weight loss or nausea and vomiting. These symptoms are more typical
in the client with a gastric ulcer.
A client with hiatal hernia chronically experiences heartburn following meals. The nurse
should plan to teach the client to avoid which action because it is contraindicated with a
hiatal hernia?
A. Lying recumbent following meals
B. Consuming small, frequent, bland meals
C. Taking H2-receptor antagonist medication
D. Raising the head of the bed on 6-inch (15 cm) blocks - Answer A
Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm
where the esophagus usually is positioned. The client usually experiences pain from
reflux caused by ingestion of irritating foods, lying flat following meals or at night, and
eating large or fatty meals. Relief is obtained with the intake of small, frequent, and
bland meals; use of H2-receptor antagonists and antacids; and elevation of the thorax
following meals and during sleep.
A client has just had surgery to create an ileostomy. The nurse assesses the client in
the immediate postoperative period for which most frequent complication of this type of
surgery?
A. Folate deficiency
B. Malabsorption of fat
C. Intestinal obstruction
D. Fluid and electrolyte imbalance - Answer D
A frequent complication that occurs following ileostomy is fluid and electrolyte
imbalance. The client requires constant monitoring of intake and output to prevent this
from occurring. Losses require replacement by intravenous infusion until the client can
tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat
malabsorption and folate deficiency are complications that could occur later in the
postoperative period.
The nurse provides instructions to a client about measures to treat inflammatory bowel
syndrome (IBS). Which statement by the client indicates a need for further teaching?
