Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A parent brings an 18-month-old toddler to the pediatric emergency department for
abdominal pain and stool mixed with blood and mucus. The pain is recurring three to four
times an hour. Which intervention will the nurse initiate first?
a. Assess laboratory results.
b. Initiate intravenous access.
c. Maintain strict intake and output.
d. Prepare for ultrasound studies.
ANS: B
Chapter: Chapter 16 Gastrointestinal Disorders
Chapter Learning Objective: 5. Identify and describe GI disorders associated with
regurgitation or vomiting.
Page: 380
Heading: Intestinal Obstruction > Intussusception > Nursing Interventions
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Elimination
Difficulty: Difficult
Feedback
A. This is incorrect. The nurse strongly suspects intussusception because of the
passage of stool mixed with blood and mucus. The nurse does assess laboratory
results; however, this is not the nurse’s first intervention.
B. This is correct. The nurse recognizes the existence of an emergency based on the
toddler’s presenting symptoms. The nurse will first initiate intravenous access in
order to have a route established for medications and/or emergency interventions.
C. This is incorrect. The initial action by the nurse does not involve maintaining a
strict intake and output.
D. This is incorrect. Once the toddler has an established IV, the nurse will initiate
other interventions, such as preparations for ultrasound studies.
PTS: 1 CON: Elimination
2. The nurse in a pediatric clinic is obtaining a health history on a child who is 9 years of
age. The nurse learns the child exhibits a chronic cough, midsternal discomfort, and
frequent sore throats without infection. Physical assessment indicates the child is on the
, 50th percentile on the height chart and on the 85th percentile for weight. Which
recommendation does the nurse make?
a. Serve citrus juices instead of carbonated beverages.
b. Begin an age-appropriate weight loss program.
c. Initiate a practice of no eating or drinking after dinner.
d. Encourage lying on the left side after eating a meal.
ANS: B
Chapter: Chapter 16, Gastrointestinal Disorders
Chapter Learning Objective: 5. Identify and describe GI disorders associated with
regurgitation or vomiting.
Pages: 376, 393
Heading: Gastrointestinal Problems Manifested by Vomiting > Gastroesophageal
Reflux Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback
A. This is incorrect. The child is exhibiting the symptoms of gastroesophageal reflux
(GERD). The nurse will recommend avoidance of fatty foods, acidic foods
(citrus juices, carbonated beverages, tomato products), and caffeine.
B. This is correct. When a child is on the 50th percentile in height and the 85th
percentile for weight, the child is overweight. The nurse needs to recommend an
age-appropriate weight loss program.
C. This is incorrect. The child with GERD needs to avoid food and drinks for 2
hours before bedtime.
D. This is incorrect. Lying on the left side after eating is likely to exacerbate the
symptoms of GERD; the patient needs to remain upright after eating.
PTS: 1 CON: Nutrition
3. The nurse in a pediatric clinic is assessing an infant 2 months of age. The parent states,
“He always spits up, but it has become so much worse. Vomit goes everywhere.” Which
additional assessment will help the nurse identify a possible diagnosis for the infant?
a. A hard mass is palpated in the mid-epigastrium.
b. Vomiting occurs both before and after eating.
c. Weight is normal even with frequent vomiting.
d. Normal skin turgor is noted over the sternum.
ANS: A
Chapter: Chapter 16 Gastrointestinal Disorders
Chapter Learning Objective: 5. Identify and describe GI disorders associated with
, regurgitation or vomiting.
Page: 377
Heading: Gastrointestinal Problems Manifested by Vomiting > Pyloric Stenosis >
Assessment
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Growth and Development
Difficulty: Moderate
Feedback
A. This is correct. Vomiting after eating that grows worse and evolves into
projectile vomiting are signs of pyloric stenosis. If the nurse palpates the infant’s
mid-epigastrium and finds a pyloric mass, it is likely indicative of pyloric
stenosis. This finding is called the olive sign.
B. This is incorrect. With pyloric stenosis, vomiting always occurs after eating.
C. This is incorrect. When an infant has pyloric stenosis, there is poor weight gain.
D. This is incorrect. A serious manifestation of pyloric stenosis is the development
of dehydration and a decrease in serum chloride.
PTS: 1 CON: Growth and Development
4. The pediatric nurse in a clinic is mentoring a newly hired nurse who has no experience in
pediatrics. The new nurse is performing a physical assessment on an infant who is 1
month of age. Which observation will prompt the nurse to discuss assessment skills with
the new nurse?
a. The new nurse states, “How can I hear bowel sounds when he cries?”
b. The new nurse keeps the sleeping infant covered for parts of the assessment.
c. The new nurse performs all observations before physical assessment.
d. The new nurse informs the attending parent about the assessment actions.
ANS: A
Chapter: Chapter 16 Gastrointestinal Disorders
Chapter Learning Objective: 1. Identify the components of an abdominal examination.
Page: 361
Heading: Assessment > Abdominal Examination > Clinical Judgment: Auscultation
Before Palpation
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Caring
Difficulty: Difficult
Feedback
Identify the choice that best completes the statement or answers the question.
1. A parent brings an 18-month-old toddler to the pediatric emergency department for
abdominal pain and stool mixed with blood and mucus. The pain is recurring three to four
times an hour. Which intervention will the nurse initiate first?
a. Assess laboratory results.
b. Initiate intravenous access.
c. Maintain strict intake and output.
d. Prepare for ultrasound studies.
ANS: B
Chapter: Chapter 16 Gastrointestinal Disorders
Chapter Learning Objective: 5. Identify and describe GI disorders associated with
regurgitation or vomiting.
Page: 380
Heading: Intestinal Obstruction > Intussusception > Nursing Interventions
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Elimination
Difficulty: Difficult
Feedback
A. This is incorrect. The nurse strongly suspects intussusception because of the
passage of stool mixed with blood and mucus. The nurse does assess laboratory
results; however, this is not the nurse’s first intervention.
B. This is correct. The nurse recognizes the existence of an emergency based on the
toddler’s presenting symptoms. The nurse will first initiate intravenous access in
order to have a route established for medications and/or emergency interventions.
C. This is incorrect. The initial action by the nurse does not involve maintaining a
strict intake and output.
D. This is incorrect. Once the toddler has an established IV, the nurse will initiate
other interventions, such as preparations for ultrasound studies.
PTS: 1 CON: Elimination
2. The nurse in a pediatric clinic is obtaining a health history on a child who is 9 years of
age. The nurse learns the child exhibits a chronic cough, midsternal discomfort, and
frequent sore throats without infection. Physical assessment indicates the child is on the
, 50th percentile on the height chart and on the 85th percentile for weight. Which
recommendation does the nurse make?
a. Serve citrus juices instead of carbonated beverages.
b. Begin an age-appropriate weight loss program.
c. Initiate a practice of no eating or drinking after dinner.
d. Encourage lying on the left side after eating a meal.
ANS: B
Chapter: Chapter 16, Gastrointestinal Disorders
Chapter Learning Objective: 5. Identify and describe GI disorders associated with
regurgitation or vomiting.
Pages: 376, 393
Heading: Gastrointestinal Problems Manifested by Vomiting > Gastroesophageal
Reflux Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback
A. This is incorrect. The child is exhibiting the symptoms of gastroesophageal reflux
(GERD). The nurse will recommend avoidance of fatty foods, acidic foods
(citrus juices, carbonated beverages, tomato products), and caffeine.
B. This is correct. When a child is on the 50th percentile in height and the 85th
percentile for weight, the child is overweight. The nurse needs to recommend an
age-appropriate weight loss program.
C. This is incorrect. The child with GERD needs to avoid food and drinks for 2
hours before bedtime.
D. This is incorrect. Lying on the left side after eating is likely to exacerbate the
symptoms of GERD; the patient needs to remain upright after eating.
PTS: 1 CON: Nutrition
3. The nurse in a pediatric clinic is assessing an infant 2 months of age. The parent states,
“He always spits up, but it has become so much worse. Vomit goes everywhere.” Which
additional assessment will help the nurse identify a possible diagnosis for the infant?
a. A hard mass is palpated in the mid-epigastrium.
b. Vomiting occurs both before and after eating.
c. Weight is normal even with frequent vomiting.
d. Normal skin turgor is noted over the sternum.
ANS: A
Chapter: Chapter 16 Gastrointestinal Disorders
Chapter Learning Objective: 5. Identify and describe GI disorders associated with
, regurgitation or vomiting.
Page: 377
Heading: Gastrointestinal Problems Manifested by Vomiting > Pyloric Stenosis >
Assessment
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Growth and Development
Difficulty: Moderate
Feedback
A. This is correct. Vomiting after eating that grows worse and evolves into
projectile vomiting are signs of pyloric stenosis. If the nurse palpates the infant’s
mid-epigastrium and finds a pyloric mass, it is likely indicative of pyloric
stenosis. This finding is called the olive sign.
B. This is incorrect. With pyloric stenosis, vomiting always occurs after eating.
C. This is incorrect. When an infant has pyloric stenosis, there is poor weight gain.
D. This is incorrect. A serious manifestation of pyloric stenosis is the development
of dehydration and a decrease in serum chloride.
PTS: 1 CON: Growth and Development
4. The pediatric nurse in a clinic is mentoring a newly hired nurse who has no experience in
pediatrics. The new nurse is performing a physical assessment on an infant who is 1
month of age. Which observation will prompt the nurse to discuss assessment skills with
the new nurse?
a. The new nurse states, “How can I hear bowel sounds when he cries?”
b. The new nurse keeps the sleeping infant covered for parts of the assessment.
c. The new nurse performs all observations before physical assessment.
d. The new nurse informs the attending parent about the assessment actions.
ANS: A
Chapter: Chapter 16 Gastrointestinal Disorders
Chapter Learning Objective: 1. Identify the components of an abdominal examination.
Page: 361
Heading: Assessment > Abdominal Examination > Clinical Judgment: Auscultation
Before Palpation
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Caring
Difficulty: Difficult
Feedback
