LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)

Chapter 21 Assessing the Gastrointestinal System

1) An adolescent patient plans to lose weight by eliminating all fat from the diet. Which action should the nurse take first?

1. Contact the physician.

2. Notify the patient's parents.

3. Refer the patient to a dietitian.

4. Discuss the role of fat in metabolism.

Page Ref: 636

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Lifestyle Choices

Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 21.1 Outline the nutrients absorbed in the gastrointestinal (GI) system.

MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

2) A patient with multiple skin lesions reports following a very-low-calorie diet to maintain weight loss. What should the nurse identify as the patient's priority problem?

1. Inadequate nutritional intake

2. Issues with activity

3. Tissue perfusion insufficiency

4. Risk for self-harm

Page Ref: 646

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.1 Outline the nutrients absorbed in the gastrointestinal (GI) system.

MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

3) A patient tells the nurse about taking large doses of vitamin A for skin health. What should the nurse respond to this patient?

1. "That is a great idea."

2. "That will not benefit your skin. You excrete high doses of vitamin A in your urine."

3. "You should take vitamin C to balance the large dose of A."

4. "Too much vitamin A can be toxic to your body."

Page Ref: 636

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 21.1 Outline the nutrients absorbed in the gastrointestinal (GI) system.

MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

4) A patient is scheduled for a liver biopsy. What should the nurse include in this patient's preprocedure teaching?

1. Abstain from all food and fluids for at least 8 hours prior to the procedure.

2. Consume a low-fat diet 1-3 days prior to the procedure.

3. Complete blood tests prior to the procedure.

4. Restrict activity for 4-6 weeks after the procedure.

Page Ref: 654

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

5) The nurse is preparing to assess a patient's gastrointestinal system. What should the nurse say to gain the most information about this patient's elimination pattern?

1. "Are you having any bowel problems?"

2. "Have you had any recent difficulties with your stools?"

3. "Tell me about your usual bowel habits."

4. "Are your bowel movements normal?"

Page Ref: 641

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

6) The nurse is preparing to examine a patient's abdomen. In which order should the nurse complete this examination? Place in order the steps of the process.

Choice 1. Percussion

Choice 2. Inspection

Choice 3. Palpation

Choice 4. Auscultation

Page Ref: 645-647

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

7) The nurse determines that a patient's body mass index (BMI) is 22 kg/m2. Based on this finding, what should the nurse conclude?

1. BMI should be between 19 and 25 kg/m2. The patient's weight is within a healthful range.

2. The patient needs to lose weight for optimum health.

3. The patient is mildly obese.

4. The patient's BMI is below normal.

Page Ref: 644

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

8) The nurse is teaching a group of older adults about expected changes in dental health related to aging. Which statement by one of the older adults indicates that teaching has been effective?

1. "Tooth enamel is more pliable."

2. "The loss of bone density with aging results in tooth decay and breakage."

3. "Increases in saliva production increase exposure of the tooth's enamel to corrosive agents."

4. "Metabolic changes in aging contribute to dental destruction."

Page Ref: 655

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance: Aging Process

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning

Learning Outcome: 21.4 Differentiate considerations for assessing the GI system of older adults, veterans, and individuals in the LGBTQI population.

MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

9) A patient with a 2-month history of diarrhea is prescribed a diagnostic test that uses a narrow x-ray beam to provide a 360-degree view of abdominal structures. For which diagnostic test should the nurse prepare the patient?

1. Liver biopsy

2. Cholecystography

3. Gastric emptying study

4. Computed tomography

Page Ref: 653

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

10) The nurse is preparing to assess a young adult female with right-upper-quadrant abdominal pain. Which question should the nurse ask when performing this assessment?

1. "Does the pain worsen when you inhale?"

2. "Do you have a history of diabetes?"

3. "When you eat, do you experience any nausea?"

4. "Have your periods been normal?"

Page Ref: 647

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

11) While conducting an abdominal assessment, the nurse notes dullness on percussion when the patient turns from the supine position to the right side. How should the nurse interpret this finding?

1. The patient is exhibiting normal findings.

2. The patient is exhibiting signs consistent with ascites.

3. The patient is exhibiting signs consistent with a bowel obstruction.

4. The patient is exhibiting signs consistent with hepatomegaly.

Page Ref: 646

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

12) The nurse is planning the diet for a patient scheduled to have a barium enema in 2 days. What kind of diet should the nurse plan for the next 48 hours?

1. General diet

2. Full diet today, clear liquids tomorrow

3. Full liquids today, nothing by mouth tomorrow

4. Clear liquids both today and tomorrow

Page Ref: 651

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

13) A patient is recovering from a sigmoidoscopy with removal of a benign polyp. What should the nurse include in this patient's discharge instructions?

1. Contact the primary healthcare provider if experiencing large amounts of flatus.

2. Avoid heavy lifting for 2 weeks after procedure.

3. Report abdominal pain, fever, or chills.

4. Beginning the evening after the procedure, eat foods high in fiber.

Page Ref: 652

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

14) An 85-year-old patient is concerned about the loss of sensation of the need to defecate. How should the nurse respond?

1. "This is a normal part of aging due to slowed intestinal absorption."

2. "As you age, the rectum loses tone, and there is a reduced sensation of the need to defecate."

3. "Have you had a colonoscopy in the past year to evaluate the condition?"

4. "Reduced vitamin K absorption is associated with this condition."

Page Ref: 655

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Aging Process

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 21.4 Differentiate considerations for assessing the GI system of older adults, veterans, and individuals in the LGBTQI population.

MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

15) The nurse is teaching a patient scheduled for a colonoscopy. Which patient statement indicates a need for further teaching?

1. "The procedure will only take about an hour."

2. "It might be quite painful."

3. "I will likely have medications that will make me drowsy during the test."

4. "The physician might take tissue samples for further analysis."

Page Ref: 651

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

16) The nurse is planning care for a patient scheduled for a barium enema the next morning. What should be included in the plan of care?

1. Enemas after the procedure

2. Full-liquid diet for 24 hours before the procedure

3. Positioning the patient on the right side during the procedure

4. Nothing by mouth for 8-12 hours prior to the procedure

Page Ref: 649

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

17) During the admission assessment, the nurse learns that a patient is menstruating. Which prescribed diagnostic test could be impacted by this finding?

1. Small bowel series

2. Barium enema

3. Stool culture

4. Colonoscopy

Page Ref: 652

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

18) An older patient does not understand why the hemoglobin level is low despite eating a healthy diet. How should the nurse respond?

1. "You might not be eating as well as you think."

2. "This happens as you get older."

3. "As we age, the amount of iron absorbed by our body decreases."

4. "Menopause is responsible for these changes."

Page Ref: 655

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Aging Process

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21.4 Differentiate considerations for assessing the GI system of older adults, veterans, and individuals in the LGBTQI population.

MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

19) When assessing a patient's abdomen, the nurse notes frequent pulsations in the epigastric region. What action should the nurse take?

1. Document the findings as hyperactive bowel sounds.

2. Review the patient's medical records for signs and symptoms of cirrhosis, which may indicate ascites.

3. Note the time when the patient last voided.

4. Notify the physician about the findings.

Page Ref: 645

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

20) The nurse is conducting an abdominal assessment. Which finding should the nurse realize is most likely related to a diagnosis of acute diverticulitis?

1. Lower-right-quadrant pain

2. Lower-left-quadrant pain

3. Upper-middle abdominal pain

4. Back pain and tenderness

Page Ref: 647

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

21) A patient reports epigastric abdominal pain, nausea, and vomiting. The serum amylase level is 450 units/dL. For which health problem should the nurse plan care?

1. Gastritis

2. Malnutrition

3. Pancreatitis

4. Diverticulitis

Page Ref: 653

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

22) The nurse determines that a patient has a scaphoid abdomen. Which health problem should the nurse suspect the patient is experiencing?

1. Type 2 diabetes mellitus

2. Crohn disease

3. Malnutrition

4. Diverticulosis

Page Ref: 645

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

23) The nurse is teaching a patient about a scheduled small bowel series. Which statement by the patient indicates that further teaching is required?

1. "It is normal to experience constipation for a few days after the procedure."

2. "I will need to increase my fluid intake the first few days after the procedure."

3. "I might have a laxative prescribed after the procedure."

4. "The barium will be inserted through my rectum."

Page Ref: 651

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

24) The nurse is planning teaching for a patient scheduled for an abdominal ultrasound. How should the nurse instruct the patient to prepare for this test?

1. "Advise the technician if you suspect you are pregnant."

2. "Drink 1 to 2 quarts of water 1 hour before the procedure."

3. "Do not eat anything 8 to 12 hours before the procedure."

4. "Take a laxative the evening before the procedure."

Page Ref: 651

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

25) A patient complains of constipation. Which question should the nurse ask to learn more about the problem?

1. "Are you taking any narcotic medication?"

2. "Have you been taking over-the-counter pain relievers?"

3. "Have you been taking over-the-counter sleep aids?"

4. "Are you taking oral contraceptives?"

Page Ref: 642

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

26) The nurse is planning care for a patient who has a moderate daily protein restriction. Which meal choice would be most appropriate for this patient?

1. Peanut butter sandwich and apple slices

2. Bean soup and spinach salad

3. Salmon fillet and asparagus

4. Fried rice and fresh strawberries

Page Ref: 636

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 21.1 Outline the nutrients absorbed in the gastrointestinal (GI) system.

MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

27) The nurse is planning a class on nutrition for middle-school students. Which data points should be included in the presentation? Select all that apply.

1. Sufficient dietary fats help people absorb vitamins.

2. Cholesterol is needed for proper hormonal function.

3. Fat tissue helps insulate the internal organs.

4. Vitamin K is formed by the action of ultraviolet radiation on the skin.

5. Vitamin D is synthesized by bacteria in the intestine.

Page Ref: 636

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning

Learning Outcome: 21.1 Outline the nutrients absorbed in the gastrointestinal (GI) system.

MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

28) The home health nurse is teaching a patient about vitamin requirements. Which statement indicates that the patient requires additional teaching?

1. "I will follow the National Academy of Sciences recommendations for daily intake of vitamins."

2. "I might need more or fewer vitamins than someone else, based on my lifestyle."

3. "Evidence-based practice sometimes changes the recommended amount of a specific vitamin."

4. "Vitamins obtained through food are superior to those obtained through tablets and pills."

Page Ref: 636

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning

Learning Outcome: 21.1 Outline the nutrients absorbed in the gastrointestinal (GI) system.

MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

29) A patient asks if going on an all-fruit diet is a good decision. How should the nurse respond? Select all that apply.

1. "Fruit is natural and a good source of carbohydrates."

2. "Fruit is a good source of carbohydrates but a poor source of fats and protein."

3. "Fruit supplies many important vitamins but can cause muscle breakdown."

4. "Incorporating fruit with complete sources of protein and healthful fats provides complete nutrition."

5. "A fruit-based diet will reduce your risk of developing diabetes mellitus."

Page Ref: 635-636

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 21.1 Outline the nutrients absorbed in the gastrointestinal (GI) system.

MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

30) The nurse is teaching a group of 6-year-olds about the digestive system. Which statement by a child indicates that teaching has been effective? Select all that apply.

1. "Grown-ups have 28 teeth."

2. "Spit helps you taste your food."

3. "Food starts breaking down in the stomach."

4. "It's like a tube. Food I need goes in one end. What I don't need comes out the other."

5. "The food moves through the tube in waves, like a snake eating a mouse."

Page Ref: 637-639

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning

Learning Outcome: 21.2 Describe the anatomy, physiology, and functions of the GI system and identify abnormal findings that may indicate impairment of the GI system.

MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

31) The nurse reviews the functions of the gastrointestinal system for a patient with celiac disease. Which statement by the patient indicates that teaching has been effective?

1. "The stomach begins the process of absorbing nutrients."

2. "The stomach turns food into liquid so it can be digested."

3. "The stomach begins the digestion of carbohydrates."

4. "The stomach secretes sulfuric acid."

Page Ref: 638

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning

Learning Outcome: 21.2 Describe the anatomy, physiology, and functions of the GI system and identify abnormal findings that may indicate impairment of the GI system.

MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

32) The nurse is preparing to conduct a physical assessment of a patient with obesity. What equipment should the nurse have available for this assessment? Select all that apply.

1. Scale

2. Skinfold calipers

3. Calculator

4. Glucose meter

5. Supplies for blood draw

Page Ref: 642

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

33) The nurse is reviewing data collected from a group of patients. Which patient has a normal waist-to-hip ratio?

1. Female patient, waist 29 inches, hips 35 inches

2. Female patient, waist 29 inches, hips 36 inches

3. Male patient, waist 37 inches, hips 36 inches

4. Male patient, waist 40 inches, hips 41 inches

Page Ref: 644

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

34) A patient whose diet consists of processed food from fast-food restaurants has painful lesions at the corners of the mouth. How should the nurse document this finding?

1. Glossitis

2. Gingivitis

3. Cheilosis

4. Leukoplakia

Page Ref: 644

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

35) The nurse is assessing a patient who uses chewing tobacco. Which data would be most important for the nurse to obtain?

1. The patient denies shortness of breath.

2. The patient has no leukoplakia.

3. The patient has no glossitis.

4. The patient has no signs of candidiasis.

Page Ref: 644

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

36) The nurse is preparing to assess a patient with a suspected abdominal mass. Which technique should the nurse use for this assessment? Select all that apply.

1. Shine a light source across the abdomen.

2. Inspect by standing beside the patient.

3. Inspect from the patient's right side.

4. Inspect for symmetry and visible peristalsis.

5. Ask the patient to deep-breathe and inspect.

Page Ref: 643

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

37) The nurse is preparing to percuss the abdomen of a patient. Which information indicates that the nurse might need assistance with this assessment?

1. The nurse plans to use a systematic approach for the assessment.

2. The nurse anticipates hearing tympany over stool-filled intestines.

3. The nurse anticipates hearing dullness over the liver.

4. The nurse plans to percuss the spleen, liver, and kidneys.

Page Ref: 645

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

38) The nurse is reviewing data within a patient's health history. Which factor in the history should the nurse recognize as related to the development of familial adenomatous polyposis?

1. The patient eats a diet high in red meat.

2. The patient has never had the recommended screening colonoscopy.

3. The patient's grandfather died of colon cancer.

4. The patient had a basal cell skin cancer removed 2 year ago.

Page Ref: 641

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance: Health Screening

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

39) The nurse is conducting an educational session for patients who have a diagnosis of Crohn disease. Fifty patients with the disorder are in attendance. Statistically, how many of these patients have a form of Crohn disease that is familial in origin? Record your answer rounding to the nearest whole number.

Page Ref: 641

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

40) The nurse is instructing a patient newly diagnosed with celiac disease. For which food choices should the nurse provide follow-up teaching?

1. Spinach salad and corn

2. Beefsteak and green beans

3. Whole-wheat toast and baked chicken

4. Apple slices and tuna salad

Page Ref: 641

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

41) A patient of Jewish heritage is experiencing body aches and fatigue. The nurse notes that the patient's skin appears pale and yellow-tinged. What nutritional health problem should the nurse suspect is occurring in this patient?

1. Tangier disease

2. Hypercholesterolemia

3. Gaucher disease

4. Lynch Syndrome

Page Ref: 641

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

42) The nurse notes that a patient's stool specimen is watery and diarrhea-like. Which health problem should the nurse suspect is occurring in this patient? Select all that apply.

1. Malabsorption

2. Antibiotic reaction

3. Lactose intolerance

4. Irritable bowel syndrome

5. Ingestion of spoiled food

Page Ref: 648

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

43) The nurse is caring for a patient with liver disease. What nutritional issue should the nurse expect this patient to exhibit? Select all that apply.

1. Alteration in fat metabolism

2. Increase in glucose utilization

3. Reduction in fat-soluble vitamins

4. Lower amount of bile being stored

5. Change in production of red blood cells

Page Ref: 640

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.2 Describe the anatomy, physiology, and functions of the GI system and identify abnormal findings that may indicate impairment of the GI system.

MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

44) A patient is being evaluated for liver disease. Which laboratory tests should the nurse expect to be prescribed for this patient? Select all that apply.

1. Serum sodium

2. Serum potassium

3. Alkaline phosphatase

4. Alanine aminotransferase

5. Aspartate aminotransferase

Page Ref: 654

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.

MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

45) A middle-aged patient with minimal health problems asks what can be done to prevent gaining weight with aging. What should the nurse instruct this patient? Select all that apply.

1. Drink adequate fluids.

2. Avoid processed foods.

3. Avoid foods high in fat.

4. Maintain the same amount of caloric intake.

5. Eat a well-balanced diet with fruit and vegetables.

Page Ref: 656

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Aging Process

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 21.5 Summarize topics that nurses teach to promote a healthy GI system across the lifespan.

MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

46) The nurse is preparing a teaching tool for a community health fair. Which should the nurse include on a list to avoid to reduce the risk of developing cancer of the gastrointestinal system? Select all that apply.

1. Smoking

2. Red meat

3. Canned foods

4. Alcohol intake

5. Excess activity

Page Ref: 656

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning

Learning Outcome: 21.5 Summarize topics that nurses teach to promote a healthy GI system across the lifespan.

MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.