NCLEX Gastrointestinal
A patient suspected of diverticulitis is admitted to the hospital for evaluation and treatment. The nurse explains to a student nurse that the classic triad of signs and symptoms are:
LLQ pain, fever, leukocytosis.
RUQ pain, bloody stool, diarrhea.
RLQ pain, diarrhea, nausea.
LUQ pain, bloody stool, fever. - • The classic symptoms of diverticulitis are fever, LLQ pain, and leukocytosis.
• Other symptoms include constipation or diarrhea, occult blood in the stool, nausea, and cramping.
The nurse is monitoring a patient with diverticulitis for the presence of a bowel perforation. The nurse should be alert to which of the following?
Lower extremity edema
Fever
Tachycardia
Abdominal guarding
Board-like rigidity of the abdomen
Diarrhea - Fever
Tachycardia
Abdominal guarding
Board-like rigidity of the abdomen
• Perforation causes a board-like rigidity of the abdomen, guarding of the abdomen, fever, chills, pallor, tachycardia, distention, and restlessness.
• Perforation causes an inflammatory reaction in the peritoneal cavity called peritonitis. Sepsis can occur when the bowel contents leak into the peritoneum.
A nurse is caring for a hospitalized client who was admitted for GI bleeding with a history of gallstones. Which of the following findings would the nurse report to the physician immediately?
400 ml of bitter tasting emesis
300 ml of emesis with fecal components
200 ml of coffee ground emesis
100 ml of yellow/green emesis - •A finding of emesis with fecal components may indicate that an intestinal obstruction has formed, leading to back up in the GI tract, and would indicate a change or worsening in the client's condition. The physician should be called for this.
•A finding of coffee ground emesis is an indication of a slow GI bleed, which the client was admitted for and of which the physician is already aware.
•Yellow/green emesis and bitter tasting emesis contains bile which is not indicative of a change or a critical condition.
The nurse is assessing a hospitalized patient after complaints of sudden abdominal pain. Which of the following abdominal assessment findings should be reported to the physician immediately?
Pulsation between the pubis and umbilicus
20 bowel sounds per minute
Left lower quadrant firm to palpation
Nausea - • Pulsation between the pubis and umbilicus indicates an abdominal aortic aneurysm.This is a medical emergency and should be reported to the physician immediately.
• 20 bowel sounds per minute is a normal finding.
• LLQ firm to palpation may be due to feces in the colon.
• Nausea does not have to be reported to the physician.
The nurse is assessing a patient who underwent a cholecystectomy 2 days ago. The nurse notes that the patient has no bowel sounds. What should the nurse do next?
Flush the NG tube.
Administer an enema.
Notify the physician.
Document the finding and continue assessing the patient's bowel function. - • Bowel sounds are often absent 2-4 days after surgery due to manipulation of the bowel. This is an expected finding and should be documented.
• The other answer choices are not necessary given that this is an expected finding.
The nurse is assessing a patient diagnosed with acute pancreatitis. Which of the following assessment findings is consistent with this diagnosis?
Nausea/vomiting
Upper epigastric pain and back pain
Weight gain
Hypertension
Elevated temperature
Right lower quadrant (RLQ) pain - Nausea/vomiting
Upper epigastric pain and back pain
Elevated temperature
• Common symptoms of acute pancreatitis include upper epigastric pain that bores through the body to the back, nausea, vomiting, weight loss, and an elevated temperature.
• Hypertension is not associated with pancreatitis, although blood pressure may become elevated in response to pain.
• RLQ pain is usually associated with appendicitis, not pancreatitis.
The nurse is administering medications to a patient with a duodenal ulcer. The patient asks about his medications and how they treat his disease. The nurse explains that duodenal ulcers are
predominately caused by:
Stress.
NSAIDs.
Alcohol.
Helicobacter pylori. - • Up to 90% of duodenal ulcers are caused by the bacteria Helicobacter pylori (H. pylori). Treatment consists of 1 or 2 antibiotics, a proton pump inhibitor, and bismuth.
• Stress, NSAID use, and alcohol can lead to gastric, not duodenal ulcers.
The nurse is caring for a patient in the advanced stages of cirrhosis. While making menu
selections, the nurse should suggest increasing:
Fiber.
Fat.
Protein.
Carbohydrates. - Protein intake was previously limited for all clients affected by cirrhosis because it added to the development of hepatic encephalopathy since ammonia is a byproduct of meat consumption and the liver is no longer able to clear that ammonia. Currently, protein is considered to be important to include in the diet of a client with cirrhosis to prevent muscle wasting.
Clients with advanced cirrhosis, however, will be more likely to develop hepatic encephalopathy since the liver disease has progressed. This client should maintain normal and adequate amounts of protein, not increased amounts of protein.
Decreased hepatic glycogen stores result in a starvation type metabolism. Increasing carbohydrates will ensure that the client stays in a "fed" state as opposed to a "fasting" state in which the body begins to consume alternate energy sources, such as muscle mass. A 50g carbohydrate snack at night, for example, improves nitrogen balance, glucose levels, and helps the client stay out of the fasting state, improving ability to maintain muscle mass.
Fiber intake is important to prevent constipation.
A low fat diet is typically recommended since obesity and high triglycerides can cause cirrhosis to advance more quickly.
The nurse is providing ostomy care for a patient after a colectomy. The patient is complaining of the foul odor coming from the ostomy. The nurse instructs the patient to consume more odor