Chapter 55

Chapter 55: Assessment of the Gastrointestinal System
Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a client who is receiving radiation treatment for oral cancer. Which
problem does the nurse anticipate for this client?

Failure to absorb nutrients from the stomach
Inability to digest protein
Impaired ability to soften and break down food
Difficulty swallowing food
a.
b.
c.
d.
ANS: C
Saliva is responsible for the softening of food in the mouth and contains an enzyme, salivary
amylase (ptyalin), which assists in the breakdown of carbohydrates. Radiation to the oral
cavity can result in reduction of saliva production. Radiation to the mouth will not impair
swallowing, ability to digest protein, or ability to absorb nutrients from the stomach.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)
MSC: Integrated Process: Nursing Process (Planning)
2. Which question best assists the nurse in assessing a client with acute diarrhea?
a. Have you traveled outside the country recently?
b. Have you had a colonoscopy lately?
c. Do you have any trouble swallowing?
d. Do you have any allergies?
ANS: A
A history of recent travel may help pinpoint an infectious source for the clients diarrhea. A
colonoscopy will not cause acute diarrhea. Trouble swallowing is not related to diarrhea.
Allergic reactions do not typically cause acute diarrhea.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body
Systems)
MSC: Integrated Process: Nursing Process (Assessment)
3. A client has been taking naproxen (Naprosyn) for several months. Which assessment question
is important for the nurse to ask?

a. Have you experienced any constipation?
b. Have you had any stomach pain or indigestion?
c. Have you had any difficulty swallowing?
d. Have you noticed any weight loss lately?
ANS: B
Long-term use of NSAIDs for chronic pain can precipitate peptic ulcer formation through
inhibition of prostaglandins, which normally protects the gastric mucosa. The client should be
assessed for stomach pain or indigestion. This medication does not typically cause
constipation or difficulty swallowing. Weight loss would not be related to this medication.
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
4. The nurse is screening clients at a health fair. Which client is at highest risk for the
development of colon cancer?

Older white client with irritable bowel syndrome
Middle-aged African-American client who smokes cigars
Middle-aged Asian client who travels and eats out frequently
Older American Indian client taking hormone replacement therapy
a.
b.
c.
d.
ANS: B
Colon cancer is more prevalent among African Americans and smokers. Irritable bowel
syndrome, travel, and hormone replacement therapy do not increase the risk for colon cancer.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 1181
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease
Prevention)
5. When performing an assessment, the nurse detects a fruity odor on the clients breath. What
does the nurse do next?

Assess the clients blood sugar level.
Assess the clients stool for occult blood.
Instruct the client in oral hygiene techniques.
Assess the client for petechiae, itching, and jaundice.
a.
b.
c.
d.
ANS: A
A fruity odor to the breath may indicate uncontrolled or undiagnosed diabetes mellitus. The
clients blood sugar level should be checked immediately for hyperglycemia. The nurse may
perform the other assessment tests for the client, but they will not be helpful in determining
the cause of the fruity breath.
REF: N/A
Systems)
6. The nurse is preparing to perform an abdominal assessment on a client with suspected
cholecystitis. In what sequence does the nurse palpate the clients abdomen?
a. Palpate the lower quadrants only.
b. Palpate the upper quadrants last.
c. Palpate the upper quadrants only.
d. Defer palpation and use percussion only.
ANS: B
The client with cholecystitis will report pain in the right upper quadrant of the abdomen.
Tender or painful areas should be palpated last to prevent the client from tensing his or her
abdominal muscles because of pain, thereby making the examination more difficult. All
quadrants should be palpated. Palpation is an important assessment tool that should not be
deferred for this client.
REF: N/A
Systems)
7. The nurse is caring for a client who has just returned from abdominal surgery. When
auscultating the clients abdomen, the nurse does not hear any bowel sounds. Which is the
nurses best action?
a. Notify the health care provider.
b. Percuss the abdomen.
c. Document the finding.
d. Insert a nasogastric tube.
ANS: C
Absent bowel sounds are expected immediately following abdominal surgery. The finding
should be noted in the clients record for later reference. The provider does not need to be
notified at this time. The nurse should insert a nasogastric tube if ordered by the physician if
the ileus persists. Percussion may be performed but may be uncomfortable for the client and
will not reveal the cause of the ileus.
REF: N/A
Systems)
8. The nurse assesses dullness at the left anterior axillary line. The nurse is concerned about
which condition that the client may have?

a. Cirrhosis
b. Splenomegaly
c. Bowel obstruction
d. Abdominal aortic aneurysm
ANS: B
Dullness in front of the tenth intercostal space, at the left anterior axillary line, is indicative of
splenomegaly, which is commonly seen with mononucleosis. Cirrhosis would be noted with
percussion in the clients left upper quadrant, indicating hepatomegaly. The nurse may note
tympanic sounds with bowel obstruction. Percussion would not be used to assess abdominal
aortic aneurysm.
REF: p. 1184
Systems)
9. The nurse finds a positive Blumbergs sign in a client with abdominal pain. Which action does
the nurse plan?

a. Have the client be NPO in preparation for surgery.
b. Document this normal finding in the clients record.
c. Immediately auscultate the clients abdomen for bowel sounds.
d. Repeat the maneuver with the client in a supine position, with the knees flexed.
ANS: A
A positive Blumbergs sign (rebound tenderness), an abnormal sign, is indicative of peritoneal

inflammation, which commonly accompanies appendicitis. The client should be made NPO in
preparation for surgery to remove the appendix. The maneuver should not be repeated with the
client in the supine position. The nurse should perform auscultation before percussion for the
abdominal assessment.

REF: N/A
Systems)
10. Which laboratory finding does the nurse expect to find on assessment of a client with
advanced cirrhosis?
a. Amylase, 129 IU/L; alkaline phosphate, 45 U/L
b. Reticulocyte count, 1%; magnesium, 1.5 mEq/L
c. Hemoglobin, 14 g/dL; direct bilirubin, 0.2 mg/dL
d. Prothrombin time (PT), 17.5 seconds; albumin, 1.6 g/dL
ANS: D
Cirrhosis frequently results in impaired production of clotting factors, with increased PT and
partial thromboplastin time (PTT). Serum albumin is decreased with cirrhosis because protein
formation within the liver is impaired. The other laboratory values are within normal limits
and would not be expected with advanced cirrhosis.
REF: N/A
Systems)
11. The nurse is caring for a client who just completed an upper GI radiographic series with oral
barium contrast. Which instructions does the nurse provide to the client?
Drink plenty of fluids over the next few days.
Do not eat or drink anything for 6 hours after the test.
You may not drive or operate heavy machinery today.
Do not take any blood thinners for 24 hours after the test.
a.
b.
c.
d.
ANS: A
The client is encouraged to drink plenty of fluids after a barium swallow to help eliminate the
barium from the colon. Limiting the diet as the barium is being cleared is not necessary. The
test will not make the client drowsy, so driving should not be limited. Similarly, blood thinners
will not affect the client.
REF: p. 1187
MSC: Integrated Process: Teaching/Learning
12. The client is scheduled for a colonoscopy. Which statement indicates that the client needs
additional teaching about the procedure?

a. I may have gas and abdominal cramps after the test.
b. I will take strong laxatives the afternoon before the test.
c. I will take my Coumadin with a sip of water tomorrow morning.
d. I will take nothing by mouth after midnight on the day of the test.
ANS: C
Blood thinners should not be taken before colonoscopy because bleeding may occur if polyps
are removed. The client should stop taking warfarin (Coumadin) approximately 2 weeks
before the colonoscopy. The other answers describe accurate complications of the
colonoscopy and preparation for the procedure.
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

13. The nurse is preparing the client for a computed tomography (CT) scan of the abdomen with
IV contrast. Which question does the nurse ask the client before the examination?
Are you allergic to shrimp, scallops, or shellfish?
Have you had anything to eat or drink in the past 12 hours?
Did you finish taking all the prescribed laxatives?
Can you tolerate being tilted from side to side?
a.
b.
c.
d.
ANS: A
Allergies to iodine or seafood can cause a cross-allergic reaction to the contrast dye used for
CT scans. Clients reporting such allergies should be scheduled for CT without contrast to
avoid anaphylactic reactions. The client does not need to be NPO for this test and does need
not to take laxatives. The client is not tilted during the CT scan.
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Error Prevention)
MSC:
Integrated Process: Nursing Process (Assessment)
14. An abdominal ultrasound is scheduled for the client. Which statement by the client indicates
that the nurses teaching about the procedure was effective?

The IV contrast may burn when it is injected.
I will drive myself home after the test is completed.
I will empty my bladder completely before the test.
I may have to take a laxative to pass the barium afterward.
a.
b.
c.
d.
ANS: B
Because sedation is not used for this test, clients may drive themselves home after the
abdominal ultrasound is completed. Barium and IV contrast are not needed. The clients
bladder should be full for accurate visualization.
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
15. While a health history is obtained from a client with a new diagnosis of advanced pancreatic
cancer, the client begins to cry. Which is the nurses best response?
I am so sorry for making you cry!
I will step out for a few minutes until you feel better.
I can see that you are upset about this. It is all right to cry.
I can see that I am upsetting you. Lets move on to something else.
a.
b.
c.
d.
ANS: C
The nurse should recognize the clients feelings and should allow the client to cry. Moving on
to another topic shows disregard for the clients feelings. The nurse should not leave the room
but should stay to offer support. Apologizing to the client does not place the focus on the
client or acknowledge the clients feelings and emotions in this situation.
REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Caring
16. The nurse is performing an abdominal assessment on an older client. Which assessment
finding does the nurse expect as a normal consequence of aging?

Increased salivation and drooling
Hyperactive bowel sounds and loose stools
Increased gastric acid production and heartburn
Impaired sensation to defecate and constipation
a.
b.
c.
d.
ANS: D
Older adults may lose the sensation to defecate, resulting in constipation. Salivation decreases
with aging, along with peristalsis and gastric acid production.
REF: N/A
Systems)
17. The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD)
completed. The client tells the nurse that her mouth is very dry after the procedure. Which is
the nurses best action?
a. Keep the client NPO (nothing by mouth).
b. Check the clients gag reflex.
c. Offer the client sips of clear liquids.
d. Provide the client with a few ice chips.
ANS: B
The back of the throat is numbed for the EGD, impairing the gag reflex. Therefore the client is
initially NPO postoperatively. The nurse should check the gag reflex before offering any type
of liquid to the client. The client may be given ice chips or sips of fluids once the gag reflex
has returned.
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Accident/Injury Prevention) MSC:
Integrated Process: Nursing Process (Assessment)
18. A client has a family history of colon cancer. Which laboratory tests are ordered to rule out
colon cancer?
Cholesterol
Serum lipase
Carcinoembryonic antigen
Xylose absorption
a.
b.
c.
d.
ANS: C
The carcinoembryonic antigen can indicate colorectal, stomach, or pancreatic cancer if

elevated. Elevated cholesterol and serum lipase may indicate pancreatitis. Decreased xylose
absorption may indicate malabsorption in the small intestine.
REF: Chart 55-3, p. 1186
MULTIPLE RESPONSE
1. The nurse performs percussion of a clients abdomen. Which findings may the nurse
determine with this assessment technique? (Select all that apply.)

Hepatomegaly
Kidney stones
Ascites
Large mass below the liver
Biliary colic
Ileus
a.
b.
c.
d.
e.
f.
ANS: A, C, D, F
Percussion allows the nurse to identify the presence of masses, fluid, enlarged organs, and air
in the abdomen. The nurse would not be able to identify biliary colic or kidney stones with
percussion.
REF: N/A
Systems)
2. A client reports that he has been passing black stools for the last few days. Which findings
from the clients health history does the nurse consider as possible causes? (Select all that
apply.)
a. Cirrhosis
b. Cholecystitis
c. Hemorrhoids
d. Diverticulitis
e. Long-term use of NSAIDs
f. Use of iron supplements
ANS: A, E, F
Cirrhosis may cause black stools when bleeding occurs from esophageal varices. Long-term
NSAID use may lead to gastric ulcer development and bleeding. Iron supplements may turn
the color of the stool black. Hemorrhoids or diverticulitis would result in stools that are
streaked with red. Cholecystitis may result in pale-colored stools if bile flow is obstructed.
REF: N/A
Systems)
3. A client has jaundice and ascites. Which laboratory values indicate hepatic disease? (Select all
that apply.)
Albumin, 2.0 g/dL
Potassium, 3.0 mEq/L
Alanine aminotransferase (ALT), 45 IU/L
Aspartate aminotransferase (AST), 45 U/L
Unconjugated (indirect) bilirubin, 1 mg/dL
Ammonia, 120 mg/dL
a.
b.
c.
d.
e.
f.
ANS: A, C, D, E, F
Decreased albumin and increased ALT, AST, unconjugated bilirubin, and ammonia all indicate
hepatic disease. When the liver is damaged, albumin is not produced by the hepatic cells. ALT
and AST liver enzymes increase with liver disease. Bilirubin, the primary component of bile,
can be measured as direct or indirect and, if elevated, can indicate impaired secretion.
Elevated levels of ammonia indicate severe hepatocellular damage. Decreased potassium does
not indicate possible liver involvement but can be reduced by vomiting and diarrhea.
REF: N/A
Systems)

Chapter 55

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Chapter 55

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Chapter 55: Assessment of the Gastrointestinal System

problem does the nurse anticipate for this client?

is important for the nurse to ask?

development of colon cancer?

does the nurse do next?

which condition that the client may have?

the nurse plan?

A positive Blumbergs sign (rebound tenderness), an abnormal sign, is indicative of peritoneal

DIF: Cognitive Level: Application/Applying or higher

additional teaching about the procedure?

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

that the nurses teaching about the procedure was effective?

finding does the nurse expect as a normal consequence of aging?

The carcinoembryonic antigen can indicate colorectal, stomach, or pancreatic cancer if

determine with this assessment technique? (Select all that apply.)

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