Nokea
A patient has been scheduled for a urea breath test in one month's time. What nursing diagnosis most likely prompted this diagnostic test?
- A. Impaired Dentition Related to Gingivitis
- B. Risk For Impaired Skin Integrity Related to Peptic Ulcers
- C. Imbalanced Nutrition: Less Than Body Requirements Related to Enzyme Deficiency
- D. Diarrhea Related to Clostridium Difficile Infection
Correct Answer: B
Rationale: Urea breath tests detect the presence of Helicobacter pylori, the bacteria that can live in the mucosal lining of the stomach and cause peptic ulcer disease. This test does not address fluid volume, nutritional status, or dentition.
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An advanced practice nurse is assessing the size and density of a patient's abdominal organs. If the results of palpation are unclear to the nurse, what assessment technique should be implemented?
- A. Percussion
- B. Auscultation
- C. Inspection
- D. Rectal examination
Correct Answer: A
Rationale: Percussion is used to assess the size and density of the abdominal organs and to detect the presence of air-filled, fluid-filled, or solid masses. Percussion is used either independently or concurrently with palpation because it can validate palpation findings.
A patient has been experiencing significant psychosocial stress in recent weeks. The nurse is aware of the hormonal effects of stress, including norepinephrine release. Release of this substance would have what effect on the patient's gastrointestinal function?
- A. Decreased motility
- B. Increased sphincter tone
- C. Increased enzyme release
- D. Inhibition of secretions
- E. Increased peristalsis
Correct Answer: A,B,D
Rationale: Norepinephrine generally decreases GI motility and secretions, but increases muscle tone of sphincters. Norepinephrine does not increase the release of enzymes.
A nursing student has auscultated a patient's abdomen and noted one or two bowel sounds in a 2-minute period of time. How would you tell the student to document the patient's bowel sounds?
- A. Normal
- B. Hypoactive
- C. Hyperactive
- D. Paralytic ileus
Correct Answer: B
Rationale: Documenting bowel sounds is based on assessment findings. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation. Paralytic ileus is a medical diagnosis that may cause absent or hypoactive bowel sounds, but the nurse would not independently document this diagnosis.
A nurse is performing an abdominal assessment of an older adult patient. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function?
- A. Increased gastric motility
- B. Decreased gastric pH
- C. Increased gag reflex
- D. Decreased mucus secretion
Correct Answer: D
Rationale: Older adults tend to secrete less mucus than younger adults. Gastric motility slows with age and gastric pH rises due to decreased secretion of gastric acids. Older adults tend to have a blunted gag reflex compared to younger adults.
A clinic patient has described recent dark-colored stools; the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the patient's current health status would contraindicate FOBT?
- A. Gastroesophageal reflux disease (GERD)
- B. Peptic ulcers
- C. Hemorrhoids
- D. Recurrent nausea and vomiting
Correct Answer: C
Rationale: FOBT should not be performed when there is hemorrhoidal bleeding. GERD, peptic ulcers and nausea and vomiting do not contraindicate the use of FOBT as a diagnostic tool.