Med Surg GI Disorders

For a colonoscopy, the nurse initially should position the client on the left side with knees bent to allow proper visualization of the large intestine.

The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis.

The nurse may not release any confidential information to unauthorized individuals, such as the client's boss. Options 1, 3, and 4 breech client confidentiality.

When examining the oral cavity of a patient with candidiasis, a gown is unnecessary. Candidiasis is a fungal infection that affects the mouth, and it does not pose a risk of transmission through contact with clothing. However, gloves are essential to prevent the spread of infection, as candidiasis can be contagious. A penlight is necessary to provide proper illumination for the examination, and a tongue blade is used to hold the patient's tongue down for better visibility.

Hypertension has the least important role in terms of peptic ulcer formation. Peptic ulcers are primarily caused by the presence of Helicobacter pylori bacteria, acid secretion in the stomach, and the use of non-steroidal anti-inflammatory drugs (NSAIDs). Hypertension, or high blood pressure, does not directly contribute to the development of peptic ulcers. While it may indirectly affect the healing process of ulcers by increasing the risk of complications and delaying recovery, it is not a significant factor in their formation.

By touching the altered body part, the client recognizes the body change and establishes that the change is real. Closing the eyes, not looking at the abdomen when the colostomy is exposed, or avoiding talking about the surgery reflects denial.

The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the client's vital signs.

Seizures are not a complication of colorectal cancer. Colorectal cancer is a type of cancer that affects the colon or rectum, and it can lead to various complications such as metastases (spreading of cancer to other parts of the body), bleeding, and infection. However, seizures are not directly associated with colorectal cancer. Seizures are more commonly seen in conditions such as epilepsy, brain tumors, or certain neurological disorders.

A regular exercise regimen promotes peristalsis and contributes to regular bowel elimination patterns. A low-fiber diet, a sedentary lifestyle, and limited water intake would predispose the client to constipation.

Decreased abdominal strength, muscle tone of the intestinal wall, and motility all contribute to chronic constipation in the elderly.

Fiber supplements are usually recommended

Beta blockers are not used to treat GERD because they primarily work by blocking the effects of adrenaline on the heart and blood vessels, reducing heart rate and blood pressure. They do not directly affect the production of stomach acid or the function of the esophagus, which are the main targets for treating GERD. Antacids, histamine receptor antagonists, and proton pump inhibitors, on the other hand, are commonly used to treat GERD as they help reduce stomach acid production or neutralize existing acid in the stomach.

To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol.

Aspiration of gastric secretions with a pH less than 6 indicates placement in the stomach.

Docusate sodium, a laxative, is used to treat constipation. It softens the stool by stimulating the secretion of intestinal fluid into the stool.

Paracentesis is a diagnostic tool, not a complication.

Because the client had surgery three days ago, the nurse can safely delegate the task of helping the client walk down the hallway.

If a paralytic ileus occurs, bowel sounds will be hypoactive or absent. Hyperactive bowel sounds may signify hunger, intestinal obstruction, or diarrhea.

Mc Burney's point is the correct answer because it refers to the location of pain in the lower, right abdominal quadrant in cases of appendicitis. This point is located between the umbilicus and the anterior superior iliac spine, approximately one-third of the distance. It is a significant clinical finding used to diagnose appendicitis and is named after the American surgeon Charles McBurney.

The graduate nurse and her preceptor should assess the new admission with acute abdominal pain first because he just arrived on the floor and might be unstable. Next, they should change the abdominal dressing for the postoperative client or measure feeding tube residual in the client with continuous tube feedings.

The antibiotic neomycin sulfate (Mycifradin) is prescribed to decrease the bacterial count and reduce the risk of fecal contamination during surgery.

Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks.

The length of endoscopies varies and it is also the least important education tool for the patient.

Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes on the blood.

Colonoscopy is the correct answer because it is the most definitive diagnostic test for both ulcerative colitis and Crohn's disease. It allows direct visualization of the colon and rectum, enabling the detection of characteristic signs such as inflammation, ulcers, and strictures. EGD (esophagogastroduodenoscopy) is used to examine the upper gastrointestinal tract and is not specific for these conditions. CBC (complete blood count) can show signs of inflammation but is not specific enough for a definitive diagnosis. Stool samples can help identify infections or other causes of gastrointestinal symptoms but are not definitive for ulcerative colitis or Crohn's disease.

Disturbed body image is not an appropriate nursing diagnosis related to appendicitis because it is not directly associated with the physical condition of the appendix. Appendicitis primarily involves symptoms such as acute pain, risk for infection due to rupture, and potential lack of knowledge about the condition and its management. Disturbed body image is more commonly associated with conditions that affect one's physical appearance or bodily functions, rather than a specific organ inflammation like appendicitis.

Hypersalivation, aka water brash, occurs in response to reflux, not hyposalivation.

The correct answer is relaxation because gastroesophageal reflux disease is caused by the abnormal relaxation of the lower esophageal sphincter. This relaxation allows stomach acid and partially digested food to flow back into the esophagus, causing symptoms such as heartburn and acid reflux.

High fiber intake is least likely to cause constipation because fiber adds bulk to the stool and helps to move it through the digestive system. It promotes regular bowel movements and prevents constipation. On the other hand, being over 75, overuse of laxatives, and immobilization can all contribute to constipation. Being older can lead to slower digestion and decreased muscle tone in the intestines, while overuse of laxatives can cause the body to become reliant on them for bowel movements. Immobilization, such as being bedridden or sedentary, can also slow down digestion and lead to constipation.

The nursing diagnosis of Deficient fluid volume is inappropriate for a client with malignant tumors of the oral cavity because it does not directly relate to the condition. Malignant tumors of the oral cavity primarily affect the oral mucous membranes and can cause impaired oral mucous membranes, acute pain, and risk for ineffective airway clearance. However, deficient fluid volume is not directly associated with this condition and may not be a priority concern for the client.

Secondary stomatitis results from infection by oppourtunistic viruses or bacteria. In this case, the patient with AIDs is, likely, the most immunosuppressed.

Of the choices listed, aspiration is the most serious potential complication of tube feedings. Dehydration — not fluid volume excess — is a concern because of decreased free water intake.

Patients with GERD should avoid peppermint, alcohol, caffeinated beverages, chocolate, tea, and coffee

Periumbilical pain is the initial symptom, followed by nausea and vomiting.

When an NG tube is no longer patent, stomach contents collect in the stomach giving the client a sensation of fullness

A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up

Hemoglobin and hematocrit are typically performed first in clients with upper GI bleeding to evaluate the extent of blood loss. Endoscopy is then performed to directly visualize the upper GI tract and locate the source of bleeding.

Patients should avoid red meat, animal fat, fatty foods, fried meats/ fish, and concentrated sweets.

The appropriate nursing diagnoses for patients with colorectal cancer include disturbed body image, deficient fluid volume, and acute/chronic pain. Colorectal cancer and its treatments can have a significant impact on a patient's body image, causing distress and a need for emotional support. Additionally, the disease and its treatments can lead to fluid imbalances, requiring careful monitoring and intervention to maintain adequate hydration. Finally, patients with colorectal cancer often experience pain, both acute and chronic, which requires assessment and management to improve their comfort and quality of life.

Toxic megacolon is a condition characterized by the dilation and paralysis of the colon, which is a complication of ulcerative colitis. It is not a fistula or a risk factor for pancreatitis. Ulcerative colitis causes inflammation and ulcers in the colon, and in severe cases, it can lead to the colon becoming enlarged and losing its ability to contract and move stool. This can result in life-threatening complications such as perforation or rupture of the colon.

All are goals

Pain is a symptom of PUD, not a complication

Corticosteroids, such as prednisone, reduce the signs and symptoms of diarrhea, pain, and bleeding by decreasing inflammation. Antidiarrheals, such as diphenoxylate (Lomotil), combat diarrhea by decreasing peristalsis.