ATI Assessment of the Gastrointestinal System, Questions and Answers with Explanations

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?

a.            Failure to absorb nutrients from the stomach

b.            Inability to digest protein

c.             Impaired ability to soften and break down food

d.            Difficulty swallowing food

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 client’s diarrhea. A colonoscopy will not cause acute diarrhea. Trouble swallowing is not related to diarrhea. Allergic reactions do not typically cause acute diarrhea.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations 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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse is screening clients at a health fair. Which client is at highest risk for the development of colon cancer?

a.            Older white client with irritable bowel syndrome

b.            Middle-aged African-American client who smokes cigars

c.             Middle-aged Asian client who travels and eats out frequently

d.            Older American Indian client taking hormone replacement therapy

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) MSC: Integrated Process: Nursing Process (Assessment)

5. When performing an assessment, the nurse detects a fruity odor on the client’s breath. What does the nurse do next?

a.            Assess the client’s blood sugar level.

b.            Assess the client’s stool for occult blood.

c.             Instruct the client in oral hygiene techniques.

d.            Assess the client for petechiae, itching, and jaundice.

ANS: A

A fruity odor to the breath may indicate uncontrolled or undiagnosed diabetes mellitus. The client’s 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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

6. The nurse is preparing to perform an abdominal assessment on a client with suspected cholecystitis. In what sequence does the nurse palpate the client’s 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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

7. The nurse is caring for a client who has just returned from abdominal surgery. When auscultating the client’s abdomen, the nurse does not hear any bowel sounds. Which is the nurse’s 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 client’s 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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

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Category ATI
Release date 2021-09-14
Pages 10
Language English
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