Chapter 21: Gastrointestinal Clinical Assessment and Diagnostic Procedures

Chapter 21: Gastrointestinal Clinical Assessment and Diagnostic Procedures

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. Percussing the patient’s stomach produces a tympanic sound. The nurse recognizes this as a sign that:

a.	the patient has impaired peristalsis.
b.	the patient’s stomach is empty.
c.	further evaluation is needed for presence of a mass.
d.	the last meal has not been digested yet.

 

ANS:   B

Percussion should proceed systematically and lightly in all four quadrants. Normal findings include tympany over the stomach when empty, tympany or hyperresonance over the intestine, and dullness over the liver and spleen.

 

DIF:    Cognitive Level: Comprehension       REF:    431

OBJ:    Nursing Process: Assessment TOP:    Gastrointestinal Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

2. The nurse is unable to hear bowel sounds in any of the four quadrants of the patient’s abdomen. This may indicate the presence of:

a.	flatus.
b.	an ileus.
c.	constipation.
d.	an obstruction.

 

ANS:   B

Abnormal findings include the absence of bowel sounds throughout a 5-minute period, extremely soft and widely separated sounds, and increased sounds with a high-pitched, loud, rushing noise (peristaltic rush). Absent bowel sounds may occur as a result of inflammation, ileus, electrolyte disturbances, and ischemia.

 

DIF:    Cognitive Level: Analysis      REF:    431

OBJ:    Nursing Process: Assessment TOP:    Gastrointestinal Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

3. Auscultation of the abdomen reveals a bruit over the left renal artery. This is an indication of:

a.	normal artery function.
b.	adventitious sounds.
c.	a partially obstructed artery.
d.	renal hypertension.

 

ANS:   C

Bruits are created by turbulent flow through a partially obstructed artery and are always considered an abnormal finding.

 

DIF:    Cognitive Level: Analysis      REF:    431

OBJ:    Nursing Process: Assessment TOP:    Gastrointestinal Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

4. The nurse observes that striae on the patient’s abdomen are pink and purple. This may be a sign of:

a.	malnutrition.
b.	ascites.
c.	Cushing’s syndrome.
d.	portal hypertension.

 

ANS:   C

Old striae (stretch marks) are generally silver, whereas pink-purple striae may be indicative of Cushing’s syndrome.

 

DIF:    Cognitive Level: Comprehension       REF:    430

OBJ:    Nursing Process: Assessment TOP:    Gastrointestinal Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation

 

5. During auscultation of the patient’s abdomen, the nurse hears frequent high-pitched, tinkling sounds. This is probably evidence of:

a.	paralytic ileus.
b.	volvulus.
c.	normal bowel sounds.
d.	peritoneal bleeding.

 

ANS:   C

Normal bowel sounds include high-pitched, gurgling sounds that occur approximately every 5 to 15 seconds or at a rate of 5 to 34 times each minute.

 

DIF:    Cognitive Level: Analysis      REF:    Table 21-1

OBJ:    Nursing Process: Assessment TOP:    Gastrointestinal Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation