NUR 230 GI Unit 2

Abdominal assessment

100

When assessing the abdomen, which assessment technique should the nurse perform before palpation?

auscultation 

200

A patient reports severe abdominal pain. The nurse immediately begins deep palpation before listening to bowel sounds. Why is this assessment sequence incorrect?

palpation can alter bowel activity, so auscultation should occur first

300

DOUBLE POINTS!

RN auscultates bowel sounds and hears <5 bowel sounds in a minute, what does this mean and what do they do next (for an assessment)?

hypoactive (slowed) bowel sounds, which indicate decreased intestinal motility. 

Listen Longer: If sounds are very sparse, listen for a full 5 minutes in each quadrant before declaring bowel sounds completely absent and assess other symptoms: Check for abdominal distention (swelling), firmness, tenderness, pain, nausea, vomiting, and the last time the patient passed gas or had a bowel movement.

400

The nurse receives four reports. Which patient requires the most immediate follow-up?

A. Patient with GERD who reports "the worst heartburn" after eating a McDonalds burger
B. Patient with a history of Crohn disease who reports mild and intermittent cramping
C. Patient with suspected kidney stones who reports flank pain (7/10) and light hematuria
D. Patient with sudden severe abdominal pain, abdominal rigidity, and vomiting

D: SUDDEN! 

likely peritonitis secondary to a GI perforation (a ruptured organ, such as an ulcer or appendix). This is a life-threatening surgical emergency that requires immediate medical evaluation, IV fluids, antibiotics, and likely emergency surgery

GI conditions

100

A patient reports pain in the right upper quadrant. Which organ is located primarily in this area?

A. Spleen
B. Liver
C. Appendix
D. Sigmoid colon

b liver

200

This condition involves inflammation of the diverticula in the GI tract.

diverticulitis 

300

This condition occurs when stomach contents flow backward into the esophagus.

GERD (reflux)

400

this is an chronic autoimmune disease that has no cure and causes inflammation anywhere in the GI tract. Common symptoms are unexplained weight loss, cramping, diarrhea and low intake. A primary goal for patients with the disease is to prevent a flare up. What is this disease? 

Crohn's disease 

Pain/symptoms

100

A patient reports pain directly below the sternum in the upper middle portion of the abdomen. What location is this?

epigastric region

200

a patient came in with inflammation and irritation of the peritoneal lining (lining around abdominal organs), what may be found upon assessment that warrants an emergency?

severe rigidity, rebound tenderness and guarding 

300

DOUBLE POINTS

patient came in with dark, tarry stools. what is going on and where is this happening in the GI tract? (what is the med term for dark and tarry stools)

MELENA 

a UPPER GI bleed. Lower GI bleed will be brighter red. but if bleeding is "digested" as it has gone thru more of the digestive tract. 

common causes would be esophageal varices, PUD, and gastritis 

400

when assessing the family and personal history, what should RN take note of? 

Any history of gastrointestinal illnesses or surgeries should be noted when obtaining a health history. Family history of gastrointestinal disorders or colon cancer should be assessed.

Random

100

the RN charted, "LUQ pain", what organ could be affected here? 

spleen, stomach, part of your pancreas, and left kidney

200

This organ stores bile produced by the liver.

gallbladder

300

Which organ produces insulin?

pancreas

400

what are the two main risk factors for PUD (and define PUD)

peptic ulcer disease: smoking and alcohol

Vocab

100

yellow discoloration of the skin?

jaundice

200

peristalsis 

automatic and wave like muscle contractions that move food, fluids, and waste through your digestive tract

300

blood in the urine: 

hematuria 

400

dysphagia

difficulty swallowing