CCRN Practice Questions -GI with complete solutions.

CCRN Practice Questions -GI with complete solutions.A 25-year-old man is admitted to the critical care unit with complaints of generalized abdominal pain for 8 hours. The pain began yesterday and has been becoming increasingly severe. He is lying still with his knees flexed. Physical examination reveals diffuse tenderness and boardlike rigidity. His temperature is 39° C, blood pressure is 124/68 mm Hg, heart rate is 120 beats/min, and respiratory rate is 25 breaths/min. He is diagnosed with acute appendicitis with intestinal perforation. Which description of abdominal pain is most specific to peritoneal irritation? a. Generalized pain of the abdominal area b. Pain lasting longer than 6 hours c. Pain becoming increasingly severe d. Pain lessened by lying still with knees flexed Correct answer: d Rationale: The pain of peritoneal irritation is lessened by limiting movement and by flexing the knees to relieve abdominal tension. Test-Taking Strategy: Note that option d is the most specific of the answers. Although options a, b, and c are seen in peritoneal irritation, the most specific to peritoneal irritation is option d. A 25-year-old man is admitted to the critical care unit with complaints of generalized abdominal pain for 8 hours. The pain began yesterday and has been becoming increasingly severe. He is lying still with his knees flexed. Physical examination reveals diffuse tenderness and boardlike rigidity. His temperature is 39° C, blood pressure is 124/68 mm Hg, heart rate is 120 beats/min, and respiratory rate is 25 breaths/min. He is diagnosed with acute appendicitis with intestinal perforation. The nurse should expect to prepare the patient for which of the following? a. Exploratory laparotomy b. Nasogastric suction c. Analgesics, sedation, and antipyretics d. Upper gastrointestinal series Correct answer: a Rationale: Immediate exploratory laparotomy is indicated for this patient to prevent further bacterial contamination and chemical irritation of the peritoneum because he has obvious indications of peritoneal irritation. Test-Taking Strategy: One approach is to link the boardlike abdomen to an acute abdomen. Another name for acute abdomen is surgical abdomen or hot belly. Choose option a. 00:26 01:27 A 52-year-old man is admitted with hepatic failure caused by chronic alcoholism. He is nonresponsive to verbal stimuli at this time. Which finding would the nurse expect in the later stages of hepatic encephalopathy? a. Asterixis b. Confusion c. Pathologic reflexes (e.g., Babinski) d. Constructional apraxia Correct answer: c Rationale: Pathologic reflexes are characteristic of stage IV hepatic encephalopathy. Asterixis occurs by stage II. Constructional apraxia (the inability to reproduce simple figures [e.g., a star or triangle]) occurs by stage III. Confusion is mild in stage I and becomes progressively worse until the patient is unconscious in stage IV. Test-Taking Strategy: Think about which finding sounds the worst. Pathologic reflexes (e.g., Babinski's reflex and grasp reflex) are indications of severe cerebral failure. A 52-year-old man is admitted with hepatic failure caused by chronic alcoholism. He is nonresponsive to verbal stimuli at this time. Which intervention would not specifically decrease serum ammonia levels in patients with hepatic encephalopathy? a. Administration of rifaximin b. Administration of lactulose c. Provision of adequate caloric intake d. Avoidance of all hepatotoxic agents Correct answer: d Rationale: Although avoidance of hepatotoxic agents is important in patients with liver failure, it only prevents further damage to the liver rather than actually reducing ammonia level. Rifaximin decreases the bacteria in the gastrointestinal tract that break down nitrogenous materials (protein) to ammonia. Lactulose increases ammonia excretion and moves nitrogenous materials through the gastrointestinal tract more quickly, allowing less time for the bacteria to convert the nitrogen to ammonia. The restriction of protein in the diet and provision of sufficient calories (primarily in the form of carbohydrates) to prevent endogenous protein catabolism decreases the ammonia. Test-Taking Strategy: The key phrase in the questions is "decrease serum ammonia levels." Look at the first word of each option. Avoidance (in option d) is not likely to actively decrease something, although it may prevent further increases. A 52-year-old man is admitted with hepatic failure caused by chronic alcoholism. He is nonresponsive to verbal stimuli at this time. Which dietary restrictions would be maintained for a patient with hepatic encephalopathy? a. Protein and sodium b. Fat and potassium c. Potassium and carbohydrates d. Sodium and potassium Correct answer: a Rationale: Protein is restricted because its breakdown causes increased ammonia levels. Sodium is restricted because patients with hepatic disease have increased circulating levels of aldosterone, which causes increased sodium reabsorption in the distal tubule and resultant edema. Adequate caloric intake in the form primarily of carbohydrates with adequate amounts of fats is necessary to prevent the catabolism of body protein stores. Potassium is not restricted and may need to be replaced because the increased circulating aldosterone levels cause the excretion of increased amounts of potassium. Test-Taking Strategy: Because you know that this patient is likely to be edematous, you should assume that sodium should be restricted. Options a and d have sodium. Because sodium and potassium are opposite in relationship to aldosterone, eliminate option d because it is unlikely to restrict both (though both are restricted in renal failure). Protein is restricted because it contributes to increased ammonia levels, so choose option a. A 71-year-old woman reports that she started vomiting large amounts of bright blood 1 hour ago. In the supine position, her blood pressure is 120/82 mm Hg. When sitting on the edge of the bed, she complains of dizziness. Which of the following blood pressure measurements would be expected? a. 140/90 mm Hg b. 120/82 mm Hg c. 100/60 mm Hg d. 60 mm Hg with Doppler ultrasound Correct answer: c Rationale: Based on the history, you would expect postural or orthostatic hypotension, which is defined as a drop of 20 mm Hg in pressure when the patient changes position. This sometimes is called tilt positive. Postural hypotension is an earlier sign of blood volume depletion than frank hypotension. Test-Taking Strategy: Considering the blood loss, you certainly would not expect the blood pressure to go up without treatment. The dizziness makes you suspect hypoperfusion to the brain in the upright position, so the blood pressure is probably less than normal. She is talking to you and so is certainly cerebrating and perfusing her brain with a blood pressure of greater than 60 mm Hg systolic. Choose option c. A 71-year-old woman reports that she started vomiting large amounts of bright blood 1 hour ago. In the supine position, her blood pressure is 120/82 mm Hg. When sitting on the edge of the bed, she complains of dizziness. The nurse would expect to administer which of the following? a. Furosemide (Lasix) b. Dobutamine (Dobutrex) c. Fluid bolus of normal saline d. Dopamine (Intropin) Correct answer: c Rationale: The blood loss represents a decrease in preload, and the blood pressure and perfusion drop that occurs with an upright position demonstrates that preload needs to be replaced. A fluid bolus is the best choice. Test-Taking Strategy: Blood loss represents a preload loss. The preload is too low, so do not decrease it further with furosemide. Eliminate option a. Do not choose dopamine to increase the blood pressure because the problem is not vascular tone, and dopamine actually may decrease flow and perfusion by constricting vessels. Eliminate option d. The problem is not contractility, so eliminate dobutamine because its primary effect is to increase contractility. Eliminate option b. Remember the patient lost volume, so replace volume in the form of normal saline. Choose option c. Blood administration may also be necessary depending on the degree of hypoperfusion. A 52-year-old accountant is admitted to the critical care unit with frank gastrointestinal bleeding for more than 18 hours. He has had a blood loss of more than 1000 mL. Which of the following sets of vital signs would be consistent with the patient's blood loss? a. Blood pressure (BP) 100/84 mm Hg, heart rate 124 breaths/min b. BP 86/40 mm Hg, heart rate 92 breaths/min c. BP 124/66 mm Hg, heart rate 124 breaths/min d. BP 112/60 mm Hg, heart rate 92 breaths/min Correct answer: a Rationale: With a loss of 750 to 1500 mL of blood, an increase in heart rate greater than 100 beats/min and a narrowing of the pulse pressure is expected. These changes are due to sympathetic nervous system innervation. Option a shows a narrow pulse pressure and tachycardia. Test-Taking Strategy: Remember that tachycardia is the first indicator of physiologic stress, so eliminate options b and d. Eliminate option c because it shows normal systolic with a decreased diastolic (widened pulse pressure). You expect this patient in early shock to show narrowed pulse pressure. Choose option a. A 52-year-old accountant is admitted to the critical care unit with frank gastrointestinal bleeding for more than 18 hours. He has had a blood loss of more than 1000 mL. Which laboratory result would be consistent with this patient's clinical presentation? a. Elevation of blood urea nitrogen (BUN) b. Elevation of amylase c. Decrease in alkaline phosphatase d. Presence of urobilinogen Correct answer: a Rationale: You would expect an increase in BUN as a result of the digestion of blood proteins. Test-Taking Strategy: Match blood with blood. Blood breakdown by the gastrointestinal tract increases BUN and ammonia. A 52-year-old accountant is admitted to the critical care unit with frank gastrointestinal bleeding for more than 18 hours. He has had a blood loss of more than 1000 mL. During the next 2 days he is diagnosed with a gastric ulcer and has had recurrent bleeding requiring multiple transfusions. A subtotal gastrectomy is planned. In preoperative teaching the nurse informs him that he may have to receive which vitamin for the rest of his life? a. Vitamin D b. Vitamin A c. Vitamin B12 d. Vitamin K Correct answer: c Rationale: Intrinsic factor, which is necessary for the absorption of vitamin B12 in the ileum, is produced by parietal (also called oxyntic) cells located in the antrum of the stomach. Removal of this area of the stomach results in pernicious anemia and the need for vitamin B12. Test-Taking Strategy: If you are not sure about this one, use the technique of looking for the option that is different from the others. Vitamins A, D, and K are fat-soluble vitamins. So choose the water-soluble vitamin, option c. A 58-year-old woman is admitted with abdominal pain and jaundice. She is diagnosed with a biliary obstruction. She tells the nurse that she does not understand why her stools are so light colored.What would be the best response? a. She is releasing a substance as a result of the obstruction that is making her stools a light color. b. It is probably something she ate and is not significant. c. Because of the obstruction, she is not able to secrete a substance into her bowel that gives her stool a dark color. d. This light color probably means that her liver is also diseased. Correct answer: c Rationale: Bilirubin is brought to the liver (attached to albumin) to be conjugated. Conjugated bilirubin normally is excreted in the urine and in the stool, but in biliary obstruction bilirubin cannot get into the gastrointestinal tract and into the stool. This results in abnormally pale (often called clay-colored) stool. Test-Taking Strategy: Think about obstruction as meaning that something does not get to where it is supposed to be. Choose option c, which says just that. A 58-year-old woman is admitted with abdominal pain and jaundice. She is diagnosed with a biliary obstruction. Biliary disease is of concern because it is a common cause of which of the following? a. Gastrointestinal bleeding b. Acute pancreatitis c. Bowel perforation d. Renal failure Correct answer: b Rationale: Alcoholism and biliary disease are the two most common causes of acute pancreatitis. Test-Taking Strategy: Envision the anatomy of the area. The common bile duct enters the gastrointestinal tract at the duodenum, anatomically close to the pancreas.