ATI RN
ATI Gastrointestinal System Questions
Question 1 of 5
A client with viral hepatitis has no appetite, and food makes the client nauseated. Which of the following interventions would be most appropriate?
Correct Answer: D
Rationale: If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. Explaining to the client that the majority of calories should be eaten in the morning hours is important because nausea occurs most often in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are tolerated better.
Question 2 of 5
The nurse is caring for a client with a diagnosis of cirrhosis and is monitoring the client for signs of portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension?
Correct Answer: D
Rationale: Rationale: 1. The correct answer is D) Crackles on auscultation of the lungs. Portal hypertension is a complication of cirrhosis where increased pressure in the portal vein system leads to various manifestations. Crackles on lung auscultation indicate hepatic hydrothorax, a common consequence of portal hypertension where ascites fluid enters the pleural space, causing crackling sounds upon breathing. 2. A) Flat neck veins are not indicative of portal hypertension. In fact, in portal hypertension, engorged neck veins (jugular venous distension) are commonly seen due to increased venous pressure. B) Hypotension is not a typical sign of portal hypertension. Instead, hypertension or normal blood pressure is more common in these cases. C) Weak pulse is not a direct sign of portal hypertension. Peripheral pulses may actually be bounding due to the hyperdynamic circulation seen in conditions like cirrhosis. 3. Understanding the signs of portal hypertension is crucial in caring for patients with liver disease. Monitoring for crackles on lung auscultation can help in early detection of complications like hepatic hydrothorax, prompting timely interventions. It is essential for nurses to be vigilant in assessing these patients for subtle changes that could indicate worsening liver function and portal hypertension.
Question 3 of 5
A client is admitted to the hospital with acute viral hepatitis. Which of the following signs or symptoms would the nurse expect to note based on this diagnosis?
Correct Answer: B
Rationale: Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis.
Question 4 of 5
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?
Correct Answer: B
Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.
Question 5 of 5
A nurse is caring for a client diagnose with pancreatitis. The nurse anticipates that the client would not experience an elevation of which of the following enzymes?
Correct Answer: B
Rationale: Rationale: 1. The correct answer is B) Lactase. Lactase is an enzyme responsible for breaking down lactose (milk sugar). Pancreatitis primarily affects enzymes produced by the pancreas, such as lipase, amylase, and trypsin. Lactase is produced by the small intestine, not the pancreas. Therefore, in pancreatitis, lactase levels would not be directly affected. 2. A) Lipase is an enzyme produced by the pancreas that helps digest fats. In pancreatitis, lipase levels are typically elevated due to pancreatic inflammation and damage. 3. C) Amylase is another enzyme produced by the pancreas that aids in digesting carbohydrates. In pancreatitis, amylase levels are often elevated, as the inflamed pancreas leaks this enzyme into the bloodstream. 4. D) Trypsin is an enzyme produced by the pancreas to digest proteins. In pancreatitis, trypsin levels can be elevated due to the release of digestive enzymes into the pancreas itself, leading to auto-digestion and further damage. Key Learning Points: - Pancreatitis is an inflammatory condition affecting the pancreas. - Elevated levels of lipase and amylase are common markers of pancreatitis. - Lactase is not produced by the pancreas but by the small intestine. - Understanding enzyme functions and origins helps in diagnosing and managing pancreatic disorders. In conclusion, recognizing the specific enzymes affected in pancreatitis is crucial for accurate assessment and treatment. Lactase remains unaffected in pancreatitis, distinguishing it from the other enzymes typically elevated in this condition.