the student nurse is preparing a teaching care plan to help improve nutrition in a patient with achalasia you include which of the following
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. The student nurse is preparing a teaching care plan to help improve nutrition in a patient with achalasia. You include which of the following:

Correct answer: C

Rationale: Eating meals while sitting upright helps improve swallowing and prevent complications in patients with achalasia.

2. Crohn’s disease can be described as a chronic relapsing disease. Which of the following areas in the GI system may be involved with this disease?

Correct answer: D

Rationale: Crohn's disease can affect any part of the gastrointestinal tract from the mouth to the anus, but it commonly affects the small intestine and colon, involving the entire thickness of the bowel wall.

3. A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?

Correct answer: B

Rationale: Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is removed usually within 48 hours. The nurse does not need to notify the physician. A sterile dressing covers the site and should be changed to prevent infection and skin excoriation.

4. Of the following signs and symptoms of bowel obstruction, which is related primarily to small bowel obstruction rather than large bowel obstruction?

Correct answer: A

Rationale: Profuse vomiting is the classic sign of small bowel obstruction and rarely occurs with large bowel obstruction. Abdominal discomfort and distention are present in both small and large bowel obstructions, but distention is more common in large bowel obstruction. High-pitched bowel sounds indicate hyperperistalsis, which occurs early in obstruction.

5. A client had an abdominal perineal resection with a colostomy 4 days ago and is ready for discharge. Which of the following would be an appropriate expected outcome at this point?

Correct answer: B

Rationale: Clients often have concerns about their sexuality after a fecal diversion. The nurse should encourage the client to discuss any questions about sexual functioning. The client will not need to maintain a high-fiber diet but will be encouraged to avoid any foods that cause odor and flatulence. The client should be able to ambulate and sit out of bed for several hours at a time at this point. Fluid intake will be encouraged, not restricted.

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