Nursing: A Concept-Based Approach to Learning, 2e (Pearson)

Module 4 Digestion

The Concept of Digestion

1) A client presents with delayed wound healing. During the digestion assessment, which is the
most likely nutrient deficit to be found in the client's diet?
A) Protein
B) Digestive enzymes
C) Insulin
D) Carbohydrates
Answer: A
Explanation: A) A deficiency of protein may delay wound healing. Digestive enzymes aid in the
digestion of nutrients. Insulin allows glucose to be used by the cells. Carbohydrates are a source
of energy.
B) A deficiency of protein may delay wound healing. Digestive enzymes aid in the digestion of
nutrients. Insulin allows glucose to be used by the cells. Carbohydrates are a source of energy.
C) A deficiency of protein may delay wound healing. Digestive enzymes aid in the digestion of
nutrients. Insulin allows glucose to be used by the cells. Carbohydrates are a source of energy.
D) A deficiency of protein may delay wound healing. Digestive enzymes aid in the digestion of
nutrients. Insulin allows glucose to be used by the cells. Carbohydrates are a source of energy.
Page Ref: 208
Cognitive Level: Understanding
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Summarize the physiological processes of the gastrointestinal system
related to digestion.

1
Copyright © 2015 Pearson Education, Inc.
2) Which client is at the highest risk of being admitted to the Emergency Department with severe
nausea and vomiting?
Select all that apply.
A) A 47-year-old with a 3-hour history of chest pressure
B) A 61-year-old reporting sudden onset of vertigo
C) A 72-year-old with an asthma exacerbation
D) A 23-year-old who sustained a head injury in a fall
E) A 19-year-old who is 6 weeks pregnant
Answer: A, D, E
Explanation: A) The vomiting center in the medulla of the brain may be affected by the
vestibular system of the ear, acute myocardial infarction, pregnancy, and increased intracranial
pressure. An asthma exacerbation is least likely to cause severe nausea and vomiting.
B) The vomiting center in the medulla of the brain may be affected by the vestibular system of
the ear, acute myocardial infarction, pregnancy, and increased intracranial pressure. An asthma
exacerbation is least likely to cause severe nausea and vomiting.
C) The vomiting center in the medulla of the brain may be affected by the vestibular system of
the ear, acute myocardial infarction, pregnancy, and increased intracranial pressure. An asthma
exacerbation is least likely to cause severe nausea and vomiting.
D) The vomiting center in the medulla of the brain may be affected by the vestibular system of
the ear, acute myocardial infarction, pregnancy, and increased intracranial pressure. An asthma
exacerbation is least likely to cause severe nausea and vomiting.
E) The vomiting center in the medulla of the brain may be affected by the vestibular system of
the ear, acute myocardial infarction, pregnancy, and increased intracranial pressure. An asthma
exacerbation is least likely to cause severe nausea and vomiting.
Page Ref: 210
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 2. Examine the relationship between digestion and other systems.

2
Copyright © 2015 Pearson Education, Inc.
3) The nurse anticipates that which condition requires surgery?
A) Hepatitis
B) Pancreatitis
C) Pyloric stenosis
D) Fecal impaction
Answer: C
Explanation: A) Pyloric stenosis ultimately requires surgery to split the pyloric muscle to allow
passage of food and fluid. Hepatitis, pancreatitis, and fecal impaction are medically treated.
B) Pyloric stenosis ultimately requires surgery to split the pyloric muscle to allow passage of
food and fluid. Hepatitis, pancreatitis, and fecal impaction are medically treated.
C) Pyloric stenosis ultimately requires surgery to split the pyloric muscle to allow passage of
food and fluid. Hepatitis, pancreatitis, and fecal impaction are medically treated.
D) Pyloric stenosis ultimately requires surgery to split the pyloric muscle to allow passage of
food and fluid. Hepatitis, pancreatitis, and fecal impaction are medically treated.
Page Ref: 213
Cognitive Level: Remembering
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 3. Identify commonly occurring alterations in digestion and their related
treatments.

3
Copyright © 2015 Pearson Education, Inc.
4) The nurse is assigned to a 4-month-old client with vomiting and diarrhea brought to the
pediatric clinic by his mother. Temperature: 37° C, apical HR: 130, R: 40/min. Your abdominal
assessment reveals a soft, concave abdomen, 10 gurgles auscultated in 1 minute in all four
quadrants, and tympani to percussion. Which collaborative care action does the nurse anticipate?
A) Check the surgical call schedule and reserve an operating suite.
B) Place the infant NPO for a barium swallow.
C) Prepare a milk-based infant formula to replace fluids.
D) Complete a thorough digestion assessment interview with the mother.
Answer: D
Explanation: A) The assessment data for this pediatric client indicates a non-emergent alteration
in digestion that requires additional interview information from the mother. Nothing in the
assessment indicates a surgical emergency. A barium swallow is not indicated for diarrhea. Milk-
based formulas would be avoided until symptoms subside.
B) The assessment data for this pediatric client indicates a non-emergent alteration in digestion
that requires additional interview information from the mother. Nothing in the assessment
indicates a surgical emergency. A barium swallow is not indicated for diarrhea. Milk-based
formulas would be avoided until symptoms subside.
C) The assessment data for this pediatric client indicates a non-emergent alteration in digestion
that requires additional interview information from the mother. Nothing in the assessment
indicates a surgical emergency. A barium swallow is not indicated for diarrhea. Milk-based
formulas would be avoided until symptoms subside.
D) The assessment data for this pediatric client indicates a non-emergent alteration in digestion
that requires additional interview information from the mother. Nothing in the assessment
indicates a surgical emergency. A barium swallow is not indicated for diarrhea. Milk-based
formulas would be avoided until symptoms subside.
Page Ref: 215
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
Learning Outcome: 4. Differentiate common physical assessment procedures used to examine
digestive health across the life span.

4
Copyright © 2015 Pearson Education, Inc.
5) A client is scheduled for a diagnostic test to determine digestion status. Which test does not
require fasting or other preparation?
A) Barium swallow
B) Amylase
C) Endoscopy
D) Lipid panel
Answer: B
Explanation: A) An amylase test does not require any special preparation. A barium swallow,
endoscopy, and a lipid panel require fasting.
B) An amylase test does not require any special preparation. A barium swallow, endoscopy, and
a lipid panel require fasting.
C) An amylase test does not require any special preparation. A barium swallow, endoscopy, and
a lipid panel require fasting.
D) An amylase test does not require any special preparation. A barium swallow, endoscopy, and
a lipid panel require fasting.
Page Ref: 221
Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing Process: Implementation
Learning Outcome: 5. Describe diagnostic and laboratory tests used to determine the individual's
digestion status.

5
Copyright © 2015 Pearson Education, Inc.
6) What statement made by the client would indicate understanding of discharge teaching for
self-care after hospitalization for acute pancreatitis?
A) "I will avoid onions, caffeine, and spices."
B) "I will take the antibiotics for 2 weeks."
C) "I will avoid alcoholic beverages."
D) "I will get immunized prior to my vacation."
Answer: C
Explanation: A) Alcohol increases the risk of pancreatitis. Antibiotics are used to prevent
pyloric stenosis. Onions, caffeine, and spices increase the risk of GERD. Immunizations can
prevent specific types of hepatitis.
B) Alcohol increases the risk of pancreatitis. Antibiotics are used to prevent pyloric stenosis.
Onions, caffeine, and spices increase the risk of GERD. Immunizations can prevent specific
types of hepatitis.
C) Alcohol increases the risk of pancreatitis. Antibiotics are used to prevent pyloric stenosis.
Onions, caffeine, and spices increase the risk of GERD. Immunizations can prevent specific
types of hepatitis.
D) Alcohol increases the risk of pancreatitis. Antibiotics are used to prevent pyloric stenosis.
Onions, caffeine, and spices increase the risk of GERD. Immunizations can prevent specific
types of hepatitis.
Page Ref: 213
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing Process: Implementation
Learning Outcome: 6. Explain management of digestive health and prevention of digestive
illnesses.

6
Copyright © 2015 Pearson Education, Inc.
7) Which intervention would best improve diet adherence of a 75-year-old Hispanic male
immigrant recently diagnosed with GERD?
A) Scheduling low-fat meal deliveries to the home
B) Providing printed diet information in Spanish
C) Interviewing the client to assess his current diet
D) Giving a list of foods to avoid to the client's wife
Answer: C
Explanation: A) Interviewing the client to assess his current diet will provide information to
base a collaborative nutrition plan. Scheduling low-fat meal delivery to the home, giving printed
diet information in Spanish, and giving a list of foods to avoid to the client's wife are not
appropriate until the nurse has information on which to base a individualized culturally sensitive
teaching plan.
B) Interviewing the client to assess his current diet will provide information to base a
collaborative nutrition plan. Scheduling low-fat meal delivery to the home, giving printed diet
information in Spanish, and giving a list of foods to avoid to the client's wife are not appropriate
until the nurse has information on which to base a individualized culturally sensitive teaching
plan.
C) Interviewing the client to assess his current diet will provide information to base a
collaborative nutrition plan. Scheduling low-fat meal delivery to the home, giving printed diet
information in Spanish, and giving a list of foods to avoid to the client's wife are not appropriate
until the nurse has information on which to base a individualized culturally sensitive teaching
plan.
D) Interviewing the client to assess his current diet will provide information to base a
collaborative nutrition plan. Scheduling low-fat meal delivery to the home, giving printed diet
information in Spanish, and giving a list of foods to avoid to the client's wife are not appropriate
until the nurse has information on which to base a individualized culturally sensitive teaching
plan.
Page Ref: 215
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Nursing Process: Teaching and Learning
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent care
across the life span for individuals with common alterations in digestion.

7
Copyright © 2015 Pearson Education, Inc.
8) The nurse is considering nutritional support for a client experiencing severe side effects of
chemotherapy. Which independent and collaborative interventions will best limit the adverse
digestive and nutritional effects of chemotherapy?
A) Encourage client to drink 350 ml of clear liquids within 1 hour prior to meals.
B) Position the client flat during intermittent enteral nutrition feedings.
C) Verify that enteral nutrition and total parenteral nutrition (TPN) are never used concurrently.
D) Offer the client music therapy in addition to IV ondansetron.
Answer: D
Explanation: A) Alternative therapy including music therapy has been used for nausea and
vomiting. Ondansetron is a serotonin receptor agonist used commonly and an antiemetic. Clients
should be positioned with the HOB elevated 30 degrees during enteral nutrition feedings. Enteral
nutrition and TPN are used concurrently. Nausea is worsened by drinking fluid within 1 hour of
meals.
B) Alternative therapy including music therapy has been used for nausea and vomiting.
Ondansetron is a serotonin receptor agonist used commonly and an antiemetic. Clients should be
positioned with the HOB elevated 30 degrees during enteral nutrition feedings. Enteral nutrition
and TPN are used concurrently. Nausea is worsened by drinking fluid within 1 hour of meals.
C) Alternative therapy including music therapy has been used for nausea and vomiting.
Ondansetron is a serotonin receptor agonist used commonly and an antiemetic. Clients should be
positioned with the HOB elevated 30 degrees during enteral nutrition feedings. Enteral nutrition
and TPN are used concurrently. Nausea is worsened by drinking fluid within 1 hour of meals.
D) Alternative therapy including music therapy has been used for nausea and vomiting.
Ondansetron is a serotonin receptor agonist used commonly and an antiemetic. Clients should be
positioned with the HOB elevated 30 degrees during enteral nutrition feedings. Enteral nutrition
and TPN are used concurrently. Nausea is worsened by drinking fluid within 1 hour of meals.
Page Ref: 223
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 8. Compare and contrast common independent and collaborative
interventions for clients with alterations in digestive function.

8
Copyright © 2015 Pearson Education, Inc.
Exemplar 4.1 Gastroesophageal Reflux Disease

1) The nurse is explaining the alteration in normal function to a client recently diagnosed with
gastrointestinal reflux disease (GERD). Which of the following etiologies contribute to GERD?
A) Transient constriction of the lower esophageal sphincter
B) Decreased pressure within the stomach
C) Incompetent lower esophageal sphincter
D) Prolonged constriction of the upper esophageal sphincter
Answer: C
Explanation: A) An incompetent lower esophageal sphincter remains open, allowing gastric acid
to reflux into the esophagus. The lower esophageal sphincter is normally constricted except
during swallowing. Increased pressure in the stomach can cause acid to reflux into the
esophagus. The action of the upper esophageal sphincter is not a cause of GERD.
B) An incompetent lower esophageal sphincter remains open, allowing gastric acid to reflux into
the esophagus. The lower esophageal sphincter is normally constricted except during
swallowing. Increased pressure in the stomach can cause acid to reflux into the esophagus. The
action of the upper esophageal sphincter is not a cause of GERD.
C) An incompetent lower esophageal sphincter remains open, allowing gastric acid to reflux into
the esophagus. The lower esophageal sphincter is normally constricted except during
swallowing. Increased pressure in the stomach can cause acid to reflux into the esophagus. The
action of the upper esophageal sphincter is not a cause of GERD.
D) An incompetent lower esophageal sphincter remains open, allowing gastric acid to reflux into
the esophagus. The lower esophageal sphincter is normally constricted except during
swallowing. Increased pressure in the stomach can cause acid to reflux into the esophagus. The
action of the upper esophageal sphincter is not a cause of GERD.
Page Ref: 227
Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Implementation
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of gastroesophageal reflux disease (GERD).

9
Copyright © 2015 Pearson Education, Inc.
2) Which of the following clients are at high risk of developing GERD?
A) A client who is 6 weeks pregnant
B) A client who is morbidly obese
C) A client who follows a strict vegetarian diet
D) A client who drinks one glass of wine monthly
Answer: B
Explanation: A) Obesity is a risk factor for GERD. Pregnancy is an increasing risk factor in the
later stages due to pressure on the stomach. A vegetarian diet is not a risk factor for GERD. Rare
alcohol consumption is not as strong a risk factor for GERD as morbid obesity.
B) Obesity is a risk factor for GERD. Pregnancy is an increasing risk factor in the later stages
due to pressure on the stomach. A vegetarian diet is not a risk factor for GERD. Rare alcohol
consumption is not as strong a risk factor for GERD as morbid obesity.
C) Obesity is a risk factor for GERD. Pregnancy is an increasing risk factor in the later stages
due to pressure on the stomach. A vegetarian diet is not a risk factor for GERD. Rare alcohol
consumption is not as strong a risk factor for GERD as morbid obesity.
D) Obesity is a risk factor for GERD. Pregnancy is an increasing risk factor in the later stages
due to pressure on the stomach. A vegetarian diet is not a risk factor for GERD. Rare alcohol
consumption is not as strong a risk factor for GERD as morbid obesity.
Page Ref: 227
Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing Process: Assessment
Learning Outcome: 2. Identify risk factors and prevention methods associated with GERD.

10
Copyright © 2015 Pearson Education, Inc.
3) A pediatric client has GERD. The nurse is observing a return demonstration of the mother
preparing and feeding the infant formula. Which of the following observations demonstrates
correct procedure for preventing GERD symptoms?
A) Burping the infant after 4 ounces of formula are taken
B) Thinning the formula with water prior to feeding
C) Positioning the infant upright for a minimum of 30 minutes
D) Warming the formula prior to feeding
Answer: C
Explanation: A) Positioning the infant upright for 30 minutes after a feeding can reduce GERD
symptoms. Infants with GERD should be burped after every 1-2 ounces of formula are taken.
Pre-thickened formulas can also reduce GERD symptoms. Warming the formula does not impact
GERD symptoms.
B) Positioning the infant upright for 30 minutes after a feeding can reduce GERD symptoms.
Infants with GERD should be burped after every 1-2 ounces of formula are taken. Pre-thickened
formulas can also reduce GERD symptoms. Warming the formula does not impact GERD
symptoms.
C) Positioning the infant upright for 30 minutes after a feeding can reduce GERD symptoms.
Infants with GERD should be burped after every 1-2 ounces of formula are taken. Pre-thickened
formulas can also reduce GERD symptoms. Warming the formula does not impact GERD
symptoms.
D) Positioning the infant upright for 30 minutes after a feeding can reduce GERD symptoms.
Infants with GERD should be burped after every 1-2 ounces of formula are taken. Pre-thickened
formulas can also reduce GERD symptoms. Warming the formula does not impact GERD
symptoms.
Page Ref: 231
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Evaluation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with GERD.

11
Copyright © 2015 Pearson Education, Inc.
4) A client presents at the Emergency Department reporting 7/10 chest burning. GERD
secondary to hiatal hernia is diagnosed. Based on your assessment, which of the following is the
priority nursing diagnosis?
A) Dysfunctional Gastrointestinal Motility
B) Anxiety
C) Acute Pain
D) Ineffective Health Maintenance
Answer: C
Explanation: A) Acute pain management is the priority of nursing care. Anxiety may be
decreased by relieving pain. Dysfunctional gastrointestinal motility and ineffective health
maintenance are less urgent.
B) Acute pain management is the priority of nursing care. Anxiety may be decreased by relieving
pain. Dysfunctional gastrointestinal motility and ineffective health maintenance are less urgent.
C) Acute pain management is the priority of nursing care. Anxiety may be decreased by relieving
pain. Dysfunctional gastrointestinal motility and ineffective health maintenance are less urgent.
D) Acute pain management is the priority of nursing care. Anxiety may be decreased by
relieving pain. Dysfunctional gastrointestinal motility and ineffective health maintenance are less
urgent.
Page Ref: 229
Cognitive Level: Evaluating
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Planning
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
GERD.

12
Copyright © 2015 Pearson Education, Inc.
5) A client is with a history of GERD presents with metabolic alkalosis. Which medication do
you suspect contributed to metabolic alkalosis?
A) Aluminum hydroxide
B) Omeprazole
C) Ranitidine
D) Metoclopramide
Answer: A
Explanation: A) Aluminum hydroxide antacids neutralize gastric acid. Overuse of antacids may
cause metabolic acidosis. Omeprazole, ranitidine, and metoclopramide are all GERD
medications that do not cause metabolic alkalosis.
B) Aluminum hydroxide antacids neutralize gastric acid. Overuse of antacids may cause
metabolic acidosis. Omeprazole, ranitidine, and metoclopramide are all GERD medications that
do not cause metabolic alkalosis.
C) Aluminum hydroxide antacids neutralize gastric acid. Overuse of antacids may cause
metabolic acidosis. Omeprazole, ranitidine, and metoclopramide are all GERD medications that
do not cause metabolic alkalosis.
D) Aluminum hydroxide antacids neutralize gastric acid. Overuse of antacids may cause
metabolic acidosis. Omeprazole, ranitidine, and metoclopramide are all GERD medications that
do not cause metabolic alkalosis.
Page Ref: 230
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing Process: Assessment
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with GERD.

13
Copyright © 2015 Pearson Education, Inc.
6) A 57-year-old client was admitted to the hospital with chest pressure. After myocardial
infarction was ruled out, he was diagnosed with erosive esophagitis through upper GI endoscopy.
He owns and operates a bakery with his wife and adult son. His BMI is 39. He smokes 1 pack of
cigarettes per day. The patient is now refusing all medications and states "I'm not getting hooked
on any pills." What would the nurse recommend for the multidisciplinary collaborative plan?
Select all that apply.
A) Assess the client's readiness for change in smoking cessation and weight loss.
B) Interview the client and his wife for a 24-hour recall of usual food content, intake, and meal
times.
C) Enlist the patient's son to elevate the foot of the client's bed at home 6 inches.
D) Offer the client a surgical consult to reduce the necessity of medication.
E) Omit the pharmacist notification of the Multidisciplinary Team meeting about the client.
Answer: A, B
Explanation: A) Weight loss and smoking cessation will improve the symptoms of GERD.
Determining food types, amounts, and times of consumption can help the client avoid foods that
stimulate acid production and avoid eating prior to lying down. The head of the bed should be
elevated and the team should recommend this to the client rather than enlisting the client's son. A
surgical consult should come from the primary provider and will not necessarily reduce the need
for medication. The pharmacist should be included in the Multidisciplinary Team meeting to
give input to strategies to improve the client's receptivity to medication therapy.
B) Weight loss and smoking cessation will improve the symptoms of GERD. Determining food
types, amounts, and times of consumption can help the client avoid foods that stimulate acid
production and avoid eating prior to lying down. The head of the bed should be elevated and the
team should recommend this to the client rather than enlisting the client's son. A surgical consult
should come from the primary provider and will not necessarily reduce the need for medication.
The pharmacist should be included in the Multidisciplinary Team meeting to give input to
strategies to improve the client's receptivity to medication therapy.
C) Weight loss and smoking cessation will improve the symptoms of GERD. Determining food
types, amounts, and times of consumption can help the client avoid foods that stimulate acid
production and avoid eating prior to lying down. The head of the bed should be elevated and the
team should recommend this to the client rather than enlisting the client's son. A surgical consult
should come from the primary provider and will not necessarily reduce the need for medication.
The pharmacist should be included in the Multidisciplinary Team meeting to give input to
strategies to improve the client's receptivity to medication therapy.
D) Weight loss and smoking cessation will improve the symptoms of GERD. Determining food
types, amounts, and times of consumption can help the client avoid foods that stimulate acid
production and avoid eating prior to lying down. The head of the bed should be elevated and the
team should recommend this to the client rather than enlisting the client's son. A surgical consult
should come from the primary provider and will not necessarily reduce the need for medication.
The pharmacist should be included in the Multidisciplinary Team meeting to give input to
strategies to improve the client's receptivity to medication therapy.

14
Copyright © 2015 Pearson Education, Inc.
E) Weight loss and smoking cessation will improve the symptoms of GERD. Determining food
types, amounts, and times of consumption can help the client avoid foods that stimulate acid
production and avoid eating prior to lying down. The head of the bed should be elevated and the
team should recommend this to the client rather than enlisting the client's son. A surgical consult
should come from the primary provider and will not necessarily reduce the need for medication.
The pharmacist should be included in the Multidisciplinary Team meeting to give input to
strategies to improve the client's receptivity to medication therapy.
Page Ref: 231
Cognitive Level: Creating
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with GERD and his or her
family in collaboration with other members of the healthcare team.

15
Copyright © 2015 Pearson Education, Inc.
7) The nurse has implemented a care plan for a 22-year-old client with GERD. On the next clinic
visit, which of the following statements by the client indicate adherence to the plan of care?
Select all that apply.
A) "Spandex camisoles are worth heartburn."
B) "I have switched from margaritas to wine."
C) "I've lost 6 pounds because I eat every 3 hours and never before bed."
D) "I take a TUMS with the ranitidine to make it work better."
E) "I haven't had any heartburn for 3 weeks."
Answer: C
Explanation: A) Appropriate client outcomes are freedom from pain and knowledge of lifestyle
changes to manage GERD. Weight loss, small, frequent meals, and avoiding lying down within 3
hours of eating indicate correct management. Changing from margaritas to wine will not improve
GERD. Antacids like TUMS should be avoided within 1 hour before or after an H2-receptor
blocker like ranitidine. Although the client knows tight-fitting spandex camisoles can worsen
GERD, she is not willing to stop wearing them.
B) Appropriate client outcomes are freedom from pain and knowledge of lifestyle changes to
manage GERD. Weight loss, small, frequent meals, and avoiding lying down within 3 hours of
eating indicate correct management. Changing from margaritas to wine will not improve GERD.
Antacids like TUMS should be avoided within 1 hour before or after an H2-receptor blocker like
ranitidine. Although the client knows tight-fitting spandex camisoles can worsen GERD, she is
not willing to stop wearing them.
C) Appropriate client outcomes are freedom from pain and knowledge of lifestyle changes to
manage GERD. Weight loss, small, frequent meals, and avoiding lying down within 3 hours of
eating indicate correct management. Changing from margaritas to wine will not improve GERD.
Antacids like TUMS should be avoided within 1 hour before or after an H2-receptor blocker like
ranitidine. Although the client knows tight-fitting spandex camisoles can worsen GERD, she is
not willing to stop wearing them.
D) Appropriate client outcomes are freedom from pain and knowledge of lifestyle changes to
manage GERD. Weight loss, small, frequent meals, and avoiding lying down within 3 hours of
eating indicate correct management. Changing from margaritas to wine will not improve GERD.
Antacids like TUMS should be avoided within 1 hour before or after an H2-receptor blocker like
ranitidine. Although the client knows tight-fitting spandex camisoles can worsen GERD, she is
not willing to stop wearing them.
E) Appropriate client outcomes are freedom from pain and knowledge of lifestyle changes to
manage GERD. Weight loss, small, frequent meals, and avoiding lying down within 3 hours of
eating indicate correct management. Changing from margaritas to wine will not improve GERD.
Antacids like TUMS should be avoided within 1 hour before or after an H2-receptor blocker like
ranitidine. Although the client knows tight-fitting spandex camisoles can worsen GERD, she is
not willing to stop wearing them.
Page Ref: 231
Cognitive Level: Evaluating
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with GERD.

16
Copyright © 2015 Pearson Education, Inc.
Exemplar 4.2 Hepatitis

1) A client is diagnosed with viral hepatitis transmitted by the fecal-oral route. Which conditions
may be acquired by this mode of transmission?
A) Hepatitis A (HAV) and hepatitis E (HEV)
B) Hepatitis B (HBV) and hepatitis C (HCV)
C) Hepatitis D (HDV)
D) Hepatitis A (HAV), Hepatitis B (HBV), Hepatitis C (HCV), Hepatitis D (HDV), and
Hepatitis E (HEV)
Answer: A
Explanation: A) Hepatitis A (HAV) and hepatitis E (HEV) are transmitted by the fecal-oral
route. Hepatitis C (HCV) is transmitted blood and body fluids. Hepatitis B (HBV) and hepatitis
D (HDV) are transmitted by blood, body fluids, and perinatal routes.
B) Hepatitis A (HAV) and hepatitis E (HEV) are transmitted by the fecal-oral route. Hepatitis C
(HCV) is transmitted blood and body fluids. Hepatitis B (HBV) and hepatitis D (HDV) are
transmitted by blood, body fluids, and perinatal routes.
C) Hepatitis A (HAV) and hepatitis E (HEV) are transmitted by the fecal-oral route. Hepatitis C
(HCV) is transmitted blood and body fluids. Hepatitis B (HBV) and hepatitis D (HDV) are
transmitted by blood, body fluids, and perinatal routes.
D) Hepatitis A (HAV) and hepatitis E (HEV) are transmitted by the fecal-oral route. Hepatitis C
(HCV) is transmitted blood and body fluids. Hepatitis B (HBV) and hepatitis D (HDV) are
transmitted by blood, body fluids, and perinatal routes.
Page Ref: 234
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of hepatitis.

17
Copyright © 2015 Pearson Education, Inc.
2) The nurse is explaining hepatitis to a high school health occupations class. The students all
volunteer examples of how hepatitis is transmitted. Which client statement indicates the student
needs further education?
A) "Body piercing or tattoo with infected equipment."
B) "Contaminated food or fluids."
C) "Alcoholism or drug overdose."
D) "Bite of an infected mosquito or tick."
Answer: D
Explanation: A) The student who believes the bite of a mosquito or tick will transmit hepatitis is
incorrect and needs further education. The students who said that infected needles, contaminated
food or fluids, alcoholism or drug overdose can cause different types of hepatitis were correct
and do not require further education.
B) The student who believes the bite of a mosquito or tick will transmit hepatitis is incorrect and
needs further education. The students who said that infected needles, contaminated food or
fluids, alcoholism or drug overdose can cause different types of hepatitis were correct and do not
require further education.
C) The student who believes the bite of a mosquito or tick will transmit hepatitis is incorrect and
needs further education. The students who said that infected needles, contaminated food or
fluids, alcoholism or drug overdose can cause different types of hepatitis were correct and do not
require further education.
D) The student who believes the bite of a mosquito or tick will transmit hepatitis is incorrect and
needs further education. The students who said that infected needles, contaminated food or
fluids, alcoholism or drug overdose can cause different types of hepatitis were correct and do not
require further education.
Page Ref: 234
Cognitive Level: Remembering
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 2. Identify risk factors and prevention methods associated with hepatitis.

18
Copyright © 2015 Pearson Education, Inc.
3) The nurse is planning education for a teenage client recently diagnosed with hepatitis. She
moved back in with her parents this morning. Which recommendation to the client's parents will
best prevent them from acquiring hepatitis B (HBV)?
A) Refuse to donate blood.
B) Avoid contaminated water.
C) Obtain post exposure prophylaxis.
D) Abstain from alcohol.
Answer: C
Explanation: A) Obtaining postexposure prophylaxis treatment will best help the client's parents
from acquiring HBV. The HBV vaccine is started concurrently. HBV is not spread in water.
Alcohol abuse is implicated in non-viral hepatitis. Donating blood will not increase the risk of
acquiring HBV.
B) Obtaining postexposure prophylaxis treatment will best help the client's parents from
acquiring HBV. The HBV vaccine is started concurrently. HBV is not spread in water. Alcohol
abuse is implicated in non-viral hepatitis. Donating blood will not increase the risk of acquiring
HBV.
C) Obtaining postexposure prophylaxis treatment will best help the client's parents from
acquiring HBV. The HBV vaccine is started concurrently. HBV is not spread in water. Alcohol
abuse is implicated in non-viral hepatitis. Donating blood will not increase the risk of acquiring
HBV.
D) Obtaining postexposure prophylaxis treatment will best help the client's parents from
acquiring HBV. The HBV vaccine is started concurrently. HBV is not spread in water. Alcohol
abuse is implicated in non-viral hepatitis. Donating blood will not increase the risk of acquiring
HBV.
Page Ref: 237
Cognitive Level: Understanding
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with hepatitis.

19
Copyright © 2015 Pearson Education, Inc.
4) During an interview with a client afflicted with hepatitis B, the nurse obtains the following
data: Ten kg weight loss is noted from the client's last visit 4 months ago. Review of systems
reveals 1) limiting fatigue, 2) not well enough for sexual intercourse but doubts if her husband
will be willing to use a condom, 3) drinks 3-5 mixed drinks weekly socially, 4) RUQ pain rated
at 6/10, and 5) "constant" pruritus. Prioritize the nursing diagnoses formulated for this client.
1. Imbalanced Nutrition
2. Impaired Skin Integrity
3. Acute Pain
4. Deficient Knowledge
Answer: 3, 4, 1, 2
Explanation: Relieving the pain associated with hepatitis and preventing the spread of infection
are priorities of hepatitis management. Interventions related to knowledge deficit will address the
potential for spread of the infection to the client's husband, use of alcohol, imbalanced nutrition,
and impaired skin integrity.
Page Ref: 236
Cognitive Level: Evaluating
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Evaluation
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
hepatitis.

5) When planning care for a client with chronic hepatitis, which collaborative discipline will be
most helpful in treating continued alcohol use?
A) Social worker
B) Primary provider
C) Pharmacist
D) Dietitian
Answer: A
Explanation: A) The social worker is an expert at identifying additional resources for treatment
of substance abuse. The primary provider, pharmacist, and dietitian will all contribute to the plan
of care.
B) The social worker is an expert at identifying additional resources for treatment of substance
abuse. The primary provider, pharmacist, and dietitian will all contribute to the plan of care.
C) The social worker is an expert at identifying additional resources for treatment of substance
abuse. The primary provider, pharmacist, and dietitian will all contribute to the plan of care.
D) The social worker is an expert at identifying additional resources for treatment of substance
abuse. The primary provider, pharmacist, and dietitian will all contribute to the plan of care.
Page Ref: 235
Cognitive Level: Understanding
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with hepatitis.

20
Copyright © 2015 Pearson Education, Inc.
6) The multidisciplinary patient care team is meeting to discuss care for a client in the exhibiting
symptoms of the prodromal phase of hepatitis. Lab results include a positive anti-HAV IgM. The
nurse creates an action plan to present to the team. Which interventions are appropriate?
Select all that apply.
A) High-fat, low-calorie, and no-alcohol diet teaching
B) Patient education on acceptable pain medication
C) Early treatment with lamivudine
D) Referral to the liver transplant team
E) Family teaching for transmission prevention.
Answer: B, E
Explanation: A) Patient education on acceptable pain medication is necessary due to the toxic
effect of common over-the-counter pain medicine. Family teaching is appropriate to avoid
transmission. Most clients recover from acute viral hepatitis without pharmacologic treatment
and certainly without liver transplant. A low-fat, high-calorie diet is recommended.
B) Patient education on acceptable pain medication is necessary due to the toxic effect of
common over-the-counter pain medicine. Family teaching is appropriate to avoid transmission.
Most clients recover from acute viral hepatitis without pharmacologic treatment and certainly
without liver transplant. A low-fat, high-calorie diet is recommended.
C) Patient education on acceptable pain medication is necessary due to the toxic effect of
common over-the-counter pain medicine. Family teaching is appropriate to avoid transmission.
Most clients recover from acute viral hepatitis without pharmacologic treatment and certainly
without liver transplant. A low-fat, high-calorie diet is recommended.
D) Patient education on acceptable pain medication is necessary due to the toxic effect of
common over-the-counter pain medicine. Family teaching is appropriate to avoid transmission.
Most clients recover from acute viral hepatitis without pharmacologic treatment and certainly
without liver transplant. A low-fat, high-calorie diet is recommended.
E) Patient education on acceptable pain medication is necessary due to the toxic effect of
common over-the-counter pain medicine. Family teaching is appropriate to avoid transmission.
Most clients recover from acute viral hepatitis without pharmacologic treatment and certainly
without liver transplant. A low-fat, high-calorie diet is recommended.
Page Ref: 236
Cognitive Level: Creating
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with hepatitis and his or her
family in collaboration with other members of the healthcare team.

21
Copyright © 2015 Pearson Education, Inc.
7) A 19-year-old waiter has been treated for viral hepatitis at your clinic. Which client outcome
indicates the need for additional intervention?
Select all that apply.
A) Body mass index (BMI) changes from 24 to 21.
B) Return demonstration of hand washing is correctly performed.
C) Social Services notified the Health Department of the occurrence.
D) Red scratch marks are noted on the arms and trunk.
E) Client denies abdominal or epigastric pain.
Answer: A, D
Explanation: A) The client will need additional intervention if weight loss occurs and if the
client has continued itching. No additional intervention is needed if hand washing is performed
correctly or pain is controlled. The health department must be notified if a food service worker is
diagnosed due to possible exposure of patrons.
B) The client will need additional intervention if weight loss occurs and if the client has
continued itching. No additional intervention is needed if hand washing is performed correctly or
pain is controlled. The health department must be notified if a food service worker is diagnosed
due to possible exposure of patrons.
C) The client will need additional intervention if weight loss occurs and if the client has
continued itching. No additional intervention is needed if hand washing is performed correctly or
pain is controlled. The health department must be notified if a food service worker is diagnosed
due to possible exposure of patrons.
D) The client will need additional intervention if weight loss occurs and if the client has
continued itching. No additional intervention is needed if hand washing is performed correctly or
pain is controlled. The health department must be notified if a food service worker is diagnosed
due to possible exposure of patrons.
E) The client will need additional intervention if weight loss occurs and if the client has
continued itching. No additional intervention is needed if hand washing is performed correctly or
pain is controlled. The health department must be notified if a food service worker is diagnosed
due to possible exposure of patrons.
Page Ref: 238
Cognitive Level: Evaluating
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with hepatitis.

22
Copyright © 2015 Pearson Education, Inc.
Exemplar 4.3 Malabsorption Disorders

1) A client diagnosed with celiac disease who has frequent diarrhea may have associated
problems of:
Select all that apply.
A) Skin integrity.
B) Fluid and electrolyte imbalance.
C) Hair loss.
D) Lifestyle issues.
Answer: A, B, D
Explanation: A) Clients with diarrhea may have perianal skin irritation. Diarrhea disturbs the
fluid and electrolyte balance. There is no known connection between diarrhea and hair loss.
Diarrhea can disrupt normal life activities.
B) Clients with diarrhea may have perianal skin irritation. Diarrhea disturbs the fluid and
electrolyte balance. There is no known connection between diarrhea and hair loss. Diarrhea can
disrupt normal life activities.
C) Clients with diarrhea may have perianal skin irritation. Diarrhea disturbs the fluid and
electrolyte balance. There is no known connection between diarrhea and hair loss. Diarrhea can
disrupt normal life activities.
D) Clients with diarrhea may have perianal skin irritation. Diarrhea disturbs the fluid and
electrolyte balance. There is no known connection between diarrhea and hair loss. Diarrhea can
disrupt normal life activities.
Page Ref: 241
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of malabsorption disorders.

23
Copyright © 2015 Pearson Education, Inc.
2) A 73-year-old African-American man with a history of celiac disease presents with abdominal
cramps, pain, and diarrhea. He reports that he does not use alcohol, but his favorite foods are
steak, cheese, and ice cream. What condition should the nurse consider likely based on the
client's risk factors?
A) Acute pancreatitis
B) Appendicitis
C) Lactase deficiency
D) Food poisoning
Answer: C
Explanation: A) The most common risk factor for pancreatitis is alcohol abuse. Appendicitis
usually involves loss of appetite and nausea and/or vomiting soon after abdominal pain begins.
Lactose intolerance is more common in Native Americans, Asians, Hispanics, and African-
Americans and in those with a history of celiac disease. Food poisoning generally causes some
nausea and vomiting.
B) The most common risk factor for pancreatitis is alcohol abuse. Appendicitis usually involves
loss of appetite and nausea and/or vomiting soon after abdominal pain begins. Lactose
intolerance is more common in Native Americans, Asians, Hispanics, and African-Americans
and in those with a history of celiac disease. Food poisoning generally causes some nausea and
vomiting.
C) The most common risk factor for pancreatitis is alcohol abuse. Appendicitis usually involves
loss of appetite and nausea and/or vomiting soon after abdominal pain begins. Lactose
intolerance is more common in Native Americans, Asians, Hispanics, and African-Americans
and in those with a history of celiac disease. Food poisoning generally causes some nausea and
vomiting.
D) The most common risk factor for pancreatitis is alcohol abuse. Appendicitis usually involves
loss of appetite and nausea and/or vomiting soon after abdominal pain begins. Lactose
intolerance is more common in Native Americans, Asians, Hispanics, and African-Americans
and in those with a history of celiac disease. Food poisoning generally causes some nausea and
vomiting.
Page Ref: 243
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 2. Identify risk factors and prevention methods associated with
malabsorption disorders.

24
Copyright © 2015 Pearson Education, Inc.
3) An elementary school nurse has become aware of an increasing number of students who have
been diagnosed with celiac disease. She requests a meeting with the school administration and
dietician in order to suggest:
Select all that apply.
A) Inclusion of an educational module to inform students about gluten-free diets and choices.
B) School lunches emphasizing low calorie selections.
C) A school based prevention program to eliminate celiac disease.
D) Daily inclusion of labeled gluten-free choices in the school lunch program.
Answer: A, D
Explanation: A) Nursing care for pediatric clients centers on teaching the necessity of a gluten-
free diet. It is important to provide the prescribed high-calorie, high-protein, low-fat, and gluten-
free diet. Celiac disease is not preventable and nursing interventions focus on prevention and
management of diarrhea and malnutrition.
B) Nursing care for pediatric clients centers on teaching the necessity of a gluten-free diet. It is
important to provide the prescribed high-calorie, high-protein, low-fat, and gluten-free diet.
Celiac disease is not preventable and nursing interventions focus on prevention and management
of diarrhea and malnutrition.
C) Nursing care for pediatric clients centers on teaching the necessity of a gluten-free diet. It is
important to provide the prescribed high-calorie, high-protein, low-fat, and gluten-free diet.
Celiac disease is not preventable and nursing interventions focus on prevention and management
of diarrhea and malnutrition.
D) Nursing care for pediatric clients centers on teaching the necessity of a gluten-free diet. It is
important to provide the prescribed high-calorie, high-protein, low-fat, and gluten-free diet.
Celiac disease is not preventable and nursing interventions focus on prevention and management
of diarrhea and malnutrition.
Page Ref: 241
Cognitive Level: Creating
Client Need: Health Promotion and Maintenance
Nursing Process: Planning
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with malabsorption disorders.

25
Copyright © 2015 Pearson Education, Inc.
4) A visiting nurse sees an 85-year-old woman who lives alone and has limited financial
resources. The client has a history of celiac disease. What are some likely nursing diagnoses for
this client?
Select all that apply.
A) Risk for Constipation
B) Risk for Nutrition, Imbalance: less than body requirements
C) Risk for Fluid Volume Imbalance
D) Risk for Diarrhea
Answer: B, C, D
Explanation: A) Constipation is not a normal manifestation of celiac disease. Nutritional
imbalance, including anemia and vitamin deficiencies, is possible. Celiac disease impairs
absorption of fluid and electrolytes, leading to excess water in the stool. Local manifestations of
celiac disease include abdominal bloating and cramps, diarrhea, and steatorrhea.
B) Constipation is not a normal manifestation of celiac disease. Nutritional imbalance, including
anemia and vitamin deficiencies, is possible. Celiac disease impairs absorption of fluid and
electrolytes, leading to excess water in the stool. Local manifestations of celiac disease include
abdominal bloating and cramps, diarrhea, and steatorrhea.
C) Constipation is not a normal manifestation of celiac disease. Nutritional imbalance, including
anemia and vitamin deficiencies, is possible. Celiac disease impairs absorption of fluid and
electrolytes, leading to excess water in the stool. Local manifestations of celiac disease include
abdominal bloating and cramps, diarrhea, and steatorrhea.
D) Constipation is not a normal manifestation of celiac disease. Nutritional imbalance, including
anemia and vitamin deficiencies, is possible. Celiac disease impairs absorption of fluid and
electrolytes, leading to excess water in the stool. Local manifestations of celiac disease include
abdominal bloating and cramps, diarrhea, and steatorrhea.
Page Ref: 241
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
malabsorption disorders.

26
Copyright © 2015 Pearson Education, Inc.
5) A 10-year-old boy, recently diagnosed with celiac disease, has diarrhea and is underweight,
vitamin-deficient, and anemic. In addition to removing gluten from his diet, what other
recommendations might be considered?
Select all that apply.
A) Fat restriction
B) A high-carbohydrate diet
C) Vitamin supplements
D) High-calorie, high-protein diet
Answer: A, C, D
Explanation: A) If nutritional deficiencies are severe, vitamin and mineral supplements may be
indicated. A high-kilocalorie, high-protein, low-fat, gluten-free diet is advised. In celiac disease,
gastrointestinal dysfunction may cause carbohydrates to be incompletely digested, leading to
malabsorption and intolerance.
B) If nutritional deficiencies are severe, vitamin and mineral supplements may be indicated. A
high-kilocalorie, high-protein, low-fat, gluten-free diet is advised. In celiac disease,
gastrointestinal dysfunction may cause carbohydrates to be incompletely digested, leading to
malabsorption and intolerance.
C) If nutritional deficiencies are severe, vitamin and mineral supplements may be indicated. A
high-kilocalorie, high-protein, low-fat, gluten-free diet is advised. In celiac disease,
gastrointestinal dysfunction may cause carbohydrates to be incompletely digested, leading to
malabsorption and intolerance.
D) If nutritional deficiencies are severe, vitamin and mineral supplements may be indicated. A
high-kilocalorie, high-protein, low-fat, gluten-free diet is advised. In celiac disease,
gastrointestinal dysfunction may cause carbohydrates to be incompletely digested, leading to
malabsorption and intolerance.
Page Ref: 242
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Planning
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with malabsorption disorders.

27
Copyright © 2015 Pearson Education, Inc.
6) Parents of a child diagnosed with celiac disease have requested guidance on how to implement
a gluten-free diet. In addition to a list of foods to include and exclude, what should the nurse
address in her discussion with them?
Select all that apply.
A) Obtaining a dietary prescription
B) Exercise recommendations
C) Educational information and training on how to read labels
D) Phone numbers and links for informational resources and support groups
Answer: A, C, D
Explanation: A) A prescription will enable them to deduct the cost of special ingredients and
commercially prepared products as a medical expense. Exercise, while beneficial, is not part of
celiac disease treatment. Client and family teaching includes how to identify gluten-containing
commercial products by reading labels and lists of ingredients. It is helpful to provide referrals to
local support groups as well as informational resources.
B) A prescription will enable them to deduct the cost of special ingredients and commercially
prepared products as a medical expense. Exercise, while beneficial, is not part of celiac disease
treatment. Client and family teaching includes how to identify gluten-containing commercial
products by reading labels and lists of ingredients. It is helpful to provide referrals to local
support groups as well as informational resources.
C) A prescription will enable them to deduct the cost of special ingredients and commercially
prepared products as a medical expense. Exercise, while beneficial, is not part of celiac disease
treatment. Client and family teaching includes how to identify gluten-containing commercial
products by reading labels and lists of ingredients. It is helpful to provide referrals to local
support groups as well as informational resources.
D) A prescription will enable them to deduct the cost of special ingredients and commercially
prepared products as a medical expense. Exercise, while beneficial, is not part of celiac disease
treatment. Client and family teaching includes how to identify gluten-containing commercial
products by reading labels and lists of ingredients. It is helpful to provide referrals to local
support groups as well as informational resources.
Page Ref: 242
Cognitive Level: Creating
Client Need: Health Promotion and Maintenance
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with malabsorption disorders
and his or her family in collaboration with other members of the healthcare team.

28
Copyright © 2015 Pearson Education, Inc.
7) What outcomes can be anticipated when the appropriate steps for managing celiac disease
have been implemented?
Select all that apply.
A) The client is free of abdominal discomfort including bloating, gas, indigestion, nausea, and
vomiting.
B) The client is able to maintain normal or routine bowel habits.
C) The client has diarrhea fewer than 3 days weekly.
D) The client is able to maintain adequate nutritional status.
Answer: A, B, D
Explanation: A) When the client with celiac disease is placed on a gluten-free diet, treatment
generally is successful, as long as the client avoids gluten totally. Symptoms such as diarrhea and
abdominal discomfort should be eliminated and nutritional status should improve.
B) When the client with celiac disease is placed on a gluten-free diet, treatment generally is
successful, as long as the client avoids gluten totally. Symptoms such as diarrhea and abdominal
discomfort should be eliminated and nutritional status should improve.
C) When the client with celiac disease is placed on a gluten-free diet, treatment generally is
successful, as long as the client avoids gluten totally. Symptoms such as diarrhea and abdominal
discomfort should be eliminated and nutritional status should improve.
D) When the client with celiac disease is placed on a gluten-free diet, treatment generally is
successful, as long as the client avoids gluten totally. Symptoms such as diarrhea and abdominal
discomfort should be eliminated and nutritional status should improve.
Page Ref: 242
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with malabsorption
disorders.

29
Copyright © 2015 Pearson Education, Inc.
Exemplar 4.4 Pancreatitis

1) Which of the following lab results would be consistent with a diagnosis of acute pancreatitis?
Select all that apply.
A) Serum calcium level of 8.8 mg/dL
B) Urine amylase 15 units/L/2 hr
C) Serum lipase 1400 U/L
D) White blood cells 7500/mm
E) Serum glucose 87 mg/dL
Answer: A, C
Explanation: A) Hypocalcemia develops in up to 25% of clients with acute pancreatitis. Urine
amylase levels rise in acute pancreatitis. Serum lipase levels rise in acute pancreatitis and remain
elevated for 7-14 days. Leukocytosis indicates inflammation and is usually present in acute
pancreatitis. There may be a transient elevation in serum glucose in acute pancreatitis.
B) Hypocalcemia develops in up to 25% of clients with acute pancreatitis. Urine amylase levels
rise in acute pancreatitis. Serum lipase levels rise in acute pancreatitis and remain elevated for 7-
14 days. Leukocytosis indicates inflammation and is usually present in acute pancreatitis. There
may be a transient elevation in serum glucose in acute pancreatitis.
C) Hypocalcemia develops in up to 25% of clients with acute pancreatitis. Urine amylase levels
rise in acute pancreatitis. Serum lipase levels rise in acute pancreatitis and remain elevated for 7-
14 days. Leukocytosis indicates inflammation and is usually present in acute pancreatitis. There
may be a transient elevation in serum glucose in acute pancreatitis.
D) Hypocalcemia develops in up to 25% of clients with acute pancreatitis. Urine amylase levels
rise in acute pancreatitis. Serum lipase levels rise in acute pancreatitis and remain elevated for 7-
14 days. Leukocytosis indicates inflammation and is usually present in acute pancreatitis. There
may be a transient elevation in serum glucose in acute pancreatitis.
E) Hypocalcemia develops in up to 25% of clients with acute pancreatitis. Urine amylase levels
rise in acute pancreatitis. Serum lipase levels rise in acute pancreatitis and remain elevated for 7-
14 days. Leukocytosis indicates inflammation and is usually present in acute pancreatitis. There
may be a transient elevation in serum glucose in acute pancreatitis.
Page Ref: 248
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Analysis
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of pancreatitis.

30
Copyright © 2015 Pearson Education, Inc.
2) A 47-year-old man comes to the ED following a dinner party presenting with nausea,
vomiting, and abdominal pain. His wife reports that only ate the appetizers but consumed a lot of
alcohol and that no one else at the party is ill. For what condition is the client most likely at risk?
A) Lactase deficiency
B) Acute pancreatitis
C) Short bowel syndrome
D) Food poisoning
Answer: B
Explanation: A) Risk factors for lactose intolerance include previous radiation therapy for
abdominal cancer, history of celiac disease or Crohn's disease, and increasing age. Alcoholism
and gallstones are the primary risk factors for acute pancreatitis. Resection of significant portions
of the small intestine may result in a condition known as short bowel syndrome. Those most at
risk for food poisoning are older adults, pregnant women, infants, and those with a chronic
disease.
B) Risk factors for lactose intolerance include previous radiation therapy for abdominal cancer,
history of celiac disease or Crohn's disease, and increasing age. Alcoholism and gallstones are
the primary risk factors for acute pancreatitis. Resection of significant portions of the small
intestine may result in a condition known as short bowel syndrome. Those most at risk for food
poisoning are older adults, pregnant women, infants, and those with a chronic disease.
C) Risk factors for lactose intolerance include previous radiation therapy for abdominal cancer,
history of celiac disease or Crohn's disease, and increasing age. Alcoholism and gallstones are
the primary risk factors for acute pancreatitis. Resection of significant portions of the small
intestine may result in a condition known as short bowel syndrome. Those most at risk for food
poisoning are older adults, pregnant women, infants, and those with a chronic disease.
D) Risk factors for lactose intolerance include previous radiation therapy for abdominal cancer,
history of celiac disease or Crohn's disease, and increasing age. Alcoholism and gallstones are
the primary risk factors for acute pancreatitis. Resection of significant portions of the small
intestine may result in a condition known as short bowel syndrome. Those most at risk for food
poisoning are older adults, pregnant women, infants, and those with a chronic disease.
Page Ref: 246-247
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Analysis
Learning Outcome: 2. Identify risk factors and prevention methods associated with pancreatitis.

31
Copyright © 2015 Pearson Education, Inc.
3) A 67-year-old client diagnosed with chronic pancreatitis has been admitted for an episode of
acute gastric and abdominal pain. What are some of the essential elements in a nursing
assessment?
Select all that apply.
A) The location of the client's pain
B) Weight loss
C) Heartburn
D) Possible opioid dependency
Answer: A, B, D
Explanation: A) Chronic pancreatitis typically causes recurrent episodes of epigastric and left
upper abdominal pain that radiates to the back. Manifestations of chronic pancreatitis include
anorexia, nausea, vomiting, and weight loss. Heartburn is characteristic of GERD. Clients with
chronic pancreatitis may also require analgesics, but must be closely monitored to prevent drug
dependence.
B) Chronic pancreatitis typically causes recurrent episodes of epigastric and left upper abdominal
pain that radiates to the back. Manifestations of chronic pancreatitis include anorexia, nausea,
vomiting, and weight loss. Heartburn is characteristic of GERD. Clients with chronic pancreatitis
may also require analgesics, but must be closely monitored to prevent drug dependence.
C) Chronic pancreatitis typically causes recurrent episodes of epigastric and left upper abdominal
pain that radiates to the back. Manifestations of chronic pancreatitis include anorexia, nausea,
vomiting, and weight loss. Heartburn is characteristic of GERD. Clients with chronic pancreatitis
may also require analgesics, but must be closely monitored to prevent drug dependence.
D) Chronic pancreatitis typically causes recurrent episodes of epigastric and left upper
abdominal pain that radiates to the back. Manifestations of chronic pancreatitis include anorexia,
nausea, vomiting, and weight loss. Heartburn is characteristic of GERD. Clients with chronic
pancreatitis may also require analgesics, but must be closely monitored to prevent drug
dependence.
Page Ref: 249
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with pancreatitis.

32
Copyright © 2015 Pearson Education, Inc.
4) A 54-year-old male is admitted to the ED with symptoms of acute pancreatitis. What are some
probable nursing diagnoses that should be evaluated in this patient?
Select all that apply.
A) Acute Pain related to inflammation and edema
B) Impaired Swallowing
C) Deficient Fluid Volume
D) Nausea related to irritation of the gastrointestinal system
Answer: A, C, D
Explanation: A) Acute pancreatitis develops suddenly, typically with an abrupt onset of
continuous severe epigastric and abdominal pain. Impaired swallowing is not associated with
pancreatitis. Systemic complications of acute pancreatitis include intravascular volume
depletion. Other manifestations of acute pancreatitis include nausea and vomiting.
B) Acute pancreatitis develops suddenly, typically with an abrupt onset of continuous severe
epigastric and abdominal pain. Impaired swallowing is not associated with pancreatitis. Systemic
complications of acute pancreatitis include intravascular volume depletion. Other manifestations
of acute pancreatitis include nausea and vomiting.
C) Acute pancreatitis develops suddenly, typically with an abrupt onset of continuous severe
epigastric and abdominal pain. Impaired swallowing is not associated with pancreatitis. Systemic
complications of acute pancreatitis include intravascular volume depletion. Other manifestations
of acute pancreatitis include nausea and vomiting.
D) Acute pancreatitis develops suddenly, typically with an abrupt onset of continuous severe
epigastric and abdominal pain. Impaired swallowing is not associated with pancreatitis. Systemic
complications of acute pancreatitis include intravascular volume depletion. Other manifestations
of acute pancreatitis include nausea and vomiting.
Page Ref: 249
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
pancreatitis.

33
Copyright © 2015 Pearson Education, Inc.
5) Helen J., a 77-year-old with a history of alcohol abuse, has been admitted to the hospital with
acute pancreatitis. In order to address possible complications that would require immediate
interventions, what are some of the functions the nurse should monitor?
Select all that apply.
A) Cardiac function
B) Mobility function
C) Respiratory function
D) Renal function
Answer: A, C, D
Explanation: A) Clients at risk for fluid and electrolyte imbalance are at risk for a fluid shift
from the intravascular space into the abdominal cavity, requiring the nurse to assess
cardiovascular status, including vital signs, cardiac rhythm, central venous and pulmonary artery
pressures, peripheral pulses and capillary refill, and skin color, temperature, moisture, and turgor.
Mobility is not a relevant function to assess in acute pancreatitis. Regularly assess respiratory
function and report tachypnea, adventitious or absent breath sounds, oxygen saturation levels
below 92%, and PaO2 < 70 mmHg or PaCO2 > 45 mmHg. Clients at risk for fluid and
electrolyte imbalance also require ongoing monitoring of renal function. The nurse assesses urine
output hourly, reporting if less than 30 mL/hr.
B) Clients at risk for fluid and electrolyte imbalance are at risk for a fluid shift from the
intravascular space into the abdominal cavity, requiring the nurse to assess cardiovascular status,
including vital signs, cardiac rhythm, central venous and pulmonary artery pressures, peripheral
pulses and capillary refill, and skin color, temperature, moisture, and turgor. Mobility is not a
relevant function to assess in acute pancreatitis. Regularly assess respiratory function and report
tachypnea, adventitious or absent breath sounds, oxygen saturation levels below 92%, and
PaO2 < 70 mmHg or PaCO2 > 45 mmHg. Clients at risk for fluid and electrolyte imbalance also
require ongoing monitoring of renal function. The nurse assesses urine output hourly, reporting if
less than 30 mL/hr.
C) Clients at risk for fluid and electrolyte imbalance are at risk for a fluid shift from the
intravascular space into the abdominal cavity, requiring the nurse to assess cardiovascular status,
including vital signs, cardiac rhythm, central venous and pulmonary artery pressures, peripheral
pulses and capillary refill, and skin color, temperature, moisture, and turgor. Mobility is not a
relevant function to assess in acute pancreatitis. Regularly assess respiratory function and report
tachypnea, adventitious or absent breath sounds, oxygen saturation levels below 92%, and
PaO2 < 70 mmHg or PaCO2 > 45 mmHg. Clients at risk for fluid and electrolyte imbalance also
require ongoing monitoring of renal function. The nurse assesses urine output hourly, reporting if
less than 30 mL/hr.

34
Copyright © 2015 Pearson Education, Inc.
D) Clients at risk for fluid and electrolyte imbalance are at risk for a fluid shift from the
intravascular space into the abdominal cavity, requiring the nurse to assess cardiovascular status,
including vital signs, cardiac rhythm, central venous and pulmonary artery pressures, peripheral
pulses and capillary refill, and skin color, temperature, moisture, and turgor. Mobility is not a
relevant function to assess in acute pancreatitis. Regularly assess respiratory function and report
tachypnea, adventitious or absent breath sounds, oxygen saturation levels below 92%, and
PaO2 < 70 mmHg or PaCO2 > 45 mmHg. Clients at risk for fluid and electrolyte imbalance also
require ongoing monitoring of renal function. The nurse assesses urine output hourly, reporting if
less than 30 mL/hr.
Page Ref: 250
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with pancreatitis.

35
Copyright © 2015 Pearson Education, Inc.
6) Harold K., a 51-year-old diagnosed with chronic pancreatitis, asks if there are any alternative
therapies that might help with his condition. The nurse advises him that there is positive evidence
for the benefits of which of the following?
Select all that apply.
A) Aerobic exercise
B) Low-salt, low-fat vegetarian diet
C) Qigong
D) Magnetic field therapy
Answer: B, C, D
Explanation: A) There is no evidence for the benefit of aerobic exercise in the treatment of
chronic pancreatitis. Fasting or use of low-salt, low-fat vegetarian diets may reduce episodes of
recurrent pain. Qigong, a system of gentle exercise, meditation, and controlled breathing, lowers
the metabolic rate, and may reduce the stimulation of pancreatic enzyme secretion. Magnetic
field therapy also may be employed for clients with pancreatitis.
B) There is no evidence for the benefit of aerobic exercise in the treatment of chronic
pancreatitis. Fasting or use of low-salt, low-fat vegetarian diets may reduce episodes of recurrent
pain. Qigong, a system of gentle exercise, meditation, and controlled breathing, lowers the
metabolic rate, and may reduce the stimulation of pancreatic enzyme secretion. Magnetic field
therapy also may be employed for clients with pancreatitis.
C) There is no evidence for the benefit of aerobic exercise in the treatment of chronic
pancreatitis. Fasting or use of low-salt, low-fat vegetarian diets may reduce episodes of recurrent
pain. Qigong, a system of gentle exercise, meditation, and controlled breathing, lowers the
metabolic rate, and may reduce the stimulation of pancreatic enzyme secretion. Magnetic field
therapy also may be employed for clients with pancreatitis.
D) There is no evidence for the benefit of aerobic exercise in the treatment of chronic
pancreatitis. Fasting or use of low-salt, low-fat vegetarian diets may reduce episodes of recurrent
pain. Qigong, a system of gentle exercise, meditation, and controlled breathing, lowers the
metabolic rate, and may reduce the stimulation of pancreatic enzyme secretion. Magnetic field
therapy also may be employed for clients with pancreatitis.
Page Ref: 249
Cognitive Level: Creating
Client Need: Health Promotion and Maintenance
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with pancreatitis and his or her
family in collaboration with other members of the healthcare team.

36
Copyright © 2015 Pearson Education, Inc.
7) A client was discharged after hospitalization for acute pancreatitis with instructions on the use
of analgesics, cautions on the importance of avoiding alcohol and smoking, and
recommendations for a low-fat diet. What would indicate that the client has implemented the
recommendations?
Select all that apply.
A) The client experiences reduction or elimination of pain.
B) The client is able to resume eating.
C) The client remains free from alterations in fluid and nutrition status.
D) The client returns to work.
E) The client is free from nausea.
Answer: A, B, C, E
Explanation: A) Nursing interventions to help the client manage pain, restore nutritional status,
and restore and maintain fluid and electrolyte balance will help reduce the client's risk for a life-
threatening event and increase the client's chances for success in meeting and maintaining a
healthy lifestyle and therapeutic regimen following discharge. Employment is not an evaluative
measure for managing acute pancreatitis.
B) Nursing interventions to help the client manage pain, restore nutritional status, and restore and
maintain fluid and electrolyte balance will help reduce the client's risk for a life-threatening event
and increase the client's chances for success in meeting and maintaining a healthy lifestyle and
therapeutic regimen following discharge. Employment is not an evaluative measure for
managing acute pancreatitis.
C) Nursing interventions to help the client manage pain, restore nutritional status, and restore and
maintain fluid and electrolyte balance will help reduce the client's risk for a life-threatening event
and increase the client's chances for success in meeting and maintaining a healthy lifestyle and
therapeutic regimen following discharge. Employment is not an evaluative measure for
managing acute pancreatitis.
D) Nursing interventions to help the client manage pain, restore nutritional status, and restore
and maintain fluid and electrolyte balance will help reduce the client's risk for a life-threatening
event and increase the client's chances for success in meeting and maintaining a healthy lifestyle
and therapeutic regimen following discharge. Employment is not an evaluative measure for
managing acute pancreatitis.
E) Nursing interventions to help the client manage pain, restore nutritional status, and restore and
maintain fluid and electrolyte balance will help reduce the client's risk for a life-threatening event
and increase the client's chances for success in meeting and maintaining a healthy lifestyle and
therapeutic regimen following discharge. Employment is not an evaluative measure for
managing acute pancreatitis.
Page Ref: 250
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with pancreatitis.

37
Copyright © 2015 Pearson Education, Inc.
Exemplar 4.5 Pyloric Stenosis

1) A 1-month-old infant with projectile vomiting is brought into the clinic. Which clinical
manifestations would make the nurse suspect pyloric stenosis?
Select all that apply.
A) Vomit containing small amounts of blood
B) Fever
C) Persistent hunger
D) Peristaltic wave
E) Refusal to eat
Answer: A, C, D
Explanation: A) In pyloric stenosis, at times the vomit may contain small amounts of blood.
Fever and refusal to eat are not symptoms of pyloric stenosis. After vomiting, the baby is hungry
and may want to feed again. Parents may notice a wave-like ripple across the baby's abdomen
after feeding and immediately preceding vomiting.
B) In pyloric stenosis, at times the vomit may contain small amounts of blood. Fever and refusal
to eat are not symptoms of pyloric stenosis. After vomiting, the baby is hungry and may want to
feed again. Parents may notice a wave-like ripple across the baby's abdomen after feeding and
immediately preceding vomiting.
C) In pyloric stenosis, at times the vomit may contain small amounts of blood. Fever and refusal
to eat are not symptoms of pyloric stenosis. After vomiting, the baby is hungry and may want to
feed again. Parents may notice a wave-like ripple across the baby's abdomen after feeding and
immediately preceding vomiting.
D) In pyloric stenosis, at times the vomit may contain small amounts of blood. Fever and refusal
to eat are not symptoms of pyloric stenosis. After vomiting, the baby is hungry and may want to
feed again. Parents may notice a wave-like ripple across the baby's abdomen after feeding and
immediately preceding vomiting.
E) In pyloric stenosis, at times the vomit may contain small amounts of blood. Fever and refusal
to eat are not symptoms of pyloric stenosis. After vomiting, the baby is hungry and may want to
feed again. Parents may notice a wave-like ripple across the baby's abdomen after feeding and
immediately preceding vomiting.
Page Ref: 252
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of pyloric stenosis.

38
Copyright © 2015 Pearson Education, Inc.
2) A mother, age 41, with a newborn son wants to know if her child is at higher risk for pyloric
stenosis since she is over 40 and the baby's father had surgery for the condition when he was an
infant. What is the most appropriate response for the nurse?
Select all that apply.
A) The risk for the baby is higher, as the father has a history of pyloric stenosis.
B) The risk for their son is not affected by the father's history of pyloric stenosis.
C) The risk for their son is higher because their infant is a boy.
D) The risk for their son is higher because of the mother's age.
Answer: A, C
Explanation: A) Children with parents who had pyloric stenosis are more likely to have the
condition. Pyloric stenosis is more common in males than females. The mother's age is not
correlated with an increased risk of pyloric stenosis.
B) Children with parents who had pyloric stenosis are more likely to have the condition. Pyloric
stenosis is more common in males than females. The mother's age is not correlated with an
increased risk of pyloric stenosis.
C) Children with parents who had pyloric stenosis are more likely to have the condition. Pyloric
stenosis is more common in males than females. The mother's age is not correlated with an
increased risk of pyloric stenosis.
D) Children with parents who had pyloric stenosis are more likely to have the condition. Pyloric
stenosis is more common in males than females. The mother's age is not correlated with an
increased risk of pyloric stenosis.
Page Ref: 252
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Communication and Documentation
Learning Outcome: 2. Identify risk factors and prevention methods associated with pyloric
stenosis.

39
Copyright © 2015 Pearson Education, Inc.
3) Which action by the nurse is most important in the physical assessment of an infant with
possible pyloric stenosis?
Select all that apply.
A) Observe the infant's abdomen.
B) Auscultate bowel sounds.
C) Provide oral feeding.
D) Palpate the right upper quadrant of the abdomen.
Answer: A, B, D
Explanation: A) Observe the infant's abdomen for the presence of peristaltic waves. Bowel
sounds are usually hyperactive on auscultation. Because projectile vomiting will continue until
the obstruction is relieved surgically, oral feedings should be withheld. Palpation reveals an
olive-shaped mass in the right upper quadrant of the abdomen.
B) Observe the infant's abdomen for the presence of peristaltic waves. Bowel sounds are usually
hyperactive on auscultation. Because projectile vomiting will continue until the obstruction is
relieved surgically, oral feedings should be withheld. Palpation reveals an olive-shaped mass in
the right upper quadrant of the abdomen.
C) Observe the infant's abdomen for the presence of peristaltic waves. Bowel sounds are usually
hyperactive on auscultation. Because projectile vomiting will continue until the obstruction is
relieved surgically, oral feedings should be withheld. Palpation reveals an olive-shaped mass in
the right upper quadrant of the abdomen.
D) Observe the infant's abdomen for the presence of peristaltic waves. Bowel sounds are usually
hyperactive on auscultation. Because projectile vomiting will continue until the obstruction is
relieved surgically, oral feedings should be withheld. Palpation reveals an olive-shaped mass in
the right upper quadrant of the abdomen.
Page Ref: 252
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with pyloric stenosis.

40
Copyright © 2015 Pearson Education, Inc.
4) The nurse is caring for an infant who is scheduled for surgery for pyloric stenosis. Which
diagnoses would the nurse use to plan care?
Select all that apply.
A) Deficient Fluid Volume related to inadequate intake and vomiting
B) Jaundice, Neonatal
C) Sleep Pattern Disturbance related to discomfort and hunger
D) Parental Anxiety related to surgery
Answer: A, C, D
Explanation: A) The nurse should assess skin turgor, fontanels, mucous membranes, urinary
output (weigh diapers), and urine specific gravity to determine whether hydration is adequate.
Jaundice is not a clinical manifestation of pyloric stenosis. Crying and general discomfort are
frequently observed. The parents' level of anxiety related to the child's condition should be noted.
B) The nurse should assess skin turgor, fontanels, mucous membranes, urinary output (weigh
diapers), and urine specific gravity to determine whether hydration is adequate. Jaundice is not a
clinical manifestation of pyloric stenosis. Crying and general discomfort are frequently observed.
The parents' level of anxiety related to the child's condition should be noted.
C) The nurse should assess skin turgor, fontanels, mucous membranes, urinary output (weigh
diapers), and urine specific gravity to determine whether hydration is adequate. Jaundice is not a
clinical manifestation of pyloric stenosis. Crying and general discomfort are frequently observed.
The parents' level of anxiety related to the child's condition should be noted.
D) The nurse should assess skin turgor, fontanels, mucous membranes, urinary output (weigh
diapers), and urine specific gravity to determine whether hydration is adequate. Jaundice is not a
clinical manifestation of pyloric stenosis. Crying and general discomfort are frequently observed.
The parents' level of anxiety related to the child's condition should be noted.
Page Ref: 253
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
pyloric stenosis.

41
Copyright © 2015 Pearson Education, Inc.
5) A nurse is caring for an infant post-surgery for pyloric stenosis. What are some important
nursing considerations?
Select all that apply.
A) Promote rest and comfort.
B) Prevent infection.
C) Always begin feeding immediately.
D) Provide supportive care.
Answer: A, B, D
Explanation: A) Postoperatively, the infant is uncomfortable because of the surgical incision and
should be administered analgesics as prescribed to relieve discomfort. Postoperatively, the
incision should be kept clean and dry. Some surgeons prefer an NPO period following
pyloromyotomy, while others will implement an earlier postoperative feeding approach. Provide
the parents with simple and clear explanations about the infant's condition and care.
B) Postoperatively, the infant is uncomfortable because of the surgical incision and should be
administered analgesics as prescribed to relieve discomfort. Postoperatively, the incision should
be kept clean and dry. Some surgeons prefer an NPO period following pyloromyotomy, while
others will implement an earlier postoperative feeding approach. Provide the parents with simple
and clear explanations about the infant's condition and care.
C) Postoperatively, the infant is uncomfortable because of the surgical incision and should be
administered analgesics as prescribed to relieve discomfort. Postoperatively, the incision should
be kept clean and dry. Some surgeons prefer an NPO period following pyloromyotomy, while
others will implement an earlier postoperative feeding approach. Provide the parents with simple
and clear explanations about the infant's condition and care.
D) Postoperatively, the infant is uncomfortable because of the surgical incision and should be
administered analgesics as prescribed to relieve discomfort. Postoperatively, the incision should
be kept clean and dry. Some surgeons prefer an NPO period following pyloromyotomy, while
others will implement an earlier postoperative feeding approach. Provide the parents with simple
and clear explanations about the infant's condition and care.
Page Ref: 253
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with pyloric stenosis.

42
Copyright © 2015 Pearson Education, Inc.
6) The nurse is concerned about the risk of infection in an infant who just underwent surgery for
pyloric stenosis. What are some important steps the nurse should take?
Select all that apply.
A) Monitor the infant's temperature every 4 hours.
B) Place pressure on the incision.
C) Inspect the incision for redness, swelling, or discharge.
D) Auscultate the lungs to assess for any adventitious sounds.
E) Give the infant a tub bath.
Answer: A, C, D
Explanation: A) The infant should be monitored for fever and local signs of infection. The lungs
should be auscultated for any indications of abnormality. No pressure should be placed on the
incision. The infant should be sponge-bathed only.
B) The infant should be monitored for fever and local signs of infection. The lungs should be
auscultated for any indications of abnormality. No pressure should be placed on the incision. The
infant should be sponge-bathed only.
C) The infant should be monitored for fever and local signs of infection. The lungs should be
auscultated for any indications of abnormality. No pressure should be placed on the incision. The
infant should be sponge-bathed only.
D) The infant should be monitored for fever and local signs of infection. The lungs should be
auscultated for any indications of abnormality. No pressure should be placed on the incision. The
infant should be sponge-bathed only.
E) The infant should be monitored for fever and local signs of infection. The lungs should be
auscultated for any indications of abnormality. No pressure should be placed on the incision. The
infant should be sponge-bathed only.
Page Ref: 253
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 6. Plan evidence-based care for an individual with pyloric stenosis and his
or her family in collaboration with other members of the healthcare team.

43
Copyright © 2015 Pearson Education, Inc.
7) A nurse is providing care to Eliot, an infant who recently underwent laparoscopic
pyloromyotomy. Which parental statement indicates successful outcomes?
Select all that apply.
A) "We always keep Eliot upright when feeding him."
B) "We are careful to slide Eliot's diaper under him when changing it."
C) "We only feed Eliot twice daily in order to avoid vomiting."
D) "Eliot is breastfeeding regularly without vomiting."
E) "We only burp Eliot when he has finished feeding."
Answer: A, B, D
Explanation: A) The parents should successfully demonstrate strategies to prevent aspiration
when feeding Eliot. Expected outcomes of care include pain control and intake of recommended
fluid and food with absence of vomiting. The infant should be burped after every 1-2 ounces
during feeding. If breastfeeding, burp the infant every 5-10 minutes.
B) The parents should successfully demonstrate strategies to prevent aspiration when feeding
Eliot. Expected outcomes of care include pain control and intake of recommended fluid and food
with absence of vomiting. The infant should be burped after every 1-2 ounces during feeding. If
breastfeeding, burp the infant every 5-10 minutes.
C) The parents should successfully demonstrate strategies to prevent aspiration when feeding
Eliot. Expected outcomes of care include pain control and intake of recommended fluid and food
with absence of vomiting. The infant should be burped after every 1-2 ounces during feeding. If
breastfeeding, burp the infant every 5-10 minutes.
D) The parents should successfully demonstrate strategies to prevent aspiration when feeding
Eliot. Expected outcomes of care include pain control and intake of recommended fluid and food
with absence of vomiting. The infant should be burped after every 1-2 ounces during feeding. If
breastfeeding, burp the infant every 5-10 minutes.
E) The parents should successfully demonstrate strategies to prevent aspiration when feeding
Eliot. Expected outcomes of care include pain control and intake of recommended fluid and food
with absence of vomiting. The infant should be burped after every 1-2 ounces during feeding. If
breastfeeding, burp the infant every 5-10 minutes.
Page Ref: 253
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with pyloric stenosis.

44
Copyright © 2015 Pearson Education, Inc.