Practice Question
The nurse performs a focused assessment of the gastrointestinal system. What assessments must the nurse perform? Select all that apply.
Answer Choices:
Correct Answer:
Abdominal inspection.
Rationale:
🔹 A. Abdominal inspection
✔️The nurse inspects the abdomen to look for distention, symmetry, visible peristalsis, scars, hernias, or surgical incisions.
✔️Skin changes such as bruising, striae, or discoloration may also point to liver disease, trauma, or chronic illness.
✔️Inspection gives a baseline view before auscultation and palpation to avoid altering bowel activity.
✔️It can reveal important GI issues such as ascites, intestinal obstruction, or masses.
✔️Abdominal inspection is always performed first in GI assessment because it is noninvasive.
🔹 B. History of nausea and vomiting
✔️A full history of nausea and vomiting provides key clues about GI disturbances.
✔️The nurse documents onset, duration, triggers, and characteristics of vomitus (e.g., bloody, bilious, coffee-ground appearance).
✔️This helps determine causes such as infection, obstruction, peptic ulcer disease, or medication side effects.
✔️Assessing the impact on nutrition and hydration is crucial, as repeated vomiting can lead to electrolyte imbalance and dehydration.
✔️This history connects current symptoms to possible underlying GI pathology.
🔹 C. Condition of teeth
✔️Oral health is directly tied to the GI system because digestion begins in the mouth.
✔️Poor dentition may limit chewing ability, which impairs breakdown of food and reduces nutrient absorption.
✔️Tooth decay or gum disease can also be linked to systemic illnesses like diabetes or malnutrition.
✔️Dentition reflects the client’s dietary habits and overall nutritional status.
✔️In older adults, missing teeth or ill-fitting dentures often contribute to GI complaints and weight loss.
🔹 D. Color of stools
✔️The color, consistency, and frequency of stool provide vital information about digestion and GI function.
✔️Clay-colored stool indicates biliary obstruction, black/tarry stool suggests upper GI bleeding, and bright red stool may indicate lower GI bleeding.
✔️Pale or greasy stools may reflect fat malabsorption or pancreatic disorders.
✔️Regular documentation of stool characteristics helps in early detection of serious GI disease.
✔️This assessment is especially important for clients with liver disease, ulcers, or suspected bleeding.
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This question is from Examplify-Health Assessment 2025 which contains 43 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Health Assessment
- Answer Choices: 5