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Nclex Gastrointestinal System Disorders Exam

NCLEX-style exam on gastrointestinal system disorders with verified solutions—focuses on GERD-related chronic cough and its link to aspiration, with rationale and analysis of differential options.

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    Nclex Gastrointestinal System Disorders Exam with verified solution ■ The client with GERD complains of a chronic cough. The nurse understands that in a client with GERD this symptom may be indicative of which of the following conditions? ] A. Development of laryngeal cancer. i B. Irritation of the esophagus. i C. Esophageal scar tissue formation. •] D. Aspiration of gastric contents. Answer: D. Aspiration of gastric contents Clients with GERD can develop pulmonary symptoms such as coughing, wheezing, and dyspnea that are caused by the aspiration of gastric contents. It is frequently thought that GERD plays a big role in chronic cough: there are reports that 25% or more of chronic cough cases are associated with GERD. Option A: GERD does not predispose the client to the development of laryngeal cancer. The most intuitive theory is called the reflux theory, whereby reflux rises above the esophagus and upper esophageal sphincter, resulting in microaspiration as microdroplets land in the larynx or occasionally enter the bronchia tree, directly causing cough as a protective mechanism against reflux. Option B: Irritation of the esophagus can deve op as a result of GERD. However, GERD is more likely to cause painful and difficult swallowing. In the reflex theory, because of the com mon embryologic origin of the respiratory tract and the digestive tract, a little bit of reflux, in the esophagus can lead to an esophagobronchial reflex that causes cough. Option C: Esophageal scar tissue formation can develop as a result of GERD. GERD occurs in approximately 20K of Americans, and chronic cough is a very common problem, which patients

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    with GERD are not immune to developing. Due to the baseline GERD rate of 20%, it is difficult to separate the presence of the disorder from the causative effect of the disorder. ■ Which of the following tasks should be included in the immediate postoperative management of a client who has undergone gastric resection? 1 A. Monitoring gastric pH to detect complications. ] B. Assessing for bowel sounds. 1 C. Providing nutritional support. •1 D. Monitoring for symptoms of hemorrhage. Answer: D. Monitoring for symptoms of hemorrhage. The client should be monitored closely for signs and symptoms of hemorrhage, such as bright red blood in the nasogastric tube suction, tachycardia, or a drop in blood pressure. Identify signs and symptoms requiring medical evaluation such as persistent nausea and vomiting or abdominal fullness; weight loss; diarrhea; foul-smelling fatty or tarry stools; bloody or coffee-ground vomitus or presence of bile, fever. Instruct the patient to report changes in pain characteristics. Option A: Gastric pH may be monitored to evaluate the need for histamine-2 receptor antagonists. Caution the patient to read labels and avoid products containing ASA, ibuprofen. This can cause gastric irritation and bleeding. Review medication purpose, dosage, and schedule, and possible side effects. Option E: Bowel sounds may not return for up to 72 hours postoperatively. Auscultate for resumption of bowel sounds and note passage of flatus. Peristalsis can be expected to return about the third postoperative day, signaling readiness to resume oral intake. Option C: Nutritional needs should be addressed soon after surgery. Monitor tolerance to fluid and food intake, noting abdominal distension, reports of increased pain, cramping, nausea, and vomiting. Avoid milk and high-carbohydrate foods in the diet because this may trigger dumping syndrome. ■ Which of the following would be an expected nutritional outcome for a client who has undergone a subtotal gastrectomy for cancer? 1 A. Regain weight loss within 1 month after surgery. 1 B. Resume normal dietary intake of three meals per day. i C. Control nausea and vomiting through regular use of antiemetics. *2 D. Achieve optimal nutritional status through oral or parenteral feedings. Answer: D. Achieve optimal nutritional status through oral or parenteral feedings.

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    An appropriate expected outcome is for the client to achieve optimal nutritional status through the use of oral feedings or total parenteral nutrition (TPN). TPN may be used to supplement oral intake, or it may be used alone if the client cannot tolerate oral feedings. Maintain patency of NG tube. Notify the physician if the tube becomes dislodged. This provides rest for the Gl tract during the acute postoperative phase until the return of normal function. Option A: The client would not be expected to regain lost weight within 1 month after surgery. Note admission weight and compare with subsequent readings. This provides information about the adequacy of dietary intake and determination of nutritional needs. Option B: The client would not be expected to tolerate a normal dietary Intake of three meals per day. Monitor tolerance to fluid and food intake, noting abdominal distension, reports of increased pain, cramping, nausea, and vomiting. Complications of paralytic ileus, obstruction, delayed gastric emptying, and gastric dilation may occur, possibly requiring reinsertion of the NG tube. Option C: Nausea and vomiting would not be considered an expected outcome of gastric surgery, and regular use of antiemetics would not be anticipated. Progress diet as tolerated, advancing from clear liquid to bland diet with several small feedings. Usually, the NG tube is clamped for specified periods of time when peristalsis returns to determine tolerance. After the NG tube is removed, intake is advanced gradually to prevent gastric irritation and distension. • The nurse would assess the client experiencing an acute episode of cholecystitis for pain that is located in the right ’ A. Upper quadrant and radiates to the left scapula and shoulder. *j B. Upper quadrant and radiates to the right scapula and shoulder. 1 C. Lower quadrant and radiates to the umbilicus. 1 D. Lower quadrant and radiates to the back. Answer: B. Upper quadrant and radiates to the right scapula and shoulder During an acute "gallbladder attack," the client may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. This is governed by the pattern on dermatomes in the body. Acute cholecystitis is inflammation of the gallbladder that occurs due to occlusion of the cystic duct or impaired emptying of the gallbladder. Often this impaired emptying is due to stones or biliary sludge. Option A: When cystic duct blockage is caused by a stone, it is called acute calculous cholecystitis. It is important to know, one can have pain due to temporary obstruction by gallstones, and that is called biliary colic. The diagnosis of biliary colic is upgraded to acute calculous cholecystitis if the pain does not resolve in six hours. If no stone is identified, it is called acute acalculous cholecystitis. Option C: Cases of chronic cholecystitis present with progressing right upper quadrant abdominal pain with bloating, food intolerances (especially greasy and spicy foods), increased

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    gas, nausea, and vomiting. Pain in the mid-back or shoulder may also occur. This pain could be present for years until diagnosis. Option D: The pathophysiologic mechanism of acute cholecystitis is blockage of the cystic duct. Cholecystitis is a condition best treated with surgery; however, it can be treated conservatively if necessary. This condition can be associated with or without the presence of gallstones and can also be classified as acute or chronic. * After a subtotal gastrectomy, care of the client's nasogastric tube and drainage system should include which of the following nursing interventions? i A. Irrigate the tube with 30 ml of sterile water every hour if needed. 1 B. Reposition the tube if it is not draining we . •1 C. Monitor the client for N/V, and abdominal distention. | D. Turn the machine to high suction if the drainage is sluggish on low suction. Answer: C. Monitor the client for N/V r and abdominal distention. Nausea, vomiting, or abdominal distention indicated that gas and secretions are accumulating within the gastric pouch due to impaired peristalsis or edema at the operative site and may indicate that the drainage system is not working properly. Assess the comfort of the client. Check for presence of nausea and vomiting, feeling of fullness, or pain. May indicate incorrect operation of NG suction or blockage in the tube. Option A: Saline solution is used to irrigate nasogastric tubes. Hypotonic solutions such as water increase electrolyte loss. In addition, a physician's order is needed to irrigate the NG tube, because this procedure could disrupt the suture line. Irrigations are recorded as intake. Drainage from the NG tube is measured as output every 0 hours. If drainage is copious, more frequent emptying of the collection container will be necessary. Documentation provides an accurate record of the client's response to NG drainage. Option B: After gastric surgery, only the surgeon repositions the NG tube because of the danger of rupturing or dislodging the suture line. Always verify if the NG tube placed is in the stomach by aspirating a small amount of stomach contents. An X-ray study is the best way to verify placement. Option D: The amount of suction varies with the type of tube used and is ordered by the physician. High suction may create too much tension on the gastric suture line. Inspect suction apparatus. Check that setting is correct for the type of suction (continuous or intermittent), range of suction (low. medium, high), and that movement of drainage through the tubing is present. • A client with a peptic ulcer is scheduled for a vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure: j A. Decreases food absorption in the stomach.

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    ! B. Heals the gastric mucosa. | C. Halts stress reactions. •1 D. Reduces the stimulus to acid secretions. Answer: D, Reduces the stimulus to acid secretions, A vagotomy, or cutting the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. A vagotomy is a type of surgery that removes all or part of the vagus nerve. This nerve runs from the bottom of the brain, through the neck, and along the esophagus, stomach, and intestines in the gastrointestinal (Gl) tract. Option A: The indications for vagotomy are few with the advancements of medical therapy. Generally, acid-reducing operations are reserved for complicated ulcer disease in a stable patient who has failed maximum medical therapy. The type of surgery performed depends on the type of ulcer (duodenal versus gastric), the complication of PUD (bleeding, perforation, obstruction, intractability), and the location of the ulcer (types I to V gastric ulcers as described by the Modified Johnson Classification system}. Option B: The relevant physiology revolves around the mechanisms relating to stomach acid secretion. Intraluminal gastric acid is released by the parietal cells, mainly located in the body of the stomach. Parietal cells are stimulated via 3 mechanisms: gastrin, acetylcholine, and histamine. All 3 mechanisms activate the hydrogen-potasslum ATPase-relea sing hydrogen ion into the stomach lumen. Option C: Vagotomy was once commonly performed to treat and prevent PUD; however, with the availability of excel ent acid secretion control with H2-receptor antagonists, proton pump inhibitors, and anti -Helicobacter pylori medications, the need for surgical management of this condition has greatly decreased. ■ After a subtotal gastrectomy, the nurse should anticipate that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery? •1 A. Dark brown • E. Bile green i C. Bright red | D. Cloudy white Answer: A, Dark brown About 12 to 24 hours after a subtotal gastrectomy, gastric drainage is normally brown, which indicates digested blood. The aims of prophylactic drainage are to prevent repeated infection (for example by discharging remnant blood and preventing abscess formation), control possible leakage from the surgical seam (by drainage of the digestive closure, for example, a colonic anastomosis), and to provide a warning of potential complications.

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    Option B: Bile green is not expected during the first 12 to 24 hours after subtotal gastrectomy. Bile-colored (greenish) drainage is characteristic when the tube is in the duodenum. Measure and record the amount of drainage. Dispose of measured drainage by flushing into the hopper or toilet. Option C: Drainage during the first 6 to 12 hours contains some bright red blood, but large amounts of blood or excessively bloody drainage should be reported to the physician promptly. In gastrointestinal! drainage, blood varies in color-it may be dark red when fresh, dark brownish- red. or in brown particles ("coffee ground drainage' 1 ) if it has been partially digested. Option D: Cloudy, pale-yellowish drainage is characteristic when the tube is in the stomach. However, this is not expected within 12 to 24 hours. Measure the contents and empty the drainage bottle at the hours ordered by the physician, when the drainage bottle is two-thirds full or when suction is discontinued. ■ The client with peptic ulcer disease is scheduled for a pyloroplasty. The client asks the nurse about the procedure. The nurse plans to respond knowing that a pyloroplasty involves: I A. Cutting the vagus nerve, I B. Removing the distal portion of the stomach. 1 C. Removal of the ulcer and a large portion of the ce Is that produce hydrochloric acid. •1 D. An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum. Correct Answer: D, An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum. Pyloroplasty is surgery to widen the opening in the lower part of the stomach (pylorus) so that stomach contents can empty into the small intestine (duodenum). The pylorus is a thick, muscular area. When it thickens, food cannot pass through. Option A: A vagotomy involves cutting the vagus nerve. A vagotomy is a type of surgery that removes all or part of the vagus nerve. This nerve runs from the bottom of the brain, through the neck, and along the esophagus, stomach, and intestines in the gastrointestinal (GI) tract. Option B: A subtotal gastrectomy involves removing the distal portion of the stomach. Gastrectomy is a surgery that's done to treat stomach cancer. During gastrectomy, the surgeon may remove part or all of the stomach. A subtotal gastrectomy includes removing the part of the stomach with cancer, nearby lymph nodes, and possibly parts of other organs near the tumor. Option C: A Billroth II procedure involves removal of the ulcer and a large portion of the tissue that produces hydrochloric acid. There are many variations on the procedure, but they generally involve resection of the diseased portion of the distal stomach and a side-to-side anastomosis of the residual stomach to jejunum through the transverse mesocolon. It can be performed with either an antecolic or a retrocolic anastomosis.

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    A 40-year-old male client has been hospitalized with peptic ulcer disease. He is being t r e a t e d with a histamine receptor antagonist (cimetidine), antacids, and diet. The nurse doing discharge planning will teach him that the action of cimetidine is to: •1 A, Reduce gastric acid output. i B. Protect the ulcer surface. 1 C. Inhibit the production of hydrochloric acid (HCl). ] D. Inhibit vagus nerve stimulation. Answer: A. Reduce gastric acid output. These drugs inhibit the action of histamine on the H2 receptors of parietal cells, thus reducing gastric acid output. The H2-receptor antagonist cimetidine competitively blocks histamine from stimulating the H 2- receptors ocated on the gastric parietal cells (these cells are responsible for hydrochloric acid secretion and secretion of the intrinsic factor). The effect results in reducing the volume of gastric acid secretion from stimuli, including histamine, food, caffeine, and insulin. Option B: Sucralfate exhibits its action by forming a protective layer, increasing bicarbonate production, exhibiting anti-peptic effects, p r o m o t i n g tissue g r o w t h , regeneration, and repair. Sucralfate is a medication used to treat duodenal ulcers, epithelial wounds, chemotherapy- induced mucositis, radiation proctitis, ulcers in Behcet disease, and burn wounds. Option C: Ultimately, PPIs function to decrease acid secretion in the stomach. The proximal small bowel absorbs these drugs, and once in circulation, affects the parietal cells of the stomach. The parietal cells contain the H+/K+ ATPase enzyme, the proton pump, that PPIs block. This enzyme serves as the final step of acid secretion into the stomach. Option D: Atropine is an antimuscarinic that works t h r o u g h competitive inhibition of postganglionic acetylcho ine receptors and direct vagolytic action, which leads to parasympathetic inhibition of the acetylcholine receptors in smooth muscle. The end effect of increased parasympathetic inhibition a ows for preexisting sympathetic stimulation to predominate, creating increased cardiac output and other associated antimuscarinic side effects as described herein. • A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During preoperative teaching, the nurse is reinforcing i n f o r m a t i o n about the procedure. Which of the following explanations is most accurate? 1 A. The procedure will result in enlargement of the pyloric sphincter. •J B. The procedure will result in anastomosis of the gastric stump to the jejunum. i C. The procedure will result in removal of the duodenum. J D. The procedure will result in repositioning of the vagus nerve.

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    Correct Answer: B. The procedure will result in anastomosis of the gastric stump to the jejunum. A Billroth II procedure bypasses the duodenum and connects the gastric stump directly to the jejunum. The pyloric sphincter is removed, along with some of the stomach fundus. If the stomach cannot be reconnected to the duodenum, a Billroth II is performed, in which an opening hole is made in the next section of the small intestine, the jejunum, and the stomach attached at that opening. Option A: A pyloromyotomy is an operation to loosen the tight muscle causing the blockage between the stomach and small intestine. During the operation, the surgeon cuts the tight muscle b e t w e e n the stomach and small intestine. This loosens the muscle so the stomach can empty and food will be able to pass easily into the small intestine. Option C: The W h i p p l e procedure (pancreaticoduodenectomy) is an operation to remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder, and the bile duct. The remaining organs are reattached to allow the client to digest food normally after surgery. Option D: Billroth II gastrojejunostomy is a procedure that has been performed for tumor or severe ulcer disease in the distal stomach. There are many variations on the procedure, but they generally involve resection of the diseased portion of the distal stomach and a side-to-side anastomosis of the residual stomach to jejunum t h r o u g h the transverse mesocolon. It can be performed with either an antecolic or a retro colic anastomosis. • The nurse provides medication instructions to a client with peptic ulcer disease. Which statement, if made by the client, indicates the best understanding of the medication therapy? A. •) "The cimetidine (Tagamet) will cause meto produce less stomach acid." J B. "Sucralfate (Carafate) will change the fluid in my stomach." 1 C. "Antacids will coat my stomach." 1 D. "Omeprazole (Prilosec) will c o a t t h e ulcer and help it heal." Answer: A. "The cimetidine (Tagamet) will cause m e t o produce less stomach acid." Cimetidine (Tagamet), a histamine H2 receptor antagonist, will decrease the secretion of gastric acid. The H2-receptor antagonist cimetidine competitively blocks histamine from stimulating the H2- receptors located on the gastric parietal cells (these cells are responsible for hydrochloric acid secretion and secretion of the intrinsic factor). The effect results in reducing the volume of gastric acid secretion from stimuli, including histamine, food, caffeine, and insulin. Option B: Sucralfate (Carafate) promotes healing by coating the ulcer. By f o r m i n g a polyanion gel, it acts as a physical barrier between luminal contents and mucosa. It also increases the production of mucus by increasing prostaglandin production. Sucralfate prevents the breakdown of mucus by pepsin A, reducing ulcerogenesis. Option C: Antacids neutralize acid in the stomach. The antacids reduce the acid reaching the duodenum by neutralizing the acid present in the stomach. The salts' mechanism of

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    neutralization of acid varies, and each salt has a different mechanism with the ultimate goal of acid neutra ization. Option D: Omeprazole (Prilosec) inhibits gastric acid secretion. Omeprazole is a proton pump inhibitor. It inhibits the parietal cell H-i- / K-+ ATP pump r the final step of acid production. In turn, omeprazole suppresses gastric basal and stimulated acid secretion. The inhibitory effects of omeprazole occur rapidly within 1 hour of administration, with the maximum effect occurring in 2 hours. • When a client has peptic ulcer disease, the nurse would expect a priority intervention to be: ] A. Assisting in inserting a Miller-Abbott tube. i B. Assisting in inserting an arterial pressure line. •1 C. Inserting a nasogastric tube. j D. Inserting an I.V. Answer: C. Inserting a nasogastric tube. An NG tube insertion is the most appropriate intervention because it will determine the presence of active Gl bleeding. Monitor the client's fluid intake and urine output. Assess for the signs of hematemesis or melena. The client with a bleeding ulcer may vomit bright red blood or coffee grounds emesis. Melena occurs when there is bleeding in the upper Gl tract. Option A: A Miller-Abbott tube is a weighted, mercury-filled bal oon tube used to resolve bowel obstructions. The modifications of lifestyle behaviors such as alcohol use, coffee, and other caffeinated beverages, and the overuse of aspirin or other nonsteroidal anti-inflammatory drugs is necessary to prevent recurrent ulcer deve opment and prevent complications during the healing phase. Option B: There is no evidence of shock or fluid overload in the client; therefore, an arterial line is not appropriate at this time. Monitor the client's vital signs, and observe BP and HR for signs of orthostatic changes. Option D: An IV is optional. Administer IV fluids, volume expanders, and blood products as ordered. Isotonic fluids, volume expanders, and blood products can restore or expand intravascular vo ume. • A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of a potential complication? 3 A. The client complains of a sore throat. 1 B. The client displays signs of sedation. *1 C. The client experiences a sudden increase in temperature.

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    ] D. The client demonstrates a lack of appetite. Correct Answer: C. The client experiences a sudden increase in temperature. The most likely complication of an endoscopic procedure is perforation. A sudden temperature spike within 1 to 2 hours after the procedure is indicative of perforation and should be reported immediately to the physician. This most commonly occurs when additional procedures are carried out at the same time. The infections are normally minor and treatable with a course of antibiotics. Option A: A sore throat is to be anticipated after an endoscopy. Risks of endoscopy may include persistent pain in the area of the endoscopy or a numb throat for a few hours due to the use of a local anesthetic. Option B: Clients are given sedatives during the procedure, so it is expected that they 'will display signs of sedation after the procedure is completed. Risks of endoscopy may include over- sedation. although sedation is not always necessary. Option D: A lack of appetite could be the result of many factors, including the disease process. There may be some soreness. With this type of endoscopy, there may be bloating and soreness, but these usually resolve quickly. • The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T- tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate? ! A. Notify the physician. 1 B. Document the findings. ' C. Irrigate the T-tube. i D. Clamp the T-tube. Answer: B. Document the findings. Following cholecystectomy, drainage from the T-tube is initially bloody and then turns green-brown. Fresh post-op (1-2 days): drainage starts out with some blood and then progresses to a greenish/yellow/ brown liquid drainage. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 ml per day. The nurse would document the output. Option A: Notifying the physician is unnecessary. The fluid may appear bloody for the first day or 2. The color will eventually be go den yellow or greenish, depending on exactly where the catheter is inside the body. There will be bile (yellow-green fluid) flowing into the bag. Option C: There is no need to irrigate the T-tube. The client will need to flush the catheter with normal saline twice a day. If the doctor instructed to flush with less than 10 mL, squirt the extra saline out before connecting the syringe. Push the plunger of the syringe to push 1/3 of the normal saline into the catheter, and then pause. Push in another 1/3 of the normal saline, and pause again. Push in the rest of the normal saline into the catheter.

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    Option D: The doctor may order the t-tube to be damped at times so bile can drain to the duodenum so fats can be digested during meal times. Assess how well the patient tolerated the t-tube being clamped. If a patient develops abdominal pain, nausea, vomiting, etc. unclamp it and notify the physician. ■ A female client complains of gnawing epigastric pain for a few hours after meals. At times, when the pain is severe, vomiting occurs. Specific tests are indicated to rule out: J A. Cancer of the stomach •1 B. Peptic ulcer disease ■ C. Chronic gastritis ] D. Pylorospasm Answer: B, Peptic ulcer disease Peptic u cer disease is characteristically gnawing epigastric pain that may radiate to the back. Vomiting usually reflects pyloric spasm from muscular spasm or obstruction. Peptic ulcer disease is characterized by discontinuation in the inner lining of the gastrointestinal (Gl) tract because of gastric acid secretion or pepsin. It extends into the muscularis propria layer of the gastric epithelium. It usually occurs in the stomach and proximal duodenum. Option A: Cancer would not evidence pain or vomiting unless the pylorus was obstructed. In the United States, most patients have symptoms of an advanced stage at the time of presentation. The most common presenting symptoms for gastric cancers are non-specific weight oss, persistent abdominal pain, dysphagia, hematemesis, anorexia, nausea, early satiety, and dyspepsia. Option C: The current classification of gastritis is based on time course (acute versus chronic), histologica features, anatomic distribution, and underlying pathological mechanisms. Acute gastritis will evolve to chronic, if not treated. There are no typica clinical manifestations of gastritis. Sudden onset of epigastric pain, nausea, and vomiting have been described to accompany acute gastritis. Option D: There has been much uncertainty about the concept of "pylorospasm' 1 . For many years radiologists considered pylorospasm to be due to spasm of the pyloric ring, where the ring was equated with the pyloric sphincter. It was thought that spasm of the ring (or "sphincter ') closed the pyloric aperture, thereby delaying gastric emptying and causing retention. ■ The nurse instructs the nursing assistant on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the assistant to incorporate into the client's daily care? 1 A. Assess the oral cavity each time mouth care is given and record observations. *i B. Use a soft toothbrush to brush the client's teeth after each meal.

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