Ch 47

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The nurse is assessing a client for constipation. Which factor should the nurse review first to identify the cause of constipation?

Usual pattern of elimination

The nurse is conducting a community education program on colorectal cancer. Which statement should the nurse include in the program?

It is the third most common cancer in the United States.

Which drug is considered a stimulant laxative?

Bisacodyl

A nurse is teaching an older adult client about good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?

"I need to use laxatives regularly to prevent constipation."

When preparing a client for a hemorrhoidectomy, the nurse should take which action?

Administer an enema as ordered.

In addition to teaching a client with constipation to increase dietary fiber intake to 25 g/day, which of the following would the nurse include as important?

Adding fiber-rich foods to the diet gradually

When a nurse recommends the following laxative, she emphasizes that it should not be taken with meals. Choose the laxative.

Mineral Oil

A nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?

Polyps

Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?

Sudden, sustained abdominal pain

A nurse is preparing a presentation for a local community group of older adults about colon cancer. Which of the following would the nurse include as the primary characteristic associated with this disorder?

A change in bowel habits

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of:

increasing fluid intake to prevent dehydration.

A client with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation?

Assist client to increase dietary fiber.

Which of the following would a nurse expect to assess in a client with peritonitis?

Board-like abdomen

The nurse is performing an abdominal assessment for a patient with diarrhea and auscultates a loud rumbling sound in the left lower quadrant. What will the nurse document this sound as on the nurse's notes?

Borborygmus

The nurse is performing and documenting the findings of an abdominal assessment. When the nurse hears intestinal rumbling and the client then experiences diarrhea, the nurse documents the presence of which condition?

Borborygmus

The nurse is performing a community screening for colorectal cancer. Which characteristic should the nurse include in the screening?

Familial polyposis

The nurse is talking with a group of clients who are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?

Change in bowel habits

A client informs the nurse that he has been having abdominal pain that is relieved when having a bowel movement. The client states that the physician told him he has irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder?

Chronic constipation with sporadic bouts of diarrhea

The nurse is irrigating a colostomy when the patient says, "You will have to stop, I am cramping so badly." What is the priority action by the nurse?

Clamp the tubing and give the patient a rest period.

Crohn's disease is a condition of malabsorption caused by which pathophysiological process?

Inflammation of all layers of intestinal mucosa

A client is being treated for diverticulosis. Which information should the nurse include in this client's teaching plan?

Drink at least 8 to 10 large glasses of fluid every day

The nurse is teaching a client with an ostomy how to change the pouching system. Which information should the nurse include when teaching a client with no peristomal skin irritation?

Dry skin thoroughly after washing

A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate?

Gently washing the area surrounding the stoma using a facecloth and mild soap

The nurse is caring for a patient diagnosed with abdominal perforation. Which of the following is a clinical manifestation of this disease process?

Hypotension

Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following?

Low residue

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.

It is important for the nurse to monitor serum electrolytes in a patient with acute diarrhea. Select the electrolyte result that should be immediately reported.

Potassium of 2.8 mEq/L

Clients with irritable bowel disease (IBS) are at significantly increased risk for which condition?

Osteoporosis

When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report?

Rectal bleeding

Which of the following is the most common symptom of a polyp?

Rectal bleeding

A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care?

Test all stools for occult blood.

A client tells the nurse, "I am not having normal bowel movements." When differentiating between what are normal and abnormal bowel habits, what indicators are the most important?

The consistency of stool and comfort when passing stool

Diet therapy for clients diagnosed with irritable bowel syndrome (IBS) includes:

high-fiber diet.

The nurse caring for an older adult client diagnosed with diarrhea is administering and monitoring the client's medications. Because one of the client's medications is digitalis (digoxin), the nurse monitors the client closely for:

hypokalemia.

A nurse is performing focused assessment on her clients. She expects to hear hypoactive bowel sounds in a client with:

paralytic ileus.

During assessment of a patient for a malabsorption disorder, the nurse notes a history of abdominal pain and weight loss, marked steatorrhea, azotorrhea, and frequent glucose intolerance. Based on these clinical features, the nurse suspects a diagnosis of:

Pancreatic insufficiency.

A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and boardlike. What complication does the nurse determine may be occurring at this time?

Peritonitis

The nurse is monitoring a client's postoperative course after an appendectomy. The nurse's assessment reveals that the client has vomited, has abdominal tenderness and rigidity, and has tachycardia. The nurse reports to the physician that the client has signs/symptoms of which complication?

Peritonitis

A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation?

lack of free water intake


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