chapter 41

dietary approach varies

A client has a 10-year history of Crohn disease and is seeing the physician due to increased diarrhea and fatigue. What is the recommended dietary approach to treat Crohn disease? · high-fiber diet · lactose-rich foods · dietary approach varies · low-fiber diet

Flush each port with diluted heparin in a 10 mL syringe once a shift.

A client has a 3 lumen central line inserted into the subclavian vein for parenteral nutrition. Which approach will the nurse take to maintain patency? · Flush each port with normal saline in a 3 mL syringe once a day. · Flush each port with sterile water in a 2 mL syringe every 8 hours. · Flush each port with normal saline in a 2-mL syringe every 12 hours. · Flush each port with diluted heparin in a 10 mL syringe once a shift.

Polyps

A nurse is interviewing a client about past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer? · Polyps · Weight gain · Hemorrhoids · Duodenal ulcers

nausea.

A typical sign/symptom of appendicitis is: · left lower quadrant pain. · nausea. · pain when pressure is applied to the right upper quadrant. · high fever.

Lubricates and softens fecal matter

As part of the management of constipation, the client is instructed to take 30 mL of mineral oil orally. How does mineral oil facilitate bowel evacuation? · Irritates nerve endings in the intestinal mucosa · Decreases water retention of stool · Lubricates and softens fecal matter · Increases the volume of intestinal contents

Dilated pits of hair follicles in the cleft

What would the nurse identify as a characteristic finding when assessing a client for pilonidal sinus? · Abdominal pain · Purulent drainage from the gluteal fold · Dilated pits of hair follicles in the cleft · Pain in the perianal area

A 35-year-old female with Crohn's disease

Which client would be at greatest risk for the development of an anorectal fistula? · A 42-year-old female with irritable bowel syndrome · A 35-year-old female with Crohn's disease · A 50-year-old male with diverticulosis · A 60-year-old male with polyps of the colon

limiting analgesics to avoid the formation of paralytic ileus.

A client has symptoms suggestive of peritonitis. Nursing management would not include: · accurate recording of input and output. · inserting a nasogastric tube. · limiting analgesics to avoid the formation of paralytic ileus. · inserting a urinary retention catheter.

constipation · diarrhea narrowing of stools

A client has been diagnosed with cancer in the descending colon. Which symptom(s) would the nurse expect the client to report? Select all that apply. · constipation · diarrhea · black, tarry stools · tenesmus · narrowing of stools

Abdominoperineal resection

A client is diagnosed with colon cancer, located in the lower third of the rectum. What does the nurse understand will be the surgical treatment option for this client? · Abdominoperineal resection · Colectomy · Segmental resection · A low colectomy

· constipation · diarrhea narrowing of stools

A client has been diagnosed with cancer in the descending colon. Which symptom(s) would the nurse expect the client to report? Select all that apply. · constipation · diarrhea · black, tarry stools · tenesmus · narrowing of stools

A client with Crohn's disease

A client has developed an anorectal abscess. Which client is likely at risk for the development of this type of abscess? · A client with Crohn's disease · A client with diverticulosis · A client with colon cancer · A client with hemorrhoids

limiting analgesics to avoid the formation of paralytic ileus.

A client has symptoms suggestive of peritonitis. Nursing management would not include: · accurate recording of input and output. · inserting a nasogastric tube. · limiting analgesics to avoid the formation of paralytic ileus. inserting a urinary retention catheter

Peritonitis

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 board-like. What complication does the nurse determine may be occurring at this time? Paralytic ileus Peritonitis Constipation Accumulation of gas

fever abdominal distention sudden, sustained abdominal pain

The nurse is caring for a client with a mechanical intestinal obstruction who is at risk for perforation. For which finding(s) should the nurse monitor the client? Select all that apply. A. high-pitched bowel sounds above the obstructed area B. fever C. abdominal distention D. intermittent, severe pain E. sudden, sustained abdominal pain

Continuous liquid flows from the stoma Stoma is pink and shiny

The nurse is caring for a client with an ileostomy because of inflammatory bowel disease. Which assessment findings indicate to the nurse that the ileostomy is functioning as expected? Select all that apply. A. Slight skin excoriation around the stoma B. Continuous liquid flows from the stoma C. Stoma is edematous and bleeding D. Stoma is pink and shiny E. Formed stool in collection pouch

Oil droplets on the toilet water

The nurse is caring for a client with diarrhea. For which finding will the nurse suspect the diarrhea is caused by pancreatic insufficiency? · Nocturnal diarrhea · Voluminous greasy stools · Oil droplets on the toilet water · Blood, mucus, and pus in the stool

Anal fissure

The nurse is performing a rectal assessment and notices a longitudinal tear or ulceration in the lining of the anal canal. The nurse documents the finding as which condition? · Hemorrhoid · Anal fistula · Anal fissure · Anorectal abscess

Fistulas are common

Which of the following is accurate regarding regional enteritis? · Severe diarrhea · Fistulas are common · Severe bleeding · No narrowing of the colon

Colorectal cancer is the third most common site of cancer in the United States.

Which statement provides accurate information regarding cancer of the colon and rectum? · Colorectal cancer is the third most common site of cancer in the United States. · Colon cancer has no hereditary component. · The incidence of colon and rectal cancer decreases with age. · Rectal cancer affects more than twice as many people as colon cancer.

Hernia

Which term refers to a protrusion of the intestine through a weakened area in the abdominal wall? · Hernia · Tumor · Adhesion · Volvulus

rupture of the appendix.

A client is admitted from the emergency department with complaints of severe abdominal pain and an elevated white blood cell count. The physician diagnoses appendicitis. The nurse knows the client is at greatest risk for: · rupture of the appendix. · ulceration of the appendix. · inflammation of the gallbladder. · emotional distress related to the pain.

Crohn disease

A client presents with an infection in the area between the internal and external sphincters. In which chronic disease is this condition commonly seen? · irritable bowel syndrome · Crohn disease · diverticulosis · ulcerative colitis

Risk for infection

A client with a cyst has been brought for care. The nurse who is contributing to the client's care knows that treatment will be chosen based on what risk? · Risk for bowel incontinence · Risk for constipation · Risk for infection · Risk for impaired tissue perfusion

B. fever C. abdominal distention E. sudden, sustained abdominal pain

The nurse is caring for a client with a mechanical intestinal obstruction who is at risk for perforation. For which finding(s) should the nurse monitor the client? Select all that apply. A. high-pitched bowel sounds above the obstructed area B. fever C. abdominal distention D. intermittent, severe pain E. sudden, sustained abdominal pain

administer an enema

The nurse working in the emergency department is caring for a client with signs and symptoms of appendicitis. Which order from the health care provider should the nurse question? · complete blood count · intravenous antibiotic therapy · nothing by mouth (NPO) · administer an enema

· Attach a Y connector to the tubing for the lipids. · Use a 0.22 micron in-line filter for the parenteral solution. · Use a 1.2 micron in-line filter for the lipids. · Place the connector for lipids to bypass the 0.22 micron filter.

A client is prescribed to receive a 2 in 1 parenteral nutrition solution in combination with lipids. Which actions will the nurse take when administering this nutrition? Select all that apply. · Attach a Y connector to the tubing for the lipids. · Use a 0.22 micron in-line filter for the parenteral solution. · Use a 1.2 micron in-line filter for the lipids. · Place the connector for lipids to bypass the 0.22 micron filter. · Piggyback the parenteral solution into the lipid tubing.