IGGY 7TH EDCH 60 Care of Patients with Inflammatory Intestinal Disorders

A client with Crohn's disease has a draining fistula. Which finding leads the nurse to intervene most rapidly? a. Serum potassium of 2.6 mEq/L b. The client not wanting to eat anything c. White blood cell count of 8200/mm3 d. The client losing 3 pounds in a week

A Fistulas place the client with Crohn's disease at risk for hypokalemia, which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium takes priority.

The nurse is caring for a client with Giardia lamblia infection. Which medication does the nurse anticipate teaching the client about? a. Metronidazole (Flagyl) b. Ciprofloxacin (Cipro) c. Sulfasalazine (Azulfidine) d. Ceftriaxone (Rocephin)

A Flagyl is the drug of choice for Giardia lamblia infection. Cipro and Rocephin are antibiotics used for bacterial infections. Azulfidine is used for ulcerative colitis and Crohn's disease.

The nurse reviews a health teaching for a client with Crohn's disease. Which instruction does the nurse provide for the client? a. "You should have a colonoscopy every few years." b. "You should eat a diet that is high in protein and fiber." c. "You should avoid heavy lifting and tight-fitting clothes." d. "You should take the Asacol whenever you have loose stools."

A Long-term inflammatory bowel disease increases the risk of colon cancer, so regular colonoscopies are recommended. A high-fiber diet is not recommended for clients with Crohn's disease because fiber can further irritate the inner lining of the bowel. Asacol (mesalamine [5-aminosalicylic acid]) should be taken daily, not as needed. Avoiding heavy lifting and tight-fitting clothes is not necessary.

The nurse is caring for a client with a parasitic gastrointestinal infection. What statement by the client indicates a need for further teaching? a. "I will have my housekeeper keep my toilet very clean." b. "I need to shower or bathe every day." c. "I need to have my well water tested." d. "My sexual partner needs to have a stool test."

A Parasitic infections can be transmitted to other people. The client himself or herself should keep the toilet area clean instead of possibly exposing another person to the disease. The other statements are accurate

The nurse is caring for a client who has acute viral gastroenteritis. Which dietary instruction does the nurse provide to the client? a. "Drink plenty of fluids to prevent dehydration." b. "You can have only clear liquids to drink." c. "Milk products will give you extra protein." d. "You can have sips of cola or tea to relieve nausea."

A The client should drink plenty of fluids to prevent dehydration. Clients are not necessarily restricted to clear liquids. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.

The nurse is caring for a client with Crohn's disease and colonic strictures. Which assessment finding requires the nurse to consult the health care provider immediately? a. Distended abdomen b. Temperature of 100.0° F (37.8° C) c. Traces of blood in the stool d. Crampy lower abdominal pain

A The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client's provider should be notified right away. Low-grade fever, bloody diarrhea, and crampy abdominal pain are common symptoms of Crohn's disease.

A client has an anorectal abscess. Which teaching topic does the nurse address as the priority? a. Perineal hygiene b. Comfort measures c. Nutrition therapy d. Antibiotic use

A The priority intervention for a client with an anorectal abscess focuses on maintaining meticulous perineal hygiene to prevent infection. Comfort measures are also important, but are not as high a priority. Nutrition management and antibiotic teaching may or may not be needed.

A nurse is teaching a community group about food poisoning and gastroenteritis. Which statements by the nurse are accurate? (Select all that apply.) a. Rotavirus is more common among infants and younger children. b. Escherichia coli diarrhea is transmitted by contact with infected animals. c. Don't drink water when swimming to prevent E. coli infection. d. All clients with botulism require hospitalization. e. Parasitic diseases may not show up for 1 to 2 weeks after infection.

A, C, D, E

The client asks the nurse how to avoid becoming ill with Salmonella infection again. Which are appropriate responses from the nurse? (Select all that apply.) a. "Wash leafy vegetables carefully before eating or cooking them." b. "Do not ingest water from the garden hose or the pool." c. "Wash your hands before and after using the bathroom." d. "Be sure meat is cooked to the proper temperature." e. "Avoid eating eggs that are sunny side up or undercooked." f. "When eating outdoors, be sure to keep flies off your food."

A, C, D, E, F Salmonella is usually contracted via contaminated eggs, beef, poultry, and green leafy vegetables. It is not transmitted through water in garden hoses or pools. Clients should wash leafy vegetables well, wash hands before and after using the restroom, make sure eggs and meat are cooked properly, and, because it can be transmitted by flies, keep flies off of food.

A nurse is teaching a community group ways to prevent Escherichia coli infection. Which statements made by the nurse are accurate? (Select all that apply.) a. "Wash your hands after any contact with animals." b. "It is not necessary to buy a meat thermometer." c. "Stay away from people who are ill with diarrhea." d. "Use separate cutting boards for meat and vegetables." e. "Avoid swimming in backyard pools and using hot tubs."

A, D Washing hands after contact with animals and using separate cutting boards for meat and other foods will help prevent E. coli infection. The other statements are not related to preventing E. coli infection.

1 The nurse conducts a physical assessment for a client with abdominal pain. Which finding leads the nurse to suspect appendicitis? Severe, steady right lower quadrant (RLQ) pain Abdominal pain that started a day after vomiting began Abdominal pain that increases with knee flexion Marked peristalsis and hyperactive bowel sounds

ANS: A Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has a gastroenteritis. Abdominal pain due to appendicitis decreases with knee flexion. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis.

A nurse is caring for a client hospitalized with botulism. The nurse obtains the following vital signs: temperature—99.8° F (37.6° C), pulse—100, respiratory rate—10 and shallow, and blood pressure—100/62 mm Hg. What action by the nurse is most appropriate? a. Allow the client rest periods without interruption. b. Stay with the client while another nurse calls the physician. c. Check the client's IV rate and document all findings. d. Help the client order appropriate food items from the menu.

B A client with botulism is at risk for respiratory failure. This client's respiratory rate is slow and shallow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. Nothing is allowed by mouth until all respiratory function and swallowing are normal. The nurse should monitor and document the IV infusion per protocol, but this does not take priority. Allowing the client to rest and ordering food items are not appropriate actions.

The nurse is caring for a client with severe ulcerative colitis who has been prescribed adalimumab (Humira). Which client statement indicates that additional teaching about the medication is needed? a. "I will avoid large crowds and people who are sick." b. "I will take this medication with food or milk." c. "Nausea and vomiting are common side effects." d. "I will wash my hands after I play with my dog."

B Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.

The nurse is caring for a client who is having approximately 20 foul-smelling stools each day. Laboratory Gram stain testing indicates the presence of white blood cells (WBCs) and red blood cells (RBCs) in the stool. Which organism does the nurse expect to see in the culture report? a. Helicobacter pylori b. Campylobacter jejuni c. Clostridium botulinum d. Norwalk virus

B Campylobacter gastroenteritis causes foul-smelling diarrhea with up to 20 to 30 stools per day for 7 days. Both RBCs and WBCs are present in a Gram stain of the stools. Infection with Clostridium causes not diarrhea, but constipation, paralysis, and respiratory failure. H. pylori is a common cause of gastric ulcers, not gastroenteritis. Norwalk virus produces milder illness with diarrhea and vomiting.

The nurse provides discharge teaching for a client who was hospitalized for Salmonella food poisoning. Which client statement indicates that additional teaching is needed? a. "I will let my husband do the cooking for my family." b. "I will take the ciprofloxacin (Cipro) until the diarrhea has resolved." c. "I will wash my hands with antibacterial soap before and after each meal." d. "I will make sure that my dishes go straight into the dishwasher after each meal."

B Cipro should be taken for 10 to 14 days to treat Salmonella infection, and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Salmonella should not prepare foods for others because the infection may be spread in this way. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Clients can be carriers for up to 1 year.

The nurse is caring for an older client with Salmonella food poisoning. Which is the priority action of the nurse? a. Monitor vital signs. b. Maintain IV fluids. c. Provide perineal care. d. Initiate Isolation Precautions.

B Dehydration can occur quickly in older clients with Salmonella food poisoning caused by diarrhea, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions, but are of lower priority than fluid replacement. Contact Isolation is not regularly instituted for Salmonella infection. Standard Precautions are usually sufficient.

The nurse is caring for a client who had ileostomy surgery 10 days ago. The client verbalizes concerns that the effluent has not become formed and is still liquid green. Which is the nurse's best response? a. "I will call your health care provider right away because the stool should be semi-solid by now." b. "Your stools will firm up in a few weeks as your body gets used to the ileostomy." c. "You should eat a high-fiber diet to help make the stool bulkier and more solid." d. "You can add buttermilk or yogurt to your diet and avoid carbonated soft drinks."

B Effluent from an ileostomy will become less liquid (but not solid) over time as the body adapts to loss of the large bowel. This process takes time and the client should be reassured of this. Clients with a new ileostomy should avoid high-fiber diets for the first few weeks because blockage of the bowel may occur. Buttermilk, yogurt, and carbonated drinks will not affect this process.

A client underwent the first stage of a restorative proctocolectomy with ileo-anal anastomosis (RPC-IPAA). What topic is a high priority for the nurse to teach? a. Perineal care b. Ostomy care c. Nutrition therapy d. Relaxation techniques

B In the first stage of the RPC-IPAA procedure, the temporary ileostomy is created. Because the effluent is caustic, severe skin irritation can occur. The client needs good instruction on ostomy care and comfort measures. Perineal care is not needed because stool drains through the ostomy. Nutrition therapy and relaxation techniques are not as high a priority as preventing skin damage.

The nurse has taught self-care measures to a client with an anal fissure. Which action by the client requires the nurse to do additional teaching? a. Taking warm sitz baths several times daily b. Administering daily enemas to prevent constipation c. Using bulk-producing agents to aid elimination d. Self-administering anti-inflammatory suppositories

B The client should not use enemas to promote elimination, but rather should rely on bulk-producing agents such as psyllium hydrophilic mucilloid (Metamucil). The other actions are appropriate.

The nurse has completed the teaching session for a client with a new colostomy. Which feedback statement by the nurse is the most appropriate? a. "I realize that you had a tough time today, but it will get easier with practice." b. "You cleaned the stoma well. Now you need to practice putting on the appliance." c. "You seem to understand what I taught you today. What else can I help you with?" d. "You seem uncomfortable. Do you want your daughter to care for your ostomy?"

B The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client.

The nurse conducts a physical assessment for a client with severe right lower quadrant (RLQ) abdominal pain. The nurse notes that the abdomen is rigid and the client's temperature is 101.1° F (38.4° C). Which laboratory value does the nurse bring to the attention of the health care provider as a priority? a. A "left shift" in the white blood cell count b. White blood cell count, 22,000/mm3 c. Serum sodium, 149 mEq/L d. Serum creatinine, 0.7 mg/dL

B This client may have appendicitis based on RLQ pain. A white blood cell count of 22,000/mm3 is severely elevated and could indicate a perforated appendix, as could the fever. The nurse should bring these findings to the provider's attention as soon as possible. A left shift would be expected in uncomplicated appendicitis. The sodium reading is only slightly high; this could be due to hemoconcentration from vomiting or from decreased intake. The creatinine level is normal.

The nurse is caring for a client with perineal excoriation caused by diarrhea from acute gastroenteritis. Which client statement indicates that additional teaching about perineal care is needed? a. "I will rinse my rectal area with warm water after each stool and then apply zinc oxide ointment." b. "I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel." c. "I will take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry." d. "I will clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment."

B Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry.

The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority? a. Skin integrity b. Blood pressure c. Heart rate and rhythm d. Abdominal percussion

C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Abdominal percussion is an important part of physical assessment but has lower priority for this client than heart rate and rhythm.

The nurse is preparing a client with diverticulitis for discharge from the hospital. Which statement by the client indicates that additional teaching is needed? a. "I will ride my bike or take a long walk at least three times a week." b. "I will try to include at least 25 g of fiber in my diet every day." c. "I will take a senna laxative at bedtime to avoid becoming constipated." d. "I will use my legs rather than my back muscles when I lift heavy objects."

C Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining.

The nurse is caring for an older client with gastroenteritis. Which order does the nurse consult with the health care provider about? a. IV 0.45% NS at 50 mL/hr b. Clear liquids as tolerated c. Diphenoxylate hydrochloride/atropine sulfate (Lomotil) orally, after each loose stool d. Acetaminophen (Tylenol), 325-650 mg orally every 4 hr PRN pain

C Lomotil can cause drowsiness and can increase the older client's risk for falls. The nurse should consult with the provider to see if this medication is really necessary and, if an antidiarrheal medication is warranted, what other options might be available. The other orders are appropriate, although the nurse would have to monitor the client's total 24-hour Tylenol dosage to ensure that the client did not receive more than 4000 mg/24 hr.

A client is brought to the emergency department with an abrupt onset of vomiting, abdominal cramping, and diarrhea 2 hours after eating food at a picnic. Which infectious microorganism does the nurse suspect as the probable cause? a. Salmonella b. Giardia lamblia c. Staphylococcus aureus d. Clostridium botulinum

C Staphylococcus can be found in meat and dairy products and can be transmitted to people. Food poisoning occurs, especially if foods are left unrefrigerated over a period of time. Symptoms of Staphylococcus food poisoning include sudden onset of vomiting, abdominal cramping, and diarrhea within 2 to 4 hours. The client's symptoms are not consistent with infection by the other microorganisms.

The nurse is caring for a client who is hospitalized with exacerbation of Crohn's disease. What does the nurse expect to find during the physical assessment? a. Positive Murphy's sign with rebound tenderness b. Dullness in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Abdominal cramping that the client says is worse at night

C The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn's disease. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohn's disease. Nightly worsening of abdominal cramping is not consistent with Crohn's disease. A positive Murphy's sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis.

The nurse is preparing to begin teaching the client about how to care for a new ileostomy. Which consideration is the highest priority for the nurse when planning teaching for this client? a. Informing the client about what to expect with basic ostomy care b. Starting the teaching after the client has received pain medication c. Starting the teaching when the client is ready to look at the stoma d. Making sure that all needed supplies are ready at the client's bedside

C The nurse should wait until the client is ready to look at the ostomy and stoma before initiating teaching about ostomy care. The nurse should monitor clues from the client and encourage him or her to start taking an active role in management. Effective learning will occur only when the learner is ready. The other considerations are of lower priority for the client and nurse.

The nurse is caring for a teenage girl with a new ileostomy. She tells the nurse tearfully that she cannot go to the prom with an ostomy. Which is the nurse's best response? a. "You should get your prom dress one size larger to hide the ostomy appliance." b. "You should avoid broccoli and carbonated drinks so that the pouch won't fill with air under your dress." c. "Let's talk to the enterostomal therapist (ET) about options for ostomy supplies and dress styles so that you can look beautiful for the prom." d. "You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable."

C The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible.

The nurse is teaching a client how to care for a new ileostomy. Which client statement indicates that additional teaching is needed? a. "I will consult the pharmacist before filling any new prescriptions." b. "I will empty the ostomy pouch when it is half-filled with stool or gas." c. "I will wash my hands with antibacterial soap before and after ostomy care." d. "I will call my health care provider if I have not had ostomy drainage for 3 hours."

D A client with an ileostomy should call the provider if no drainage has come from the ostomy in 6 to 12 hours. The other statements indicate good understanding of self-management.

The nurse is caring for a client who is taking mesalamine (5-aminosalicylic acid) (Asacol, Rowasa) for ulcerative colitis. The client has trouble swallowing the pill. Which action by the nurse is most appropriate? a. Crush the pill carefully and administer it to the client in applesauce or pudding. b. Empty the contents of the capsule into applesauce or pudding for administration. c. Contact the client's health care provider to request an order for Asacol suspension. d. Contact the client's health care provider to request an order for Rowasa enemas instead.

D Asacol is enteric coated and should not be crushed, chewed, or broken. If the client is unable to swallow the Asacol pill, Rowasa enemas may be administered instead, with a provider's order. Asacol is not available as a suspension or elixir.

The nurse is caring for a client who has food poisoning that may be the result of Clostridium botulinum infection. Which is the priority nursing assessment for this client? a. Heart rate and rhythm b. Bowel sounds and heart tones c. Fluid balance and urine output d. Oxygen saturation and respiratory rate

D Severe infection with Clostridium botulinum can lead to respiratory failure, so assessments of oxygen saturation and respiratory rate are of high priority for clients with suspected Clostridium botulinum infection. The other assessments may be completed after the respiratory system has been assessed.

The nurse is caring for a client with Crohn's disease who has developed a fistula. Which nursing intervention is the highest priority? a. Monitor the client's hematocrit and hemoglobin. b. Position the client to allow gravity drainage of the fistula. c. Check and record blood glucose levels every 6 hours. d. Encourage the client to consume a diet high in protein and calories.

D The client with Crohn's disease is already at risk for malabsorption and malnutrition. Malnutrition impairs healing of the fistula and immune responses. Therefore, maintaining adequate nutrition is a priority for this client. The client will require 3000 calories per day to promote healing of the fistula. Monitoring the client's blood sugar and hemoglobin levels is important, but less so than encouraging nutritional intake. The client need not be positioned to facilitate gravity drainage of the fistula, because fistulas often are found in the abdominal cavity.

A female client is admitted with an exacerbation of ulcerative colitis. Which laboratory value does the nurse correlate with this condition? a. Potassium, 5.5 mEq/L b. Hemoglobin, 14.2 g/dL c. Sodium, 144 mEq/L d. Erythrocyte sedimentation rate (ESR), 55 mm/hr

D The erythrocyte sedimentation rate (ESR) is an indicator of inflammation, which is elevated during an exacerbation of ulcerative colitis. The normal range for the ESR is 0 to 33 mm/hr. Diarrhea caused by ulcerative colitis will result in loss of potassium and hypokalemia with levels lower than 3.5 mEq/L. Bloody diarrhea will lead to anemia, with hemoglobin levels lower than 12 g/dL in females. The sodium level is normal.

The nurse helps a client with diverticular disease choose appropriate dinner options. Which menu selections are most appropriate? a. Roasted chicken, rice pilaf, cup of coffee with cream b. Spaghetti with meat sauce, fresh fruit cup, hot tea with lemon c. Chicken Caesar salad, cup of bean soup, glass of low-fat milk d. Baked fish with steamed asparagus, dinner roll with butter, glass of apple juice

D Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet.