Med Surg Ch 58 Coordinating Care for Patients with Intestinal Disorders

What other priority information may the nurse assess in order to care for a patient presenting with abdominal pain and watery, bloody stools? A. Psychosocial history, family history, vital signs, previous bowel history B. Vaccine history, medication history, heart rate C. Orientation status, ability to participate in sports, blood pressure D. Cranial nerves, sensation, skin assessment

Answer: A Rationale: All of these are important assessments for the nurse. However, IBD often show a familial tendency and it must be noted whether there is any family history. Psychosocial history is important as IBD patients often have many psychosocial issues and symptoms are exacerbated during stress. Vital signs are important as during the inflammatory process, the patient if often febrile. The patient's previous bowel history is used to determine the onset. A is the correct answer.

The patient with which condition is at the highest risk for fistula formations? A. Crohn's disease B. Ulcerative colitis C. Diverticulitis D. Irritable bowel disease

Answer: A Rationale: Because Crohn's disease is transmural, affecting all layers of the bowel, it can develop sinus tracts leading to fistula formation.

The nurse is caring for a postoperative patient who has had surgery for a ventral hernia repair. The nurse is reinforcing postoperative care teaching and asks the patient to verbalize what was taught to him. Which statement requires the nurse to clarify the patient's perception of the teaching? A. "I should turn, cough, and deep breathe every 2 hours." B. "I should avoid heavy lifting until my provider tells me that I can lift again." C. "I can use ice packs and scrotal support for scrotal swelling." D. "I will observe my incision for redness, heat, swelling, and drainage. I will report these signs to my provider at once."

Answer: A Rationale: Coughing will cause undue pressure on the surgical site and possibly lead to recurrence of the hernia. If coughing is necessary, the surgical site should be splinted with pillows to prevent pressure on the site.

What clinical manifestations are consistent with a diagnosis of ulcerative colitis? (Select all that apply.) A. Bloody stools B. Constipation C. Belching D. Chest pain E. Dysphagia

Answer: A Rationale: The stool of patients with ulcerative colitis is usually watery diarrhea, with blood in the stool. Constipation is associated with disorders that slow GI motility, such as opioids. Belching is usually associated with disorders of the upper gastrointesti- nal system, and chest pain is associated with GERD and hiatal hernias.

The nurse recognizes which findings as diagnostic for IBS? A. Rome III and/or Manning criteria B. CT scan of the abdomen shows inflammatory process C. Blood urea nitrogen and creatinine are elevated D. Patient has abdominal pain and a psychiatric diagnosis

Answer: A Rationale: There are two tools used for the diagnosis of IBS: the Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders and the Manning criteria for the diagnosis of irritable bowel syndrome. The other tests may be used, but are not as specific.

The nurse correlates strangulated hernias to which finding? A. Impede blood flow of the intestines B. Result from pressure on an old surgical incision C. Are more common in infants D. A hernia in which contents can be placed back into place

Answer: A Rationale: When the intestine protruding through an abnormal opening cannot be placed easily back into the abdominal cavity manually or by lying down, it is known as irreducible or incarcerated. If the blood sup- ply is obstructed, it is then known as a strangulated hernia, and the patient may present with symptoms of an intestinal obstruction. This is a medical emergency, and the patient must be prepared for surgery immedi- ately to prevent gangrene from developing

Which interventions are considered conservative treatments for hemorrhoids? (Select all that apply.) A. Hemorrhoid creams and ointments B. Sitz baths C. Over-the-counter analgesics D. Cryosurgery E. Rubber-band ligation

Answer: A, B, and C Rationale: Treatment of hemorrhoids is usually conser- vative and involves relief of symptoms and associated pain. Cold packs and sitz baths (warm water baths covering the hips and buttocks) three or four times a day reduce some swelling and pain. There are a num- ber of over-the-counter preparations available in creams and suppositories used to treat hemorrhoids. Rubber band ligation and cryosurgery are surgical in- terventions for higher grade hemorrhoids.

A patient has just been brought to the emergency department by emergency medical services after a motor vehicle accident. What is the first thing the nurse should do? A. Ask the patient if he or she is in pain B. Mental status examination and vital signs C. Ask the patient to move all extremities D. Order laboratory tests

Answer: B

The nurse is caring for a patient with colorectal cancer who just had a total colectomy with placement of a permanent ileostomy. Which nursing diagnosis is a priority for the immediate postoperative period? A. Disturbed body image B. Acute pain C. Potential for infection D. Knowledge deficit

Answer: B Rationale: Adequate pain management is necessary for the patient to return to an optimal level of functioning and to prevent postoperative complications, such as atelectasis. The other nursing diagnoses are relevant, but acute pain is the priority in the immediate post- operative period.

The nurse is caring for a patient in the emergency department with abdominal pain, fever, nausea, and vomiting. The patient is suspected of having appendicitis. What assessments may the provider perform to confirm diagnosis? A. Flat-plate x-ray of the abdomen, chemistry panel B. CT scan, complete blood count (CBC), abdominal assessment for rebound tenderness C. Give patient a laxative to see if symptoms improve D. Colonoscopy, esophagogastroduodenoscopy (EGD), and endoscopic retrograde cholangiopancreatogram (ERCP)

Answer: B Rationale: In patients with appendicitis, as the inflam- matory process proceeds, pain is shifted to the right lower quadrant of the abdomen and becomes more severe and steady in the area of McBurney's point. When applying and releasing pressure to this area, if the patient notes increased pain when pressure is released, this is called rebound tenderness and is another indication of appendicitis. An abdominal CT may indicate inflammation or enlargement of the appendix. While a flat plate x-ray of the abdomen and serum chemistries may be ordered, they are diagnosti- cally definitive. Laxatives are contraindicated due to the risk of perforation. There is no indication for colonoscopy, EGD, or ERCP in the patient with appendicitis.

A patient has just been brought to the emergency department by emergency medical services after a motor vehicle accident. What is the first thing the nurse should do? A. Ask the patient if he or she is in pain. B. Mental status examination and vital signs. C. Ask the patient to move all extremities. D. Order laboratory tests.

Answer: B Rationale: Once the trauma patient's airway, breathing, and circulation have been thoroughly assessed, then the patient needs to be evaluated for signs of hemorrhage, shock, and peritonitis. Vital signs and mental status examination are priority nursing assessments. The clinical manifestations vary widely according to the organ of injury, and assessment includes the presence, location, and quality of any pain experienced by the patient.

A patient is admitted to the hospital for treatment for diverticulitis. The nurse recognizes which interventions appropriate for this patient? A. High-fiber diet, ambulate frequently, IV fluids, pain medications B. Antibiotics, IV fluids, NPO, NG tube, pain medications C. Laxatives, enemas, diet, pain medications D. Surgery with follow-up physical therapy

Answer: B Rationale: Patients with diverticulitis who are hospital- ized are treated with broad-spectrum antibiotics, IV fluids, and placed NPO to allow the bowel to rest. The patient may have a nasogastric (NG) tube for bowel decompression. Laxatives and enemas should be avoided because they increase intestinal motility. Pain medications may be given as needed, and opiates are frequently needed. If patients develop complications such as perforation, hemorrhage, obstruction, or abscess, they may require surgery to remove the diseased portion of the colon.

Which information does the nurse include in the teaching to Jack related to his diagnosis of ulcerative colitis? A. "Decrease fluid intake to decrease diarrhea." B. "Spread out your meals to six times per day." C. "Avoid foods high in potassium." D. "Increase your intake of simple sugars for energy."

Answer: B Rationale: The patient is encouraged to eat small, frequent meals in order to decrease gastric motility and decrease diarrhea. The patient is at risk for fluid volume deficit, so fluids are not decreased. Loss of potassium may be increased with diarrhea and may require supplementation. Simple sugars increase gastric motility and can exacerbate diarrhea.

A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, "I need to have a bowel movement." The nurse is aware this is the first bowel movement. Which priority safety action should the nurse take? A. Obtain a bedside commode for the client to use B. Stay with the client while providing privacy C. Make sure the call light is in reach to signal completion D. Gather supplies to collect a stool sample for the laboratory

Answer: B The first bowel movement after surgery may be painful, and the patient needs to take an analgesic prior. Fainting has occurred during bowel movements early after surgery because of the intensity of the pain along with vagal stimulation. Because of the fainting risk, staying with the patient is an important safety measure.

Where is the primary location of nutrient absorption in the gastrointestinal system? A. Stomach B. Small intestine C. Large intestine D. Pancreas

Answer: B The small intestine's primary function is digestion and absorption of nutrients across the intestinal wall into the circulation.

A patient presents to the ED with complaints of abdominal pain and watery, bloody stools. What diagnostic tests does the nurse expect to be ordered on the basis of these symptoms? A. CBC, MRI, electrolytes, stool analysis B. CT scan, MRI, chemistry panel, ERCP C. Colonoscopy, CBC, wireless capsule endoscopy, upper GI endoscopy D. BUN, creatinine, ultrasound, chest x-ray

Answer: C Rationale: Bloody stools are more common with ulcerative colitis. Therefore a CBC should be ordered. Wireless capsule endoscopy evaluates the portion between what can be seen with upper GI endoscopy and the colonoscopy. Ulcerative colitis affects only the large intestine but Crohn's disease affects anywhere from mouth to anus and must be ruled out before a surgical decision can be made. Blood, mucus, and pus are common with ulcerative colitis but not with Crohn's.

An 80-year-old patient is admitted to the hospital for diverticulitis. The family states that the family member isn't acting normally. The patient does not have specific complaints. The nurse correlates this data to which characteristics of older adults? A. They typically complain of a lot of pain with diverticulitis. B. They often have referred pain to another site. C. They may exhibit a change in mental status before any other symptoms occur. D. They will be having other symptoms such as nausea and vomiting.

Answer: C Rationale: The first sign that may appear in the elderly is a change in mental status. Baseline temper- ature is often decreased from normal in the older adult. Therefore, one of the most common signs of infection may not be apparent in the older adult and the patient may present with increased confusion, falling, and anorexia.

The nurse is caring for a postoperative patient who has had surgery for hemorrhoids. What information should be taught to the patient in the postoperative period? A. Apply dry heat to the surgical area as soon as you return home. B. Maintain a low-fiber diet. C. Contact the provider if urinary retention occurs. D. No bowel movement is expected for 3 days.

Answer: C Rationale: Urinary retention may occur because of rectal spasms and pain. The nurse needs to make sure the patient has urinated prior to leaving the outpatient facility. Patients also need to be taught to call the physician immediately if they are unable to urinate once they return home.

Reabsorption of the majority of the water from the gastrointestinal tract occurs in the: A. Liver B. Small intestine C. Large intestine D. Rectum

Answer: C The large intestine's primary function is absorption of water. There is also some absorption of electrolytes although not to the extent of absorption in the small intestine.

What is the most distal section of the small intestine? A. Cecum B. Duodenum C. Ileum D. Jejunum

Answer: C There are three sections to the small intestine: • Duodenum—attaches to the pylorus and is approximately 10 in. (25 cm) long • Jejunum—approximately 8 ft (2.5 m) • Ileum—approximately 12 ft (3.5 m)

The nurse is caring for a patient who has had surgery for colon cancer and has a permanent colostomy. Which assessment must the nurse report to the provider immediately? A. The stoma is reddish pink and moist. B. The stoma is flat against the skin. C. The stoma has not expelled any flatus or stool in the first 24 hours. D. The stoma is dark and bluish in appearance.

Answer: D Rationale: If the stoma begins to show signs of ischemia (dark red, purplish, or black color) or unusual bleeding, the physician should be notified immediately. This is a sign that there is little or no blood flow to the stoma.

On the basis of the presenting symptoms of abdominal pain with watery, bloody stools, what will the nurse consider a priority to notify the provider? A. Height and weight B. Temperature C. Blood pressure D. Hemoglobin and hematocrit

Answer: D Rationale: The patient's hemoglobin is 7.6 and hematocrit of 21.2. This probably accounts for the pulse of 133. His weight is on the low end of normal for his height but not a priority of care. His temperature is 100.5 F (38 C) due to the inflammatory process and the body's immune system at work. The blood pressure is of no concern. The nurse should expect the physician to address the potential of Jack to receive blood products for his hemoglobin and hematocrit.

Of the following three patients, which one would the nurse see first: A. 78-year-old female with diverticulitis. The patient had just arrived from the emergency department at the end of the previous shift. In report, the previous nurse states that the patient had arrived 1 hour prior to shift change. In the emergency department, the patient had abdominal x-rays and CT scan completed. A nasogastric tube is in place and the patient is NPO. Pain medication has been given although the patient continues to complain of generalized abdominal pain and is holding their abdomen. The family states that her mental status has changed with increased confusion over the past 48 hours. B. 22-year-old female with complications associated with Crohn's disease. She has a PCA pump for pain management that the patient says is not relieving her pain. She has a medication ordered for breakthrough pain in which she requests every 2 hours. It is now shift change and she is requesting her medication for breakthrough pain. She has called the nurses' station three times in the last 15 minutes. C. 60-year-old male with colon cancer who had surgery three days ago. The previous nurse reports that vital signs are within normal limits, patient slept most of the night with no complaints of pain. He has had training from the Wound Ostomy Continence Nurse (WOCN) on how to care for his ostomy and is emptying it on his own. He ambulates the halls independently.

Answer: Patient A Rationale: Although the patient with Crohn's is calling the nurses' station frequently requesting pain medica- tion, be aware that the patient with diverticulitis may be experiencing a ruptured diverticulum with peritonitis. This patient should be assessed first as the physician needs to be notified of their pain unrelieved from medication, guarding behavior, and change in mental status. The patient requesting pain medication can be delegated to another nurse to take care of while you are assessing a more urgent situation. The patient with colon cancer appears to be the most stable and can be seen last.