Prep U Ch. 47 Crohn and Ulcerative Colitis

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? a) Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. b) The appendix may develop gangrene and rupture, especially in a middle-aged client. c) Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. d) Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.

A (A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Elderly, not middle-aged, clients are especially susceptible to appendix rupture.)

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which statement best indicates that the disease process is under control? a) The client exhibits signs of adequate GI perfusion. b) The client maintains skin integrity. c) The client expresses positive feelings about himself. d) The client verbalizes a manageable level of discomfort.

A (Adequate GI perfusion can be maintained only if Crohn's disease is controlled. If the client experiences acute, uncontrolled episodes of Crohn's disease, impaired GI perfusion may lead to a bowel infarction. Positive self-image, a manageable level of discomfort, and intact skin integrity are expected client outcomes, but aren't related to control of the disease.)

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: a) increasing fluid intake to prevent dehydration. b) consuming a low-protein, high-fiber diet. c) taking only enteric-coated medications. d) wearing an appliance pouch only at bedtime.

A (Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can't absorb them after an ileostomy.)

A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, blood pressure of 100/80 mm Hg, pulse rate of 88 beats/minute, respiratory rate of 20 breaths/minute, temperature 100° F (37.8° C). The nurse suspects the client will be diagnosed with: a) inflammatory bowel disease (IBD). b) colorectal cancer. c) diverticulitis. d) liver failure.

A (IBD is a collective term for several GI inflammatory diseases with unknown causes. The most prominent sign of IBD is mild diarrhea, which sometimes is accompanied by fever and abdominal discomfort. Colorectal cancer is usually diagnosed after the client complains of bloody stools; the client will rarely have abdominal discomfort. A client with diverticulitis commonly states he has chronic constipation with occasional diarrhea, nausea, vomiting, and abdominal distention. Jaundice, coagulopathies, edema, and hepatomegaly are common signs of liver failure.)

A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patient's stools will have what characteristics? A) Watery with blood and mucus B) Hard and black or tarry C) Dry and streaked with blood D) Loose with visible fatty streaks

Ans: A Feedback: The predominant symptoms of ulcerative colitis are diarrhea and abdominal pain. Stools may be bloody and contain mucus. Stools are not hard, dry, tarry, black or fatty in patients who have ulcerative colitis.

A nurse is providing care for a patient whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis? A) Encourage the patient to conduct online research into colostomies. B) Engage the patient in the care of the ostomy to the extent that the patient is willing. C) Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem. D) Emphasize the fact that the colostomy is temporary measure and is not permanent.

Ans: B Feedback: For some patients, becoming involved in the care of the ostomy helps to normalize it and enhance familiarity. Emphasizing the benefits of the intervention is unlikely to improve the patient's body image, since the benefits are likely already known. Online research is not likely to enhance the patient's body image and some ostomies are permanent.

A patient has had an ileostomy created for the treatment of irritable bowel disease and the patient is now preparing for discharge. What should the patient be taught about changing this device in the home setting? A) Apply antibiotic ointment as ordered after cleaning the stoma. B) Apply a skin barrier to the peristomal skin prior to applying the pouch. C) Dispose of the clamp with each bag change. D) Cleanse the area surrounding the stoma with alcohol or chlorhexidine.

Ans: B Feedback: Guidelines for changing an ileostomy appliance are as follows. Skin should be washed with soap and water, and dried. A skin barrier should be applied to the peristomal skin prior to applying the pouch. Clamps are supplied one per box and should be reused with each bag change. Topical antibiotics are not utilized, but an antifungal spray or powder may be used

A nurse caring for a patient with a newly created ileostomy assesses the patient and notes that the patient has had not ostomy output for the past 12 hours. The patient also complains of worsening nausea. What is the nurse's priority action? A) Facilitate a referral to the wound-ostomy-continence (WOC) nurse. B) Report signs and symptoms of obstruction to the physician. C) Encourage the patient to mobilize in order to enhance motility. D) Contact the physician and obtain a swab of the stoma for culture.

Ans: B Feedback: It is important to report nausea and abdominal distention, which may indicate intestinal obstruction. This requires prompt medical intervention. Referral to the WOC nurse is not an appropriate short-term response, since medical treatment is necessary. Physical mobility will not normally resolve an obstruction. There is no need to collect a culture from the stoma, because infection is unrelated to this problem

A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient? A) Spinach B) Tofu C) Multigrain bagel D) Blueberries

Ans: B Feedback: Nutritional management of inflammatory bowel disease requires ingestion of a diet that is bland, low-residue, high-protein, and high-vitamin. Tofu meets each of the criteria. Spinach, multigrain bagels, and blueberries are not low-residue.

An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform? A) Encourage the patient to take stool softener daily. B) Assess the patient's food and fluid intake. C) Assess the patient's surgical history. D) Encourage the patient to take fiber supplements.

Ans: B Feedback: The nurse should follow the nursing process and perform an assessment prior to interventions. The patient's food and fluid intake is more likely to affect bowel function than surgery.

26. A patient's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather that ulcerative colitis, as the cause of the patient's signs and symptoms? A) A pattern of distinct exacerbations and remissions B) Severe diarrhea C) An absence of blood in stool D) Involvement of the rectal mucosa

Ans: C Feedback: Bloody stool is far more common in cases of UC than in Crohn's. Rectal involvement is nearly 100% in cases of UC (versus 20% in Crohn's) and patients with UC typically experience severe diarrhea. UC is also characterized by a pattern of remissions and exacerbations, while Crohn's often has a more prolonged and variable course.

A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the patient's coping after discharge? A) The family's ability to take care of the patient's special diet needs B) The family's ability to monitor the patient's changing health status C) The family's ability to provide emotional support D) The family's ability to manage the patient's medication regimen

Ans: C Feedback: Emotional support from the family is key to the patient's coping after discharge. A 21-year-old would be expected to self-manage the prescribed medication regimen and the family would not be primarily responsible for monitoring the patient's health status. It is highly beneficial if the family is willing and able to accommodate the patient's dietary needs, but emotional support is paramount and cannot be solely provided by the patient alone.

A patient's colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the patient has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurse's most appropriate response to this observation? A) Ensure that the patient knows that he or she will be responsible for care after discharge. B) Reassure the patient that many people are fearful after the creation of an ostomy. C) Acknowledge the patient's reluctance and initiate discussion of the factors underlying it. D) Arrange for the patient to be seen by a social worker or spiritual advisor.

Ans: C Feedback: If the patient is reluctant to participate in ostomy care, the nurse should attempt to dialogue about this with the patient and explore the factors that underlie it. It is presumptive to assume that the patient's behavior is motivated by fear. Assessment must precede referrals and emphasizing the patient's responsibilities may or may not motivate the patient.

A nurse is working with a patient who is learning to care for a continent ileostomy (Kock pouch). Following the initial period of healing, the nurse is teaching the patient how to independently empty the ileostomy. The nurse should teach the patient to do which of the following actions? A) Aim to eventually empty the pouch every 90 minutes. B) Avoid emptying the pouch until it is visibly full. C) Insert the catheter approximately 5 cm into the pouch. D) Aspirate the contents of the pouch using a 60 mL piston syringe.

Ans: C Feedback: To empty a Kock pouch, the catheter is gently inserted approximately 5 cm to the point of the valve or nipple. The length of time between drainage periods is gradually increased until the reservoir needs to be drained only every 4 to 6 hours and irrigated once each day. It is not appropriate to wait until the pouch is full, and this would not be visible. The contents of the pouch are not aspirated.

A nurse is talking with a patient who is scheduled to have a hemicolectomy with the creation of a colostomy. The patient admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. Which of the following nursing actions is most appropriate? A) Reassure the patient that the procedure is relatively low risk and that patients are usually successful in adjusting to an ostomy. B) Provide the patient with educational materials that match the patient's learning style. C) Encourage the patient to write down these concerns and questions to bring forward to the surgeon. D) Maintain an open dialogue with the patient and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

Ans: D Feedback: A wound-ostomy-continence (WOC) nurse is a registered nurse who has received advanced education in an accredited program to care for patients with stomas. The enterostomal nurse therapist can assist with the selection of an appropriate stoma site, teach about stoma care, and provide emotional support. The surgeon is less likely to address the patient's psychosocial and learning needs. Reassurance does not address the patient's questions, and education may or may not alleviate anxiety.

Which of the following is a true statement regarding regional enteritis (Crohn's disease)? a) It has a progressive disease pattern. b) The clusters of ulcers take on a cobblestone appearance. c) The lesions are in continuous contact with one another. d) It is characterized by lower left quadrant abdominal pain.

B (The clusters of ulcers take on a cobblestone appearance. It is characterized by remissions and exacerbations. The pain is located in the lower right quadrant. The lesions are not in continuous contact with one another and are separated by normal tissue.)

A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left upper quadrant b) Right lower quadrant c) Left lower quadrant d) Right upper quadrant

B (The pain of acute appendicitis localizes in the right lower quadrant (RLQ) at McBurney's point, an area midway between the umbilicus and the right iliac crest. Often, the pain is worse when manual pressure near the region is suddenly released, a condition called rebound tenderness.)

The nurse is caring for a patient who is undergoing diagnostic testing for suspected malabsorption. When taking this patient's health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis? A) Recurrent constipation coupled with weight loss B) Foul-smelling diarrhea that contains fat C) Fever accompanied by a rigid, tender abdomen D) Bloody bowel movements accompanied by fecal incontinence

B Feedback: The hallmarks of malabsorption syndrome from any cause are diarrhea or frequent, loose, bulky, foul-smelling stools that have increased fat content and are often grayish (steatorrhea). Constipation and bloody bowel movements are not suggestive of malabsorption syndromes. Fever and a tender, rigid abdomen are associated with peritonitis.

A 16-year-old presents at the emergency department complaining of right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this patient's nursing care, the nurse should prioritize what nursing diagnosis? A) Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Oral Intake B) Risk for Infection Related to Possible Rupture of Appendix C) Constipation Related to Decreased Bowel Motility and Decreased Fluid Intake D) Chronic Pain Related to Appendicitis

B Feedback: The patient with a diagnosis of appendicitis has an acute risk of infection related to the possibility of rupture. This immediate physiologic risk is a priority over nutrition and constipation, though each of these concerns should be addressed by the nurse. The pain associated with appendicitis is acute, not chronic.

The nurse is caring for a patient diagnosed with abdominal perforation. Which of the following is a clinical manifestation of this disease process? a) Normal erythrocyte sedimentation rate (ESR) b) Subnormal temperature c) Hypotension d) Bradycardia

C (Clinical manifestations include hypotension, increased temperature, tachycardia, and elevated ESR.)

The nurse is teaching a patient with an ostomy how to change the pouching system. Which of the following should the nurse include in the teaching of a patient with no peristomal skin irritation? a) Apply Kenalog spray b) Apply barrier powder c) Dry skin thoroughly after washing d) Dust with nystatin powder

C (The nurse should teach the patient without peristomal skin irritation to dry the skin thoroughly after washing. Barrier powder, Kenalog spray, and nystatin powder are used when there is peristomal skin irritation and/or fungal infection.)

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma? a) "The stoma should appear dark and have a bluish hue." b) "The stoma should remain swollen distal to the abdomen." c) "At first, the stoma may bleed slightly when touched." d) "A burning sensation under the stoma faceplate is normal."

C (The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation u)nder the faceplate is abnormal and indicates skin breakdown.)

The nurse working in the ED is evaluating a patient for signs and symptoms of appendicitis. Which of the patient's signs/symptoms should the nurse include in the report to the physician on the patient's signs/symptoms of appendicitis? a) Left lower quadrant pain b) Pain when pressure is applied to the right lower quadrant of the abdomen c) High fever d) Nausea

D (Nausea is typically associated with appendicitis with or without vomiting. Pain is generally felt in the right lower quadrant. Rebound tenderness, or pain felt with release of pressure applied to the abdomen, may be present with appendicitis. Low-grade fever is associated with appendicitis.)

A client with complaints of right lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the physician immediately? a) Hematocrit 42% b) Serum sodium 135 mEq/L c) Serum potassium 4.2 mEq/L d) White blood cell (WBC) count 22.8/mm3

D (The nurse should report the elevated WBC count. This finding, which is a sign of infection, indicates that the client's appendix might have ruptured. Hematocrit of 42%, serum potassium of 4.2 mEq/L, and serum sodium of 135 mEq/L are within normal limits. Alterations in these levels don't indicate appendicitis.)

Post appendectomy, a nurse should assess the patient for abdominal rigidity and tenderness, fever, loss of bowel sounds, and tachycardia, all clinical signs of: 1. A pelvic abscess. 2. Peritonitis 3. An ileus. 4. An abscess under the diaphragm.

Peritonitis Peritonitis is inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera. Peritonitis is typically a life-threatening emergency that requires prompt surgical intervention, and typically involves postoperative critical care monitoring due to the risk of sepsis, organ failure, and subsequent infections.