Chapter 41

After assessing a client with peritonitis, how would the nurse most likely document the client's bowel sounds?

Absent

A nurse is caring for a client admitted with symptoms of an anorectal infection; cultures indicate that the client has a viral infection. The nurse should anticipate the administration of what drug?

Acyclovir

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?

Anal fissure

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

Board-like abdomen

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

A patient with IBD would be encouraged to increase fluids, use vitamins and iron supplements, and follow a diet designed to reduce inflammation. Select the meal choice that would be recommended for a low-residue diet.

Broiled chicken with low-fiber pasta

A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer?

Change in bowel habits

A client informs the nurse of having abdominal pain that is relieved when having a bowel movement. The health care provider diagnosed the client with 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 client's colostomy when the client begins to report cramping. What is the appropriate action by the nurse?

Clamp the tubing and allow client to rest.

What information should the nurse include in the teaching plan for a client being treated for diverticulosis?

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 surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member?

Enterostomal nurse

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

Familial polyposis

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 diluted heparin in a 10 mL syringe once a shift.

A client with Crohn's disease is losing weight. For which reason will the nurse anticipate the client being prescribed parenteral nutrition?

Impaired ability to absorb food

A patient visited a nurse practitioner because he had diarrhea for 2 weeks. He described his stool as large and greasy. The nurse knows that this description is consistent with a diagnosis of:

Intestinal malabsorption.

The nurse is comparing Crohn's disease (regional enteritis) with ulcerative colitis. Which of the following describes Crohn's disease?

Its course is prolonged and variable

A patient is not having daily bowel movements and has begun taking a laxative for this problem. What should the nurse educate the patient about regarding laxative use?

Laxatives should not be routinely taken due to destruction of nerve endings in the colon.

The instructor is teaching a group of students about irritable bowel syndrome (IBS) and antidiarrheal agents, the instructor determines that the teaching was effective when the students identify which of the following as an example of an antidiarrheal agent commonly administered for IBS?

Loperamide

Which of the following is considered a bulk-forming laxative?

Metamucil

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.

The nurse is caring for a client with intussusception of the bowel. What does the nurse understand occurs with this disorder?

One part of the intestine telescopes into another portion of the intestine.

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 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

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

Rectal bleeding

A nurse is caring for a client who had an ileal conduit 3 days earlier. The nurse examines the stoma site and determines that she should consult with the ostomy nurse. Which assessment finding indicates the need for further consultation?

Red, sensitive skin around the stoma site

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?

Right lower quadrant

A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis?

Sigmoidoscopy

A client who has undergone colostomy surgery is experiencing constipation. Which intervention should a nurse consider for such a client?

Suggest fluid intake of at least 2 L/day

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 presents to the emergency department with complaints of acute GI distress, bloody diarrhea, weight loss, and fever. Which condition in the family history is most pertinent to the client's current health problem?

Ulcerative colitis

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

A client is admitted to the emergency department with reports right lower quadrant pain. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the health care provider immediately?

White blood cell (WBC) count 22.8/mm3

An older adult client seeks help for chronic constipation. What factor related to aging can cause constipation in elderly clients?

decrease abdominal strength

A client reports severe pain and bleeding while having a bowel movement. Upon inspection, the health care provider notes a linear tear in the anal canal tissue. The client is diagnosed with a:

fissure

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

Which client requires immediate nursing intervention? The client who:

presents with a rigid, board-like abdomen.

An older adult client in a long-term care facility is concerned about bowel regularity. During a client education session, the nurse reinforces the medically acceptable definition of "regularity." What is the actual measurement of "regular"?

stool consistency and client comfort

A nurse is caring for a client with constipation whose primary provider has recommended senna for the management of this condition. The nurse should provide which of the following education points?

"Avoid taking the drug on a long-term basis."

A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult?

"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread."

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."

A nurse is preparing a presentation for a local community group of older adults about colon cancer. What 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, what would the nurse stress the importance of?

Increasing fluid intake to prevent dehydration

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

Low residue

The nurse is caring for an older adult patient experiencing fecal incontinence. When planning the care of this patient, what should the nurse designate as a priority goal?

Maintaining skin integrity

A client's large bowel obstruction has failed to resolve spontaneously and the client's worsening condition has warranted admission to the medical unit. Which of the following aspect of nursing care is most appropriate for this client?

Preparing the client for surgical bowel resection