Chapter 47: Bowel Elimination (Bowel Elimination)

A student nurse is learning about the various factors that influence the process of bowel elimination. Which statement if made by the student nurse indicates a need for further learning?

*A. "A woman should drink at least 1 L of fluid to maintain normal bowel elimination."* B. "Prolonged emotional stress increases peristalsis, causing diarrhea and gaseous distension." C. "Older adults may have difficulty in controlling defecation due to weakened muscle tone in the perineal floor and anal sphincter." D. "A position that allows a person to lean forward exerts intraabdominal pressure, contracts the gluteal muscles, and facilitates easy defecation." Rationale: Various factors such as fluid intake, stress, age, and position during defecation influence the process of bowel elimination. A fluid intake of 2.2 L/day is recommended for women. During emotional stress, the digestive process is accelerated, and peristalsis is increased; this may cause diarrhea and gaseous distension. In older adults, muscle tone in the perineal floor and anal sphincter weakens, which causes difficulty in controlling defecation. Squatting allows a person to lean forward, exert intraabdominal pressure, and contract the gluteal muscles. This position facilitates easy defecation. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect. Pg. 1151

The primary health care provider prescribes guaiac fecal occult blood testing for a patient who reports constipation and a family history of colon cancer. Which instruction should be provided to the patient?

*A. "Avoid eating red meat for 3 days before testing."* B. "Repeat the test at least two times on two separate bowel movements." C. "Take vitamin C supplements and citrus fruits and juices before the test." D. "Stop taking aspirin, ibuprofen, naproxen, or other nonsteroidal antiinflammatory drugs for 4 days before the test." Rationale: A patient who is scheduled for guaiac fecal occult blood testing should be instructed to avoid eating red meat for 3 days before testing to prevent altered test results. This test should be repeated at least three times on three separate bowel movements. The patient should also avoid vitamin C supplements and citrus fruits and juices for 3 days before the test to prevent a false-negative result. The nurse should also instruct the patient to stop taking aspirin, ibuprofen, naproxen, or other nonsteroidal antiinflammatory drugs for 7 days, not 4 days, before the test to prevent a false-positive test result. Pg. 1156

Which medication is used to treat hyperactive bowel disorder?

*A. Atropine* B. Polycarbophil C. Casanthranol D. Docusate calcium Rationale: Atropine is an anticholinergic drug that inhibits gastric acid secretion and depresses gastrointestinal motility. It is used to treat patients with hyperactive bowel disorder. Polycarbophil is used to treat constipation. Docusate calcium is a stool softener and is used as a short-term therapy to relieve straining on defecation. Casanthranol is used to cleanse and prepare the bowel for diagnostic procedures. Pg. 1163

Which are defining characteristics of constipation? Select all that apply.

*A. Firm left abdominal quadrant* *B. Feeling of abdominal fullness* *C. No bowel movement for 4 days* D. Difficulty controlling the urge to defecate E. Abdominal distention and severe, sharp pain Rationale: A firm left abdominal quadrant, feeling of abdominal fullness, and no bowel movement for 4 days are defining characteristics of constipation. Difficulty controlling the urge to defecate indicates diarrhea. Abdominal distention and severe, sharp pain are characteristics of flatulence. Pg. 1160

A nurse is preparing to administer an enema to a patient who is scheduled for a colonoscopy. Which action taken by the nurse may lead to a complication?

*A. Giving the enema with the patient sitting on the toilet* B. Giving the enema with the patient positioned on a bedpan C. Refraining from sterile technique while administering the enema D. Asking the patient to retain the enema solution for a specific length of time Rationale: The nurse should not give an enema to a patient sitting on the toilet because the position of the rectal tubing could injure the rectal wall. When giving an enema to an immobilized patient, it is always recommended that the patient be positioned on a bedpan. The use of sterile technique is not necessary when administering an enema, because the colon already contains bacteria. However, the nurse should wear gloves to prevent the transmission of fecal microorganisms. It is appropriate to ask the patient to retain the enema solution for a specific length of time before defecation. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. Pg. 1166

The nurse is reviewing the records of a patient who has chronic constipation. The record states that the patient has type 3 stools according to the Bristol stool form scale. What would be the characteristic of the stool?

*A. Like a sausage but with cracks on the surface* B. Like a sausage or snake, smooth and soft C. Soft blobs with clear-cut edges D. Sausage-shaped but lumpy Rationale: Type 3 stools are like a sausage but with cracks on the surface. Type 4 stools are like a sausage or a snake, and are smooth and soft. Types 5 stools are soft blobs with clear-cut edges. Type 2 stools are sausage-shaped but lumpy. Pg. 1155

A patient is admitted to the hospital with constipation. Which could be a possible reason?

*A. Reduced fluid intake* B. Vigorous exercise C. Antibiotic use via any route D. Food allergies Rationale: A reduced fluid intake may make the stool hard and difficult to pass, causing constipation. A lack of exercise usually results in constipation due to slow peristalsis. Antibiotic use destroys the intestinal flora and causes diarrhea. Food allergies also tend to induce diarrhea by increasing the peristalsis. Pg. 1151

Which type of enema may cause electrolyte imbalances or damage to the intestinal mucosa in pregnant women and older adults?

*A. Soapsuds enema* B. Tap water enema C. Oil-retention enema D. Normal saline enema Rationale: Soapsuds enemas may cause electrolyte imbalances or damage to the intestinal mucosa in pregnant women and older adults. Repeated use of tap-water enemas may cause water toxicity or circulatory overload. Oil-retention enemas and normal saline enemas may not have any adverse effect. Normal saline enemas are the safest. Pg. 1164

The health care provider prescribes methylcellulose to a patient with chronic constipation. Which instruction provided by the nurse will help prevent complications?

A. "Do not use the medication on a regular basis." *B. "Mix the powder with 250 mL of water or juice and swallow it quickly."* C. "Report to the health care provider if you do not pass stool within 8 to 10 hours of taking the medication." D. "Stop taking the medication if you note increased gas formation and flatus when you first start taking it." Rationale: Methylcellulose is a bulk-forming stool softener that absorbs water and increases solid intestinal bulk. It is a drug of choice for chronic constipation and is available in powder form. The nurse should instruct the patient to mix the powder with at least 250 mL of water or juice and swallow it quickly; if not, it could cause constipation. The nurse should advise patients that prescribed stimulant laxatives should only be taken occasionally to prevent dependence on the stimulus for defecation. Methylcellulose may cause the passage of stool 12 to 24 hours after taking the medication. Therefore, the patient need not report to the health care provider if he or she does not pass stool within 8 to 10 hours of taking the medication. Increased gas formation and flatus may occur when the patient first starts taking methylcellulose; this will subside after 4 or 5 days. Therefore, the nurse should not instruct the patient to stop taking the medication in such situations. Pg. 1165

A nurse is caring for four patients. While collecting stool specimens for laboratory examination, the nurse observes the stool colors. Which patient does the nurse suspect to be taking iron supplements?

A. A *B. B* C. C D. D Rationale: Black or tarry stool indicates iron ingestion or gastrointestinal bleeding; therefore, patient B is most likely to be taking iron supplements. White or clay-colored stool indicates an absence of bile. Red stool may indicate gastrointestinal bleeding, hemorrhoids, or ingestion of beets. Brown stool is a normal finding. Pg. 1157

Which patient has the highest risk of constipation?

A. A patient who is taking antibiotics *B. A patient who is taking opioid analgesics* C. A patient who has undergone endoscopy D. A patient who drinks only 1.5 L of fluids per day Rationale: Opioid analgesics slow peristalsis and contractions, thereby causing constipation. Therefore, a patient taking opioid analgesics has the highest risk of constipation. A patient who is taking antibiotics may have diarrhea because antibiotics decrease intestinal bacterial flora, resulting in diarrhea. Patients who have undergone diagnostic procedures that require visualization of the gastrointestinal tract may experience increased gas or loose stools, not constipation. A person should drink at least 1.5 L of fluids per day to avoid constipation. Pg. 1151

Where does normal defecation begin?

A. Anus *B. Colon* C. Stomach D. Small intestine Rationale: Normal defecation begins with movement in the left colon, moving stool toward the anus. It does not begin in the anus, stomach, or small intestine. Pg. 1150

The nurse is caring for a patient with a colostomy. Which intervention is most important?

A. Cleansing the stoma with hot water B. Inserting a deodorant tablet in the stoma bag *C. Selecting a bag with an appropriate-size stoma opening* D. Wearing sterile gloves while caring for the stoma Rationale: The opening of the appliance should be no larger than 0.15 to 0.3 cm (1/16 to 1/8 in) surrounding the stoma to ensure that the skin around the stoma is protected from the enzymes present in the effluent without impinging the stoma. Pg. 1168

Which medication may be used to promote defecation?

A. Codeine *B. Laxatives* C. Loperamide D. Opium tincture Rationale: Laxatives are often prescribed to promote defecation in patients with constipation. Codeine and opium tincture may be used to manage chronic severe diarrhea in patients with Crohn's disease, ulcerative colitis, or acquired immunodeficiency syndrome. Loperamide is also an antidiarrheal agent. Pg. 1163

Which bowel elimination problem is associated with abdominal fullness, cramping, distention, and severe, sharp pain?

A. Diarrhea *B. Flatulence* C. Hemorrhoids D. Fecal incontinence Rationale: Flatulence may cause abdominal fullness, cramping, distention, and severe, sharp pain. Diarrhea may be associated with fever, chills, weight loss, or abdominal pain. Hemorrhoids are associated with pain in the area around the anus. Fecal incontinence is the inability to control the passage of fecal matter from the anus. Pg. 1153

While assessing a patient with a bowel elimination problem, the nurse asks the patient, "Do you feel as though your bowel movements are incomplete?" Which condition is the nurse trying to determine in the patient?

A. Diarrhea B. Indigestion *C. Constipation* D. Hemorrhoids Rationale: To determine constipation, the nurse should ask the patient about feelings of having incomplete bowel movements. To determine indigestion, the nurse should ask the patient about a bloated feeling after eating. To determine diarrhea, the nurse may ask whether the patient has taken any antibiotics recently. Pain in the area around the anus may indicate hemorrhoids. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. Pg. 1156

A nurse is discussing common bowel elimination problems. Which statement indicates effective understanding of the difference between fecal impaction and fecal incontinence?

A. Fecal impaction may occur due to antibiotic therapy, whereas fecal incontinence may occur due to opiate therapy. B. Fecal impaction is the accumulation of gas in the lumen of the intestines, whereas fecal incontinence is the inability to control the passage of feces and gas from the anus. *C. Fecal impaction is common in debilitated, confused, or unconscious patients, whereas fecal incontinence is common in patients with impaired cognitive function.* D. Fecal impaction is characterized by loss of appetite, nausea and/or vomiting, and rectal pain, whereas fecal incontinence is characterized by abdominal distention and severe, sharp abdominal pain. Rationale: Debilitated, confused, or unconscious patients have an increased risk of fecal impaction, whereas patients with impaired cognitive function are more likely to have fecal incontinence. Diarrhea, not fecal impaction, may occur due to antibiotic therapy, whereas constipation may occur due to opiate therapy. Flatulence is the accumulation of gas in the lumen of the intestines, whereas fecal incontinence is the inability to control the passage of feces and gas from the anus. Fecal impaction is characterized by a loss of appetite, nausea and/or vomiting, and rectal pain, whereas flatulence, not fecal incontinence, is characterized by abdominal distention and severe, sharp abdominal pain. Pg. 1152

Which condition may be caused by frequent straining during defecation?

A. Flatulence B. Constipation *C. Hemorrhoids* D. Fecal incontinence Rationale: Increased venous pressure from straining at defecation, pregnancy, heart failure, and chronic liver disease cause hemorrhoids. Flatulence is caused by an accumulation of gas in the lumen of the intestines. Improper diet, reduced fluid intake, lack of exercise, and certain medications may cause constipation. Physical conditions that impair anal sphincter function or large-volume liquid stools may cause incontinence. Pg. 1153

During the nursing assessment, a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with which condition?

A. Food allergy B. Irritable bowel *C. Lactose intolerance* D. Decreased peristalsis Rationale: This patient possibly lacks the enzyme needed to digest milk sugar lactase and therefore is potentially lactose intolerant. Lactose intolerance is not a food allergy but rather a food intolerance that increases peristalsis, not decreases. Based on the circumstances of the condition, irritable bowel is not indicated. Test-Taking Tip: Remember that lact- means milk, as in lactation. Milk-containing products may produce diarrhea in lactose-intolerant patients. Lactose is the sugar (- ose is the suffix indicating sugar), and lactase (- ase indicates enzyme) is the enzyme that breaks down lactose. Pg. 1153

Which may be recommended for a patient in whom fecal impaction is suspected?

A. Gastroscopy B. Barium swallow C. Fecal occult blood test *D. Digital examination of the rectum* Rationale: Digital examination of the rectum may be recommended for a patient in whom fecal impaction is suspected. Gastroscopy is used to gain direct visualization of the upper gastrointestinal tract. A barium swallow is a radiographic examination using an opaque contrast medium (barium, which is swallowed) to examine the structure and motility of the upper gastrointestinal tract. The fecal occult blood test is a stool test to measure microscopic amounts of blood in the feces. These examinations may not be recommended for a patient in whom fecal impaction is suspected. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Pg. 1152

While collecting a patient's stool specimen for laboratory examination, a nurse observes the stool specimen and finds it to be oily. What should the nurse anticipate to be the cause of this finding?

A. Infection B. Intestinal irritation C. Infestation of parasites *D. Malabsorption syndrome* Rationale: Malabsorption syndrome may lead to oily stool. Infection and intestinal irritation may lead to presence of mucus in the stool. Infestation of parasites may lead to presence of blood, pus, mucus, and worms in the stool. Pg. 1157

While assessing a patient before administering an enema, the nurse inspects the patient's abdomen for distention. What is the purpose of this nursing intervention?

A. It allows the nurse to plan for appropriate teaching measures. B. It helps determine the number and type of enemas to be given. C. It helps determine conditions that contraindicate the use of enemas. *D. It provides a baseline for determining the effectiveness of the enema.* Rationale: Before administering an enema, the nurse should inspect the patient's abdomen for distention. This provides a baseline for determining the effectiveness of the enema. To plan for appropriate teaching measures, the nurse should determine the patient's level of understanding of the purpose of the enema. The nurse should review the health care provider's order for the type of enema and the amount to be given. Before administering an enema, the nurse should review the patient's medical record for increased intracranial pressure, glaucoma, or recent abdominal, rectal, or prostate surgery because these conditions contraindicate the use of enemas. Pg. 1171

The nurse is teaching a patient healthy bowel habits. Which information should be included in the teaching? Select all that apply.

A. Laxatives should be used regularly. *B. Dietary fibers should be an essential component of the diet.* *C. Fluid intake should be at least 6 to 8 glasses of water per day.* D. Physical exercises should be avoided to prevent constipation. *E. Stress management techniques should be practiced.* Rationale: Consuming dietary fiber increases the bulk of stool and helps in better bowel elimination. Maintaining adequate fluid intake increases the water content of the stool, prevents it from hardening, and permits easy passage through the rectum and anus. Stress can cause constipation; therefore, the patient should be instructed to practice stress management techniques. Laxatives should not be used regularly, because the bowel becomes habituated to laxative use. Physical activity helps prevent constipation by facilitating bowel movements. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed key words in the statement. One of the choices includes the word, "avoided," which is key to not choosing that response. Pg. 1152

The nurse is caring for a 78-year-old man with diarrhea. Which problem is the most important to consider?

A. Malnutrition *B. Dehydration* C. Skin breakdown D. Incontinence Rationale: Diarrhea interferes with absorption time of digestive juices. With frequent loose, watery stools, dehydration becomes a major problem in the older adult. Skin breakdown is another outcome of diarrhea that should be prevented with meticulous hygiene, though it is not the most important factor to consider. Malnutrition and incontinence are not the most important factors to consider in this case. Pg. 1152

Which part of the gastrointestinal tract plays a major role in bowel elimination?

A. Stomach B. Esophagus C. Small intestine *D. Large intestine* Rationale: The main functions of the large intestine, or colon, are absorption, secretion, and elimination. Therefore, the large intestine plays a major role in bowel elimination. The small intestine is involved in digestion and absorption, but not elimination. The main functions of the stomach include storage of swallowed food and liquid, mixing of food with digestive juices into a substance, and regulated emptying of its contents into the small intestine. The esophagus is the part of the gastrointestinal tract through which food reaches the upper end of the stomach. It is not involved in elimination. Pg. 1150

After performing a physical assessment of a patient with altered bowel elimination, a nurse suspects that the patient has an obstruction of the small intestine. Which finding supports the nurse's suspicion?

A. Swelling and pain in the rectal area B. Abdominal skin appearing stretched *C. High-pitched and hyperactive bowel sounds on auscultation of the abdomen* D. The occurrence of bowel sounds every 5 to 15 seconds on auscultation of the abdomen Rationale: While performing a physical assessment of a patient with altered bowel elimination, the nurse may auscultate the patient's abdomen. High-pitched and hyperactive bowel sounds proximal to the obstruction may indicate that the patient has obstruction of the small intestine. Swelling and pain in the rectal area may indicate hemorrhoids. Intestinal gas, large tumors, or fluid in the peritoneal cavity may cause abdominal distention, which may be indicated by the abdominal skin appearing stretched. The occurrence of bowel sounds every 5 to 15 seconds on auscultation of the abdomen is a normal finding. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. Pg. 1155