EAQ CHAPTER 30

A nurse is caring for a patient taking the antidepressant medication sertraline. The patient tells the nurse, "I often get constipated because of this medicine." What is an appropriate response by the nurse?

"Constipation usually occurs due to the drying effect of the medication. Drink plenty of water."

A teenage patient from Ghana is receiving treatment for diarrhea. The nurse finds that the patient is not used to hand washing. What is appropriate advice given by the nurse?

"Hand washing makes your hands clean and removes dirt and filthy germs."

A patient is ordered nothing by mouth (NPO) following a surgical procedure. The patient tells the nurse, "The doctor said I cannot eat or drink until peristalsis returns. What is peristalsis?" What is an appropriate response by the nurse?

"Peristalsis produces a sound in the abdomen that indicates movement of liquid and gas caused by the wavelike movements that push the contents of the GI tract forward."

The nurse is analyzing the characteristics of a patient's stool. Which substances indicate an abnormality? Select all that apply.

-Blood -Mucus -Excess fat

The primary health care provider has prescribed an ostomy for a patient. What are some of the conditions that can lead to this surgical procedure? Select all that apply.

-Cancer -Ulcerative colitis -Abdominal trauma -Congenital bowel malformation

Which of the following medical conditions may require an ostomy? Select all that apply.

-Colon cancer -Ulcerative colitis -Congenital bowel malformation

Which instruction of the nurse will be beneficial for the patient who has had abdominal surgery and is experiencing constipation? Select all that apply.

-Exercise every day -Eat a diet high in fiber

The nurse is caring for a patient scheduled to undergo an ostomy procedure the following day. What mental symptoms does the nurse expect in the patient? Select all that apply.

-Fear -Denial -Fear of rejection -Social withdrawal

The nurse is caring for a patient who recently had abdominal surgery. What potential complications is the nurse monitoring for? Select all that apply.

-Gas pain -Constipation -Abdominal distention

Which condition does the nurse suspect in the patient diagnosed with hypoactive bowels? Select all that apply.

-Immobility -Abdominal Surgery -Lack of sufficient fiber in the diet

The nurse discovers the presence of hypoactive bowel sounds in a patient during a wellness check-up. The patient denies pain or discomfort and insists, "I feel fine. I don't have any health problems." What advice will the nurse give to the patient? Select all that apply.

-Increase fibers intake in your diet -Take part in regular physical activity

The nurse is examining a patient's stool for abnormalities. In addition to the stool's color, the nurse should be alert for the presence of which abnormal findings? Select all that apply.

-Large amounts of fat -Large amounts of pus -Presence of parasites -Large amount of mucous

A patient complains of bright red blood in the stool. What does the nurse suspect as the cause of this condition? Select all that apply.

-Recent gastrointestinal bleeding -Undigested blood in the upper part of the bowel

A nurse is caring for a patient with severe diarrhea. What symptoms should the nurse look for? Select all that apply.

-Thick Saliva -Decreased skin turgor

Which factors cause diarrhea? Select all that apply.

-Ulcerative colitis -Gastric bypass surgery

The nurse observes bright red blood in the stool of a 70-year-old patient. Identify possible causes of bright red blood in the stool. Select all that apply.

-Ulcers -Cancer -Hemorrhoids

The nurse is giving dietary advice to a patient to soften the consistency of the patient's stool. What foods does the nurse emphasize for the patient's diet? Select all that apply.

-Water -Spicy foods -Caffeinated beverages

A nurse gives dietary advice to a patient experiencing diarrhea from antibiotics. What foods will the nurse emphasize? Select all that apply.

-Yogurt -Buttermilk

A nurse is administering a cleansing enema to an infant. What volume of cleaning enema will the nurse use?

100 mL

A 70-year-old patient tells the nurse, "I eat a lot, but I don't seem to get any stronger. Why is this so?" What is an appropriate response by the nurse?

Aging only affects the absorption of fats and vitamin B12

A nurse notes that a patient has not had a stool for 2 days. Which should be the initial action of the nurse?

Ask about the patient's normal bowel pattern

A 33-year-old patient using a bedpan complains about not having moved his bowels for the past 3 days. What is an appropriate nursing action in this context?

Assess the patient to check whether assistance is required for bowel elimination.

A patient experienced fecal incontinence and is feeling uncomfortable. What is the most appropriate nursing intervention after fecal incontinence?

Clean the patient's skin

An elderly African American reports a change in bowel habits, with rectal bleeding and a sense of incomplete bowel evacuation. What disorder does the nurse suspect in this patient?

Colon cancer

A primary health care provider advises a patient with colon cancer: "I would recommend surgery to make an alternative opening into the intestine for waste elimination." What surgical procedure is the primary health care provider referring to?

Colostomy

A patient with a chronic illness has been bedridden for three months. What bowel irregularity is the patient at risk for related to lack of mobility?

Constipation

What information should be included in the nursing care plan of a patient with constipation?

Consume 1 to 3 tablespoons of bran mixed with applesauce.

The primary health care provider prescribes diphenoxylate hydrochloride with atropine for a patient. Which condition is the patient most likely suffering from?

Diarrhea

A nurse is caring for a patient with a history of congestive heart failure. To reduce the incidence of the patient developing excessive fluid accumulation, the nurse expects to find which medication on the patient's medication administration record (MAR)?

Diuretics

The nurse is caring for an elderly patient admitted with pneumonia. The patient is complaining of abdominal pain. According to documentation, the patient has been passing small amounts of watery rectal discharge. Upon auscultation, the nurse notes hypoactive bowel sounds and abdominal distension. What is the most likely cause of the patient's complaints?

Fecal impaction

The nurse knows that what initiates peristalsis?

Gastrocolic reflex

The primary health care provider notes that a patient has occult blood in his bowel movements. What does the nurse understand by occult blood?

Hidden blood

A primary health care provider tells a patient, "Make sure that your bowel movements are regular." What is the primary health care provider referring to as "bowel"?

Intestine

During an intake assessment, the patient tells the nurse she has been "passing light gray bowel movements" for the past week. What does the nurse say may be causing the light gray stools?

It could be a liver abnormality

The primary health care provider has prescribed digital removal for a patient with severe fecal impaction. What action will the nurse associate with digital removal?

Manually remove fecal matter

A patient is suffering from chronic constipation but has no other symptoms. Which medication would provide the most relief for the patient's constipation?

Polycarbophil

Which position is beneficial for administering an enema to a patient?

Sims position

A 70-year-old patient experiences fecal incontinence. Fecal incontinence involves which gastrointestinal structure?

Sphincter

Fecal incontinence may be caused by what illness?

Stroke

An elderly male patient has a poor diet and chronic constipation. Which of these would be the best recommendation for the nurse to make?

Take a fiber supplement daily

A patient who recently had an appendectomy asks the nurse, "Are there any undesirable effects of removing the appendix?" What is an appropriate response by the nurse?

The appendix has no known digestive function.

A nurse is caring for a 70-year-old patient with constipation. The patient has been regularly taking mineral oil to facilitate defecation. What should the nurse educate the patient about mineral oil?

The oil may inhibit absorption of key nutrients.

The nurse is caring for a patient admitted for observation due to abdominal pain. Stool sample testing reveals the presence of pus. What will the nurse interpret from this finding?

The patient has an infected or inflamed ulcer.

A nurse is auscultating a patient for bowel sounds and hears loud, hyperactive sounds. How does the nurse interpret this?

The patient may have diarrhea.

The nurse is teaching a group of students about hand hygiene. What statement by a student indicates a need for additional teaching?

Wear artificial nails

A patient with an ostomy pouch is beginning to feel uncomfortable as the pouch fills with fecal matter. When does the nurse empty stool from the pouch?

When the pouch is one-third to one-half full