med surg prep u ch 47
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
Vomiting results in which of the following acid-base imbalances?
metabolic alkalosis
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 the client to rest
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
A nurse is reviewing the history and physical of a client admitted for a hemorrhoidectomy. Which predisposing condition does the nurse expect to see?
constipation
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
After teaching a group of students about intestinal obstruction, the instructor determines that the teaching was effective when the students identify which of the following as a cause of a functional obstruction?
abdominal surgery
A client with anorexia reports constipation. Which nursing measure would be most effective in helping the client reduce constipation?
assist client to increase dietary fiber
Which of the following is considered a bulk-forming laxative?
Metamucil
The nurse is performing an abdominal assessment for a patient with diarrhea and auscultates a loud rumbling sound in the left lower quadrant. What will the nurse document this sound as on the nurse's notes?
borborygmus
The nurse is irrigating a colostomy when the patient says, "You will have to stop, I am cramping so badly." What is the priority action by the nurse?
Clamp the tubing and give the patient a rest period
Which category of laxatives draws water into the intestines by osmosis?
Saline agents (e.g., magnesium hydroxide)
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
The nurse is performing a community screening for colorectal cancer. Which characteristic should the nurse include in the screening?
familial polyposis
A client informs the nurse that he has been having abdominal pain that is relieved when having a bowel movement. The client states that the physician told him he has irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder?
Chronic constipation with sporadic bouts of diarrhea
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.
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
Which statement provides accurate information regarding cancer of the colon and rectum?
colorectal cancer is the third most common site of cancer in the United States
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
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 admitting a client with a diagnosis of diverticulitis and assesses that the client has a boardlike abdomen, no bowel sounds, and reports of severe abdominal pain. What is the nurse's first action?
notify the health care provider.
A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and boardlike. What complication does the nurse determine may be occurring at this time?
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 client requires immediate nursing intervention? The client who:
presents with a rigid, boardlike abdomen
When interviewing a client with internal hemorrhoids, what would the nurse expect the client to report?
rectal bleeding
Which is a true statement regarding regional enteritis (Crohn's disease)?
The clusters of ulcers take on a cobblestone appearance.
Medical management of a patient with peritonitis includes fluid, electrolyte, and colloid replacement. The nurse knows to prepare the initial, most appropriate intravenous solution. Which of the following is the correct solution?
0.9% NS
A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate?
gently washing the area surrounding the stoma using a facecloth and mild soap
Diet therapy for clients diagnosed with irritable bowel syndrome (IBS) includes:
high-fiber diet
An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to?
hypokalemia
Which of the following is the most common symptom of a polyp?
rectal bleeding
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 nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. What else would the nurse expect to find?
severe abdominal pain with direct palpation or rebound tenderness
Which of the following would a nurse expect to assess in a client with peritonitis?
board-like abdomen
An older adult client seeks help for chronic constipation. What factor related to aging can cause constipation in elderly clients?
decreased abdominal strength
The nurse is caring for a patient who has malabsorption syndrome with an undetermined cause. What procedure will the nurse assist with that is the best diagnostic test for this illness?
endoscopy with mucosal biopsy
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 conducting a gastrointestinal assessment. When the client reports the presence of mucus and pus in the stool, the nurse assesses for additional signs/symptoms of which disease/condition?
ulcerative colitis
The nurse is assessing a client for constipation. To identify the cause of constipation, the nurse should begin by reviewing the client's:
usual pattern of elimination
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
After assessing a client with peritonitis, how would the nurse most likely document the client's bowel sounds?
absent
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 tells the nurse, "I am not having normal bowel movements." When differentiating between what are normal and abnormal bowel habits, what indicators are the most important?
the consistency of stool and comfort when passing stool