MedSurg2 Exam 2 Part 5
A patient diagnosed with multiple sclerosis (MS) has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication?
Decreased muscle spasms in the lower extremities
A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state?
Urinary incontinence
A client is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate?
Administer morphine sulfate as prescribed.
A nurse is providing care for a patient who has a diagnosis of irritable bowel syndrome (IBS). Whenplanning this patients care, the nurse should collaborate with the patient and prioritize what goal? A) Patient will accurately identify foods that trigger symptoms. B) Patient will demonstrate appropriate care of his ileostomy. C) Patient will demonstrate appropriate use of standard infection control precautions. D) Patient will adhere to recommended guidelines for mobility and activity.
Ans: A Feedback:A major focus of nursing care for the patient with IBS is to identify factors that exacerbate symptoms.Surgery is not used to treat this health problem and infection control is not a concern that is specific tothis diagnosis. Establishing causation likely is more important to the patient than managing physicalactivity.
A nurse is caring for a patient admitted with symptoms of an anorectal infection; cultures indicate thatthe patient has a viral infection. The nurse should anticipate the administration of what drug? A) Acyclovir (Zovirax) B) Doxycycline (Vibramycin) C) Penicillin (penicillin) D) Metronidazole (Flagyl)
Ans: A Feedback:Acyclovir (Zovirax) is often given to patients with viral anorectal infections. Doxycycline (Vibramycin)and penicillin (penicillin G) are drugs of choice for bacterial infections. Metronidazole (Flagyl) is usedfor other infections with a bacterial etiology; it is ineffective against viruses
A 35-year-old male patient presents at the emergency department with symptoms of a small bowelobstruction. In collaboration with the primary care provider, what intervention should the nurseprioritize?A) Insertion of a nasogastric tubeTest Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 895 B) Insertion of a central venous catheter C) Administration of a mineral oil enema D) Administration of a glycerin suppository and an oral laxative
Ans: A Feedback:Decompression of the bowel through a nasogastric tube is necessary for all patients with small bowelobstruction. Peripheral IV access is normally sufficient. Enemas, suppositories, and laxatives are notindicated if an obstruction is present.
A teenage patient with a pilonidal cyst has been brought for care by her mother. The nurse who iscontributing to the patients care knows that treatment will be chosen based on what risk? A) Risk for infection B) Risk for bowel incontinence C) Risk for constipation D) Risk for impaired tissue perfusion
Ans: A Feedback:Pilonidal cysts frequently develop into an abscess, necessitating surgical repair. These cysts do notcontribute to bowel incontinence, constipation, or impaired tissue perfusion.
A nurse is presenting an educational event to a local community group. When speaking about colorectalcancer, what risk factor should the nurse cite? A) High levels of alcohol consumption B) History of bowel obstruction C) History of diverticulitis D) Longstanding psychosocial stress
Ans: A Feedback:Risk factors include high alcohol intake; cigarette smoking; and high-fact, high-protein, low-fiber diet.Diverticulitis, obstruction, and stress are not noted as risk factors for colorectal cancer.
The nurse is providing care for a patient whose inflammatory bowel disease has necessitated hospitaltreatment. Which of the following would most likely be included in the patients medication regimen? A) Anticholinergic medications 30 minutes before a meal B) Antiemetics on a PRN basis C) Vitamin B12 injections to prevent pernicious anemia D) Beta adrenergic blockers to reduce bowel motility
Ans: A Feedback:The nurse administers anticholinergic medications 30 minutes before a meal as prescribed to decreaseintestinal motility and administers analgesics as prescribed for pain. Antiemetics, vitamin B12 injectionsand beta blockers do not address the signs, symptoms, or etiology of inflammatory bowel disease
A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has requiredhospital admission. During an exacerbation of this health problem, the nurse would anticipate that thepatients 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 bloodyand contain mucus. Stools are not hard, dry, tarry, black or fatty in patients who have ulcerative colitis.
A patient is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this patients care, which of the following nursing diagnoses should the nurse prioritize? A) Ineffective Tissue Perfusion Related to Bowel Ischemia B) Imbalanced Nutrition: Less Than Body Requirements Related to Impaired Absorption C) Anxiety Related to Bowel Obstruction and Subsequent Hospitalization D) Impaired Skin Integrity Related to Bowel Obstruction
Ans: A Feedback:When the bowel is completely obstructed, the possibility of strangulation and tissue necrosis (i.e., tissuedeath) warrants surgical intervention. As such, this immediate physiologic need is a nursing priority.Nutritional support and management of anxiety are necessary, but bowel ischemia is a more immediatethreat. Skin integrity is not threatened.
A nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of thefollowing would be appropriate nursing diagnoses for this patient? Select all that apply. A) Acute Pain Related to Increased Peristalsis and GI Inflammation B) Activity Intolerance Related to Generalized Weakness C) Bowel Incontinence Related to Increased Intestinal Peristalsis D) Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea E) Impaired Urinary Elimination Related to GI Pressure on the Bladder
Ans: A, B, D Feedback:Patients with diverticulitis are likely to experience pain and decreased activity levels, and are at risk offluid volume deficit. The patient is unlikely to experience fecal incontinence and urinary function is notdirectly influenced.
A patient with a diagnosis of colon cancer is 2 days postoperative following bowel resection andanastomosis. The nurse has planned the patients care in the knowledge of potential complications. WhatTest Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 909assessment should the nurse prioritize?A) Close monitoring of temperature B) Frequent abdominal auscultation C) Assessment of hemoglobin, hematocrit, and red blood cell levels D) Palpation of peripheral pulses and leg girth
Ans: B Feedback:After bowel surgery, it is important to frequently assess the abdomen, including bowel sounds andabdominal girth, to detect bowel obstruction. The resumption of bowel motility is a priority over each ofthe other listed assessments, even though each should be performed by the nurse.
A nurse caring for a patient with colorectal cancer is preparing the patient for upcoming surgery. Thenurse administers cephalexin (Keflex) to the patient and explains what rationale? A) To treat any undiagnosed infections B) To reduce intestinal bacteria levels C) To reduce bowel motility D) To reduce abdominal distention postoperatively
Ans: B Feedback:Antibiotics such a kanamycin (Kantrex), neomycin (Mycifradin), and cephalexin (Keflex) areadministered orally the day before surgery to reduce intestinal bacterial. Preoperative antibiotics are notgiven to treat undiagnosed infections, reduce motility, or prevent abdominal distention.
A nurse is providing care for a patient whose recent colostomy has contributed to a nursing diagnosis ofDisturbed 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 healthproblem. 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 enhancefamiliarity. Emphasizing the benefits of the intervention is unlikely to improve the patients body image,since the benefits are likely already known. Online research is not likely to enhance the patients bodyimage and some ostomies are permanent.
A patient has had an ileostomy created for the treatment of irritable bowel disease and the patient is nowpreparing for discharge. What should the patient be taught about changing this device in the homeTest Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 894setting? 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 andwater, 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 notutilized, but an antifungal spray or powder may be used.
During a patients scheduled home visit, an older adult patient has stated to the community health nursethat she has been experiencing hemorrhoids of increasing severity in recent months. The nurse shouldrecommend which of the following? A) Regular application of an OTC antibiotic ointment B) Increased fluid and fiber intake C) Daily use of OTC glycerin suppositories D) Use of an NSAID to reduce inflammation
Ans: B Feedback:Hemorrhoid symptoms and discomfort can be relieved by good personal hygiene and by avoidingexcessive straining during defecation. A high-residue diet that contains fruit and bran along with anTest Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 905increased fluid intake may be all the treatment that is necessary to promote the passage of soft, bulkystools to prevent straining. Antibiotics, regular use of suppositories, and NSAIDs are not recommended,as they do not address the etiology of the health problem.
A nursing instructor is discussing hemorrhoids with the nursing class. Which patients would the nursinginstructor identify as most likely to develop hemorrhoids? A) A 45-year-old teacher who stands for 6 hours per day B) A pregnant woman at 28 weeks gestation C) A 37-year-old construction worker who does heavy lifting D) A 60-year-old professional who is under stress
Ans: B Feedback:Hemorrhoids commonly affect 50% of patients after the age of 50. Pregnancy may initiate hemorrhoidsor aggravate existing ones. This is due to increased constipation during pregnancy. The significance ofpregnancy is greater than that of standing, lifting, or stress in the development of hemorrhoids.
A nurse caring for a patient with a newly created ileostomy assesses the patient and notes that the patienthas had not ostomy output for the past 12 hours. The patient also complains of worsening nausea. Whatis the nurses 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. Thisrequires prompt medical intervention. Referral to the WOC nurse is not an appropriate short-termresponse, since medical treatment is necessary. Physical mobility will not normally resolve anobstruction. There is no need to collect a culture from the stoma, because infection is unrelated to thisproblem.
A nurse is caring for a patient with constipation whose primary care provider has recommended senna(Senokot) for the management of this condition. The nurse should provide which of the followingeducation points? A) Limit your fluid intake temporarily so you dont get diarrhea. B) Avoid taking the drug on a long-term basis. C) Make sure to take a multivitamin with each dose. D) Take this on an empty stomach to ensure maximum effect.
Ans: B Feedback:Laxatives should not be taken on an ongoing basis in order to reduce the risk of dependence. Fluidshould be increased, not limited, and there is no need to take each dose with a multivitamin. Senna doesnot need to be taken on an empty stomach.
A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. Whatmenu 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, lowresidue,high-protein, and high-vitamin. Tofu meets each of the criteria. Spinach, multigrain bagels, andblueberries are not low-residue.
A nurse at an outpatient surgery center is caring for a patient who had a hemorrhoidectomy. Whatdischarge education topics should the nurse address with this patient? A) The appropriate use of antibiotics to prevent postoperative infection B) The correct procedure for taking a sitz bath C) The need to eat a low-residue, low-fat diet for the next 2 weeksTest Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 910 D) The correct technique for keeping the perianal region clean without the use of water
Ans: B Feedback:Sitz baths are usually indicated after perianal surgery. A low-residue, low-fat diet is not necessary andwater is used to keep the region clean. Postoperative antibiotics are not normally prescribed.
An older adult who resides in an assisted living facility has sought care from the nurse because ofrecurrent episodes of constipation. Which of the following actions should the nurse first perform? A) Encourage the patient to take stool softener daily.Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 898 B) Assess the patients food and fluid intake. C) Assess the patients 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. Thepatients food and fluid intake is more likely to affect bowel function than surgery.
A 16-year-old presents at the emergency department complaining of right lower quadrant pain and issubsequently diagnosed with appendicitis. When planning this patients nursing care, the nurse shouldprioritize 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
Ans: B Feedback:The patient with a diagnosis of appendicitis has an acute risk of infection related to the possibility ofrupture. This immediate physiologic risk is a priority over nutrition and constipation, though each ofthese concerns should be addressed by the nurse. The pain associated with appendicitis is acute, notchronic.
A patient admitted with acute diverticulitis has experienced a sudden increase in temperature andcomplains of a sudden onset of exquisite abdominal tenderness. The nurses rapid assessment reveals thatthe patients abdomen is uncharacteristically rigid on palpation. What is the nurses best response? A) Administer a Fleet enema as ordered and remain with the patient. B) Contact the primary care provider promptly and report these signs of perforation. C) Position the patient supine and insert an NG tube. D) Page the primary care provider and report that the patient may be obstructed.
Ans: B Feedback:The patients change in status is suggestive of perforation, which is a surgical emergency. Obstructiondoes not have this presentation involving fever and abdominal rigidity. An enema would be stronglycontraindicated. An order is needed for NG insertion and repositioning is not a priority.
The nurse is caring for a patient who is undergoing diagnostic testing for suspected malabsorption.When taking this patients health history and performing the physical assessment, the nurse shouldrecognize 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
Ans: B Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 900Feedback:The hallmarks of malabsorption syndrome from any cause are diarrhea or frequent, loose, bulky, foulsmellingstools that have increased fat content and are often grayish (steatorrhea). Constipation andbloody bowel movements are not suggestive of malabsorption syndromes. Fever and a tender, rigidabdomen are associated with peritonitis
An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation.The patient will be treated on an outpatient basis. What components of treatment should the nurseanticipate? Select all that apply. A) Anticholinergic medications B) Increased fiber intake C) Enemas on alternating days D) Reduced fat intakeE) Fluid reduction
Ans: B, D Feedback:Patients whose diverticular disease does not warrant hospital treatment often benefit from a high-fiber,low-fat diet. Neither enemas nor anticholinergics are indicated, and fluid intake is encouraged
A nurse is assessing a patients stoma on postoperative day 3. The nurse notes that the stoma has a shinyappearance and a bright red color. How should the nurse best respond to this assessment finding?A) Irrigate the ostomy to clear a possible obstruction. B) Contact the primary care provider to report this finding. C) Document that the stoma appears healthy and well perfused. D) Document a nursing diagnosis of Impaired Skin Integrity.
Ans: C Feedback:A healthy, viable stoma should be shiny and pink to bright red. This finding does not indicate that thestoma is blocked or that skin integrity is compromised.
A patients screening colonoscopy revealed the presence of numerous polyps in the large bowel. Whatprinciple should guide the subsequent treatment of this patients health problem? A) Adherence to a high-fiber diet will help the polyps resolve. B) The patient should be assured that these are a normal, age-related physiologic change. C) The patients polyps constitute a risk factor for cancer. D) The presence of polyps is associated with an increased risk of bowel obstruction.
Ans: C Feedback:Although most polyps do not develop into invasive neoplasms, they must be identified and followedclosely. They are very common, but are not classified as a normal, age-related physiologic change. Dietwill not help them resolve and they do not typically lead to obstructions.
An older adult has a diagnosis of Alzheimers disease and has recently been experiencing fecalincontinence. However, the nurse has observed no recent change in the character of the patients stools.What is the nurses most appropriate intervention? A) Keep a food diary to determine the foods that exacerbate the patients symptoms. B) Provide the patient with a bland, low-residue diet. C) Toilet the patient on a frequent, scheduled basis. D) Liaise with the primary care provider to obtain an order for loperamide
Ans: C Feedback:Because the patients fecal incontinence is most likely attributable to cognitive decline, frequent toiletingis an appropriate intervention. Loperamide is unnecessary in the absence of diarrhea. Specific foods arenot likely to be a cause of, or solution to, this patients health problem.
A patients health history is suggestive of inflammatory bowel disease. Which of the following wouldsuggest Crohns disease, rather that ulcerative colitis, as the cause of the patients 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 Crohns. Rectal involvement is nearly 100% incases of UC (versus 20% in Crohns) and patients with UC typically experience severe diarrhea. UC isalso characterized by a pattern of remissions and exacerbations, while Crohns often has a moreprolonged and variable course.
A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerativecolitis. When planning family assessment, the nurse should recognize that which of the following factorswill likely have the greatest impact on the patients coping after discharge? A) The familys ability to take care of the patients special diet needs B) The familys ability to monitor the patients changing health status C) The familys ability to provide emotional support D) The familys ability to manage the patients medication regimen
Ans: C Feedback:Emotional support from the family is key to the patients coping after discharge. A 21-year-old would beexpected to self-manage the prescribed medication regimen and the family would not be primarilyresponsible for monitoring the patients health status. It is highly beneficial if the family is willing andable to accommodate the patients dietary needs, but emotional support is paramount and cannot be solelyprovided by the patient alone.
A nurse is working with a patient who has chronic constipation. What should be included in patientteaching to promote normal bowel function? A) Use glycerin suppositories on a regular basis. B) Limit physical activity in order to promote bowel peristalsis. C) Consume high-residue, high-fiber foods. D) Resist the urge to defecate until the urge becomes intense.
Ans: C Feedback:Goals for the patient include restoring or maintaining a regular pattern of elimination by responding tothe urge to defecate, ensuring adequate intake of fluids and high-fiber foods, learning about methods toavoid constipation, relieving anxiety about bowel elimination patterns, and avoiding complications.Ongoing use of pharmacologic aids should not be promoted, due to the risk of dependence. Increasedmobility helps to maintain a regular pattern of elimination. The urge to defecate should be heeded.
A patients colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4days since the surgery, the patient has been unwilling to look at the ostomy or participate in any aspectsof ostomy care. What is the nurses 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 patients 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 thiswith the patient and explore the factors that underlie it. It is presumptive to assume that the patientsbehavior is motivated by fear. Assessment must precede referrals and emphasizing the patientsresponsibilities 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 theileostomy. The nurse should teach the patient to do which of the following actions?Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 902 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 ornipple. The length of time between drainage periods is gradually increased until the reservoir needs to bedrained only every 4 to 6 hours and irrigated once each day. It is not appropriate to wait until the pouchis 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 acolostomy. The patient admits to being anxious, and has many questions concerning the surgery, the careof 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 successfulin adjusting to an ostomy. B) Provide the patient with educational materials that match the patients learning style. C) Encourage the patient to write down these concerns and questions to bring forward to the surgeon.Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 899 D) Maintain an open dialogue with the patient and facilitate a referral to the wound-ostomycontinence(WOC) nurse.
Ans: D Feedback:A wound-ostomy-continence (WOC) nurse is a registered nurse who has received advanced education inan accredited program to care for patients with stomas. The enterostomal nurse therapist can assist withthe selection of an appropriate stoma site, teach about stoma care, and provide emotional support. Thesurgeon is less likely to address the patients psychosocial and learning needs. Reassurance does notaddress the patients questions, and education may or may not alleviate anxiety.
A nurse is caring for an older adult who has been experiencing severe Clostridium difficile-relateddiarrhea. When reviewing the patients most recent laboratory tests, the nurse should prioritize which ofthe following? A) White blood cell levelTest Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 907 B) Creatinine level C) Hemoglobin level D) Potassium level
Ans: D Feedback:In elderly patients, it is important to monitor the patients serum electrolyte levels closely. Diarrhea is lesslikely to cause an alteration in white blood cell, creatinine, and hemoglobin levels.
A patient has been experiencing disconcerting GI symptoms that have been worsening in severity.Following medical assessment, the patient has been diagnosed with lactose intolerance. The nurse shouldrecognize an increased need for what form of health promotion? A) Annual screening colonoscopies B) Adherence to recommended immunization schedules C) Regular blood pressure monitoringTest Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 903 D) Frequent screening for osteoporosis
Ans: D Feedback:Persons with lactose intolerance often experience hypocalcemia and a consequent risk of osteoporosisrelated to malabsorption of calcium. Lactose intolerance does not create an increased need for screeningfor colorectal cancer, immunizations, or blood pressure monitoring.
A patient has been experiencing occasional episodes of constipation and has been unable to achieveconsistent relief by increasing physical activity and improving his diet. What pharmacologic interventionshould the nurse recommend to the patient for ongoing use? A) Mineral oil enemas B) Bisacodyl (Dulcolax) C) Senna (Senokot) D) Psyllium hydrophilic mucilloid (Metamucil)
Ans: D Feedback:Psyllium hydrophilic mucilloid (Metamucil) is a bulk-forming laxative that is safe for ongoing use.None of the other listed laxatives should be used on an ongoing basis because of the risk of dependence.
A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurseshould describe which of the following as the most common sign of possible colon cancer? A) Development of new hemorrhoids B) Abdominal bloating and flank pain C) Unexplained weight gain D) Change in bowel habits
Ans: D Feedback:The most common presenting symptom associated with colorectal cancer is a change in bowel habits.The passage of blood is the second most common symptom. Symptoms may also include unexplained anemia, anorexia, weight loss, and fatigue. Hemorrhoids and bloating are atypical.
Which of the following is the most plausible nursing diagnosis for a patient whose treatment for coloncancer has necessitated a colonostomy? A) Risk for Unstable Blood Glucose Due to Changes in Digestion and Absorption B) Unilateral Neglect Related to Decreased Physical Mobility C) Risk for Excess Fluid Volume Related to Dietary Changes and Changes In Absorption D) Ineffective Sexuality Patterns Related to Changes in Self-Concept
Ans: D Feedback:The presence of an ostomy frequently has an effect on sexuality; this should be addressed thoughtfullyin nursing care. None of the other listed diagnoses reflects the physiologic changes that result fromcolorectal surgery.
A patients large bowel obstruction has failed to resolve spontaneously and the patients worseningcondition has warranted admission to the medical unit. Which of the following aspects of nursing care ismost appropriate for this patient? A) Administering bowel stimulants as ordered B) Administering bulk-forming laxatives as ordered C) Performing deep palpation as ordered to promote peristalsis D) Preparing the patient for surgical bowel resection
Ans: D Feedback:The usual treatment for a large bowel obstruction is surgical resection to remove the obstructing lesion.Administration of laxatives or bowel stimulants are contraindicated if the bowel is obstructed. Palpationwould be painful and has no therapeutic benefi
A patient has been diagnosed with a small bowel obstruction and has been admitted to the medical unit.The nurses care should prioritize which of the following outcomes? A) Preventing infection B) Maintaining skin and tissue integrity C) Preventing nausea and vomiting D) Maintaining fluid and electrolyte balance
Ans: D Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 908Feedback:All of the listed focuses of care are important for the patient with a small bowel obstruction. However,the patients risk of fluid and electrolyte imbalances is an immediate threat to safety, and is a priority innursing assessment and interventions.
When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?
Increased intracranial pressure (ICP)