CH 47

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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 would a nurse expect to assess in a client with peritonitis?

Board-like abdomen

In women, which of the following types of cancer exceeds colorectal cancer?

Breast

The nurse is talking with a group of clients who are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?

Change in bowel habits

The nurse is conducting discharge teaching for a client with diverticulosis. Which instruction should the nurse include in the teaching?

Drink 8 to 10 glasses of fluid daily.

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

Familial polyposis

A patient diagnosed with IBS is advised to eat a diet that is:

High in fiber.

The nurse is conducting a community education program on colorectal cancer. Which statement should the nurse include in the program?

It is the third most common cancer in the United States.

After teaching a group of students about irritable bowel syndrome and antidiarrheal agents, the instructor determines that the teaching was effective when the students identify which of the following as an example of an opiate-related antidiarrheal agent?

Loperamide

Vomiting results in which of the following acid-base imbalances?

Metabolic alkalosis

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 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

When interviewing a client with internal hemorrhoids, what would the nurse expect the client to report?

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 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.

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

A longitudinal tear or ulceration in the lining of the anal canal is termed a(n):

anal fissure.

An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to?

Hypokalemia

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 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

Celiac sprue is an example of which category of malabsorption?

Mucosal disorders causing generalized malabsorption

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

Rectal bleeding

The nurse caring for an older adult client diagnosed with diarrhea is administering and monitoring the client's medications. Because one of the client's medications is digitalis (digoxin), the nurse monitors the client closely for:

hypokalemia.

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

A nurse is performing focused assessment on her clients. She expects to hear hypoactive bowel sounds in a client with:

paralytic ileus.

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 American Cancer Society recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should a nurse recommend?

Annual digital examination after age 40

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.

A client is having a diagnostic workup for reports of frequent diarrhea, right lower abdominal pain, and weight loss. The nurse is reviewing the results of the barium study and notes the presence of "string sign." What does the nurse understand that this is significant of?

Crohn's disease

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 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

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

The nurse is assessing a client for constipation. Which review should the nurse conduct first to identify the cause of constipation?

Usual pattern of elimination

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

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 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 board-like. What complication does the nurse determine may be occurring at this time?

Peritonitis

A client informs the nurse that he is taking a stimulant laxative in order to be able to have a bowel movement daily. What should the nurse inform the client about taking a stimulant laxative?

They can be habit forming and will require increasing doses to be effective.

A client with enteritis reports frequent diarrhea. What assessment should the nurse should anticipate?

metabolic acidosis

Which client requires immediate nursing intervention? The client who:

presents with a rigid, board-like abdomen.


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