ch24: intestinal
The nurse is assisting a client to drain his continent ileostomy (Kock pouch). The nurse should insert the catheter how far through the nipple/valve? 2 in. 3 in. 4 in. 5 in.
2 in. The nurse should insert the lubricated catheter about 2 inches (5 cm) through the nipple/valve. Please refer to the section on care of ileostomy.
A client reports constipation. Which nursing measure would be most effective in helping the client reduce constipation? Provide adequate quantity of food. Obtain medical and allergy history. Assist client to increase dietary fiber. Obtain complete food history.
Assist client to increase dietary fiber. The nurse should assist the client to increase the dietary fiber in food because it helps reduce constipation. Providing an adequate quantity of food is necessary in maintaining sufficient nutrition and in sustaining normal body weight. Obtaining medical, allergy, and food history would provide valuable information, however, it would not help reduce constipation.
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. Salami on whole grain bread and V-8 juice Broiled chicken with low-fiber pasta A peanut butter sandwich and fruit cup A fruit salad with yogurt
Broiled chicken with low-fiber pasta A low-residue, high-protein, and high-calorie diet is recommended to reduce the size and number of stools. Foods to avoid include yogurt, fruit, salami, and peanut butter.
A client informs the nurse of having abdominal pain that is relieved when having a bowel movement. The health care provider diagnosed the client with irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder? Client is awakened from sleep due to abdominal pain. Blood and mucus in the stool Chronic constipation with sporadic bouts of diarrhea Weight loss due to malabsorption
Chronic constipation with sporadic bouts of diarrhea Most clients with irritable bowel syndrome (IBS) describe having chronic constipation with sporadic bouts of diarrhea. Some report the opposite pattern, although less commonly. Most clients experience various degrees of abdominal pain that defecation may relieve. Weight usually remains stable, indicating that when diarrhea occurs, malabsorption of nutrients does not accompany it. Stools may have mucus, but blood is not usually found because the bowel is not locally inflamed. The sleep is not disturbed from abdominal pain.
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? Stop the irrigation and remove the tube. Inform the patient that it will only last a minute and continue with the procedure. Clamp the tubing and give the patient a rest period. Replace the fluid with cooler water since it is probably too warm.
Clamp the tubing and give the patient a rest period. When irrigating a colostomy, the nurse should allow tepid fluid to enter the colon slowly. If cramping occurs, the nurse should clamp off the tubing and allow the patient to rest before progressing. Water should flow in over a 5- to 10-minute period.
A 60-year-old woman had a right hemicolectomy and the creation of an ileostomy 4 days ago, and she has been admitted to the postsurgical unit for a 7-day recovery. The nurse's assessment at the beginning of the shift has focused on common postsurgical complications and the patient's stoma and output. At this stage in the patient's recovery, what type of output should the nurse expect from the patient's ileostomy? Output has not likely begun at this point Brown, semi-formed stool Continuous output of liquid effluent Intermittent output of semi-liquid stool
Continuous output of liquid effluent Ileostomy output usually begins within 72 hours of surgery. The drainage is a continuous liquid from the small intestine because the stoma does not have a controlling sphincter.
Which is one of the primary symptoms of irritable bowel syndrome (IBS)? Bloating Abdominal distention Diarrhea Pain
Diarrhea The primary symptoms of IBS include constipation, diarrhea, or a combination of both. Pain, bloating, and abdominal distention often accompany changes in bowel pattern.
A nurse is caring for a client with cardiac disease. The client asks the nurse which medication is best for help with regular bowel movements. What is the best response by the nurse? Docusate Bisacodyl Mineral oil Magnesium hydroxide
Docusate Docusate (Colace) can be used safely by patients who should avoid straining, such as cardiac clients. Magnesium hydroxide (Milk of Magnesia) is a saline agent. Bisacodyl (Dulcolax) is a stimulant laxative. Mineral oil is a lubricant laxative.
An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to? Hyponatremia Hypernatremia Hypokalemia Hyperkalemia
Hypokalemia The older client taking digitalis must be aware of how quickly dehydration and hypokalemia can occur with diarrhea. The nurse teaches the client to recognize the symptoms of hypokalemia because low levels of potassium intensify the action of digitalis, leading to digitalis toxicity.
The instructor is teaching a group of students about irritable bowel syndrome (IBS) and antidiarrheal agents, the instructor determines that the teaching was effective when the students identify which of the following as an example of an antidiarrheal agent commonly administered for IBS? Loperamide Lubiprostone Peppermint oil Dicyclomine
Loperamide Loperamide is an opiate-related antidiarrheal agent. Lubiprostone is used to treat constipation; it activates chloride channels in the gastrointestinal tract to increase gastrointestinal transit. Dicyclomine, a smooth muscle antispasmodic agent, is used to treat pain accompanying IBS. Peppermint oil may also be taken to ease discomfort.
Which is a true statement regarding regional enteritis (Crohn's disease)? It has a progressive disease pattern. It is characterized by pain in the lower left abdominal quadrant. The lesions are in continuous contact with one another. The clusters of ulcers take on a cobblestone appearance.
The clusters of ulcers take on a cobblestone appearance. The clusters of ulcers take on a cobblestone appearance. It is characterized by remissions and exacerbations. The pain is located in the lower right quadrant. The lesions are not in continuous contact with one another and are separated by normal tissue.
The presence of mucus and pus in the stools suggests which condition? Small-bowel disease Ulcerative colitis Disorders of the colon Intestinal malabsorption
Ulcerative colitis The presence of mucus and pus in the stools suggests ulcerative colitis. Watery stools are characteristic of small-bowel disease. Loose, semisolid stools are associated more often with disorders of the colon. Voluminous, greasy stools suggest intestinal malabsorption.
A nurse is reviewing lab results for a client with an intestinal obstruction, and infection is suspected. What would be an expected finding? leukocytosis; elevated hematocrit; low sodium, potassium, and chloride leukopenia, decreased hematocrit; low sodium, potassium, and chloride leukocytosis; metabolic alkalosis; elevated sodium, potassium, and chloride leukopenia; metabolic acidosis; elevated sodium, potassium, and chloride
leukocytosis; elevated hematocrit; low sodium, potassium, and chloride Tests of serum electrolytes may indicate low levels of sodium, potassium, and chloride. Metabolic alkalosis is evidenced by arterial blood gas results. A complete blood count (CBC) shows an increased WBC count in instances of infection. The hematocrit level is elevated if dehydration develops.
A physician has ordered a liver biopsy for a client with cirrhosis whose condition has recently deteriorated. The nurse reviews the client's recent laboratory findings and recognizes that the client is at risk for complications due to: low hemoglobin. low sodium level. decreased prothrombin time. low platelet count.
low platelet count. Prolonged prothrombin time (PT) and low platelet count place the client at high risk for hemorrhage. The client may receive intravenous (IV) administration of vitamin K or infusions of platelets before liver biopsy to reduce the risk of bleeding.
A client is diagnosed with Zollinger-Ellison syndrome. The nurse knows to assess the client for which characteristic clinical feature of this syndrome? Lymphadenopathy Folate deficiency Decreased intestinal lactose Steatorrhea
steatorrhea Hyperacidity in the duodenum inactivates pancreatic enzymes causing steatorrhea and ulcer diathesis.
An older adult client in a long-term care facility is concerned about bowel regularity. During a client education session, the nurse reinforces the medically acceptable definition of "regularity." What is the actual measurement of "regular"? two bowel movements daily one bowel movement every other day one bowel movement daily stool consistency and client comfort
stool consistency and client comfort Normal bowel patterns range from three bowel movements per day to three bowel movements per week. In differentiating normal from abnormal, the consistency of stools and the comfort with which a person passes them are more reliable indicators than is the frequency of bowel elimination.
