Chapter 48: Management of Patients With Intestinal and Rectal Disorders NCLEX

B (A client who cannot swallow food cannot drink enough water to meet daily needs. Inadequate fluid intake is a common cause of constipation. Poor fluid intake is the most likely cause.)

A 68-year-old resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. She receives nutrition via a PEG tube. The client remains physically and socially active and has adapted well to the tube feedings. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. Which of the following is the most likely cause of this client's constipation? a) Lack of exercise b) Lack of free water intake c) Increased fiber d) Lack of solid food

B (Whenever stool remains stationary in the large intestine, moisture continues to be absorbed from the residue. Consequently, retention of stool, for any number of reasons, causes stool to become dry and hard. This would be caused by stool remaining in the large intestine too long.)

A client has noticed increased incidence of constipation since he broke his ankle and cannot complete his daily 3-mile walk. As his home care nurse, you complete your assessment and discuss the potential causes. During your client education session, what do you explain as the mechanical cause of his constipation? a) No known cause b) Stool remaining in the large intestine too long c) Drinking excessive water d) Ingesting excessive fiber

B (The pain of acute appendicitis localizes in the right lower quadrant (RLQ) at McBurney's point, an area midway between the umbilicus and the right iliac crest. Often, the pain is worse when manual pressure near the region is suddenly released, a condition called rebound tenderness.)

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? a) Left upper quadrant b) Right lower quadrant c) Left lower quadrant d) Right upper quadrant

B (An anorectal abscess is common in clients with Crohn's disease. His symptoms describe an anorectal abscess, which is common in clients with Crohn's disease.)

A client is being seen in the gastroenterology office where you practice nursing. He presents with an infection in the area between the internal and external sphincters. In which of the following chronic diseases is this condition commonly seen? a) Diverticulosis b) Crohn's disease c) Ulcerative colitis d) Irritable bowel syndrome

A, C (Avoid constipation. Do not suppress the urge to defecate. Consume at least 2 L/day (within limits of the client's cardiac and renal reserve) and include foods that are soft but have increased fiber, such as prepared cereals or soft-cooked vegetables, to increase the bulk of the stool and facilitate peristalsis, thereby promoting defecation. Avoid the use of laxatives or enemas except when recommended by the physician. Exercise regularly if the current lifestyle is somewhat inactive.)

A client is being treated for diverticulosis. Which of the following points should the nurse include in this client's teaching plan? Select all that apply. a) Drink at least 8 to 10 large glasses of fluid every day. b) Avoid daily exercise; indulge only in mild activity. c) Do not suppress the urge to defecate. d) Use laxatives or enemas at least once a week.

D (The nurse should report the elevated WBC count. This finding, which is a sign of infection, indicates that the client's appendix might have ruptured. Hematocrit of 42%, serum potassium of 4.2 mEq/L, and serum sodium of 135 mEq/L are within normal limits. Alterations in these levels don't indicate appendicitis.)

A client with complaints of right lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the physician immediately? a) Hematocrit 42% b) Serum sodium 135 mEq/L c) Serum potassium 4.2 mEq/L d) White blood cell (WBC) count 22.8/mm3

C (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 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. a) A fruit salad with yogurt b) A peanut butter sandwich and fruit cup c) Broiled chicken with low-fiber pasta d) Salami on whole grain bread and V-8 juice

C (The older person taking digitalis must be aware of how quickly dehydration and hypokalemia can occur with diarrhea. The nurse teaches the patient to recognize the symptoms of hypokalemia because low levels of potassium intensify the action of digitalis, leading to digitalis toxicity.)

An elderly patient diagnosed with diarrhea is taking digoxin (Lanoxin). Which of the following electrolyte imbalances should the nurse be alert to? a) Hypernatremia b) Hyponatremia c) Hypokalemia d) Hyperkalemia

D (Any suggestion from the patient that an area of the abdomen is tender or painful or "feels as if something just gave way" must be reported. The sudden occurrence of serosanguineous wound drainage strongly suggests wound dehiscence (see Chapter 19).)

The nurse is assigned to care for a patient 2 days after an appendectomy due to a ruptured appendix with resultant peritonitis. The nurse has just assisted the patient with ambulation to the bedside commode when the patient points to the surgical site and informs the nurse that "something gave way." What does the nurse suspect may have occurred? a) The surgical wound has begun to bleed. b) Infection has developed. c) A drain may have become dislodged. d) Wound dehiscence has occurred.

C (Clinical manifestations include hypotension, increased temperature, tachycardia, and elevated ESR.)

The nurse is caring for a patient diagnosed with abdominal perforation. Which of the following is a clinical manifestation of this disease process? a) Normal erythrocyte sedimentation rate (ESR) b) Subnormal temperature c) Hypotension d) Bradycardia

B (The most common presenting symptom is a change in bowel habits. Fatigue, anorexia, and weight loss may occur, but are not the most common presenting symptom.)

Which of the following is the most common presenting symptom of colon cancer? a) Anorexia b) Change in bowel habits c) Fatigue d) Weight loss

A (The nurse should discourage self-treatment with daily or frequent enemas or laxatives. Chronic use of such products causes natural bowel function to be sluggish. In addition, laxatives continuing stimulants can be habit forming, requiring continued use in increasing doses. Although the nurse should encourage the client to have adequate fluid intake, laxative use should not be encouraged. The laxative may interact with other medications the client is taking and may cause a decrease in absorption. A fiber supplement may be taken alone but should not be taken with a stimulant laxative.)

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 the taking a stimulant laxative? a) They can be habit forming and will require increasing doses to be effective. b) The laxative is safe to take with other medication the client is taking. c) The client should take a fiber supplement along with the stimulant laxative. d) As long as the client is drinking 8 glasses of water per day, he can continue to take them.

C (Blood in the stools is one of the warning signs of colorectal cancer. The nurse should plan on checking all stools for both frank and occult blood. The blood in the stool is coming from the colon or rectum; administering an ointment wouldn't help decrease the bleeding. Preparing a client for a gastrostomy tube isn't appropriate when diagnosing colorectal cancer. Colorectal cancer is usually painless; administering opioid pain medication isn't needed.)

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? a) Administer topical ointment to the rectal area to decrease bleeding. b) Prepare the client for a gastrostomy tube placement. c) Test all stools for occult blood. d) Administer morphine (Duramorph PF) routinely, as ordered.

D (A cancerous mass in the lower third of the rectum will result in an abdominoperineal resection with a wide excision of the rectum and the creation of a sigmoid colostomy. An encapsulated colorectal tumor may be removed without taking away surrounding healthy tissue. This type of tumor, however, may call for partial or complete surgical removal of the colon (colectomy). Occasionally, the tumor causes a partial or complete bowel obstruction. If the tumor is in the colon and upper third of the rectum, a segmental resection is performed. In this procedure, the surgeon removes the cancerous portion of the colon and rejoins the remaining portions of the GI tract to restore normal intestinal continuity.)

A client is diagnosed with colon cancer, located in the lower third of the rectum. What does the nurse understand will be the surgical treatment option for this client? a) A low colectomy b) Colectomy c) Segmental resection d) Abdominoperineal resection

A (Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can't absorb them after an ileostomy.)

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of: a) increasing fluid intake to prevent dehydration. b) consuming a low-protein, high-fiber diet. c) taking only enteric-coated medications. d) wearing an appliance pouch only at bedtime.

C (The nurse should assist the client to increase the dietary fiber in her 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 client with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation? a) Obtain complete food history. b) Provide adequate quantity of food. c) Assist client to increase dietary fiber. d) Obtain medical and allergy history.

B (An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion. The nurse should interpret this finding as an indication that the stoma's blood supply is interuppted, which may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding 1 day after surgery. Adjusting the ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn't change stoma color.)

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding? a) This is a normal finding 1 day after surgery. b) Blood supply to the stoma has been interrupted. c) The ostomy bag should be adjusted. d) An intestinal obstruction has occurred.

A (Fissures are usually caused by the trauma of passing a large, firm stool or from persistent tightening of the anal canal secondary to stress or anxiety (leading to constipation). An anorectal abscess is an infection in the pararectal spaces. An anal fistula is a tiny, tubular, fibrous tract that extends into the anal canal from an opening located beside the anus. A hemorrhoid is a dilated portion of vein in the anal canal.)

A longitudinal tear or ulceration in the lining of the anal canal is termed a (an) a) anal fissure. b) anorectal abscess. c) anal fistula. d) hemorrhoid.

A (IBD is a collective term for several GI inflammatory diseases with unknown causes. The most prominent sign of IBD is mild diarrhea, which sometimes is accompanied by fever and abdominal discomfort. Colorectal cancer is usually diagnosed after the client complains of bloody stools; the client will rarely have abdominal discomfort. A client with diverticulitis commonly states he has chronic constipation with occasional diarrhea, nausea, vomiting, and abdominal distention. Jaundice, coagulopathies, edema, and hepatomegaly are common signs of liver failure.)

A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, blood pressure of 100/80 mm Hg, pulse rate of 88 beats/minute, respiratory rate of 20 breaths/minute, temperature 100° F (37.8° C). The nurse suspects the client will be diagnosed with: a) inflammatory bowel disease (IBD). b) colorectal cancer. c) diverticulitis. d) liver failure.

A (Adequate GI perfusion can be maintained only if Crohn's disease is controlled. If the client experiences acute, uncontrolled episodes of Crohn's disease, impaired GI perfusion may lead to a bowel infarction. Positive self-image, a manageable level of discomfort, and intact skin integrity are expected client outcomes, but aren't related to control of the disease.)

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which statement best indicates that the disease process is under control? a) The client exhibits signs of adequate GI perfusion. b) The client maintains skin integrity. c) The client expresses positive feelings about himself. d) The client verbalizes a manageable level of discomfort.

D (The client requires more teaching if he states that he'll use laxatives regularly to prevent constipation. The nurse should teach this client to gradually eliminate the use of laxatives because using laxatives to promote regular bowel movements may have the opposite effect. A high-fiber diet, ample amounts of fluids, and regular exercise promote good bowel health.)

A nurse is teaching an elderly client about good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required? a) "I should exercise four times per week." b) "I should eat a fiber-rich diet with raw, leafy vegetables, unpeeled fruit, and whole grain bread." c) "I need to drink 2 to 3 liters of fluids every day." d) "I need to use laxatives regularly to prevent constipation."

B (Watery stools are characteristic of disorders of the small bowel, whereas loose, semisolid stools are associated more often with disorders of the large bowel. Large, greasy stools suggest intestinal malabsorption, and the presence of mucus and pus in the stools suggests inflammatory enteritis or colitis.)

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: a) A small bowel disorder. b) Intestinal malabsorption. c) A disorder of the large bowel. d) Inflammatory colitis.

C (Colorectal cancer is the third most common type of cancer in the United States. The lifetime risk of developing colorectal cancer is 1 in 20. The incidence increases with age (the incidence is highest in people older than 85). Colorectal cancer occurrence is higher in people with a family history of colon cancer.)

The nurse is conducting a community education program on colorectal cancer. Which of the following statements should the nurse include in the program? a) The lifetime risk of developing colorectal cancer is 1 in 10. b) The incidence of colorectal cancer decreases with age. c) It is the third most common cancer in the United States. d) There is no hereditary component to colorectal cancer.

D (The nurse should instruct a patient with diverticulosis to drink at least 8 to 10 large glasses of fluid every day. The patient should include unprocessed bran in the diet because it adds bulk and should avoid the use of laxatives or enemas except when recommended by the physician. In addition, the patient should exercise regularly if his or her current lifestyle is somewhat inactive.)

The nurse is conducting discharge teaching for a patient with diverticulosis. Which of the following should the nurse include in the teaching? a) Avoid daily exercise. b) Use laxatives weekly. c) Avoid unprocessed bran. d) Drink 8 to 10 glasses of fluid daily.

B (The chief characteristic of cancer of the colon is a change in bowel habits, such as alternating constipation and diarrhea. Excess gas, daily bowel movements, and abdominal cramping when having a bowel movement are not indicators of colon cancer.)

The nurse is talking with a group of clients that 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? a) Excess gas b) Change in bowel habits c) Daily bowel movements d) Abdominal cramping when having a bowel movement

C (The nurse should teach the patient without peristomal skin irritation to dry the skin thoroughly after washing. Barrier powder, Kenalog spray, and nystatin powder are used when there is peristomal skin irritation and/or fungal infection.)

The nurse is teaching a patient with an ostomy how to change the pouching system. Which of the following should the nurse include in the teaching of a patient with no peristomal skin irritation? a) Apply Kenalog spray b) Apply barrier powder c) Dry skin thoroughly after washing d) Dust with nystatin powder

B (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.)

Which of the following is a true statement regarding regional enteritis (Crohn's disease)? a) It has a progressive disease pattern. b) The clusters of ulcers take on a cobblestone appearance. c) The lesions are in continuous contact with one another. d) It is characterized by lower left quadrant abdominal pain.

A (Borborygmus is the intestinal rumbling that accompanies diarrhea. Tenesmus is the term used to refer to ineffectual straining at stool. Azotorrhea is the term used to refer to excess of nitrogenous matter in the feces or urine. Diverticulitis refers to inflammation of a diverticulum from obstruction (by fecal matter) resulting in abscess formation.)

Which of the following terms is used to refer to intestinal rumbling? a) Borborygmus b) Diverticulitis c) Tenesmus d) Azotorrhea

C (The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation u)nder the faceplate is abnormal and indicates skin breakdown.)

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma? a) "The stoma should appear dark and have a bluish hue." b) "The stoma should remain swollen distal to the abdomen." c) "At first, the stoma may bleed slightly when touched." d) "A burning sensation under the stoma faceplate is normal."

D (Although abdominal distention and blood in the stool (frank or occult) may be present, the chief characteristic of cancer of the colon is a change in bowel habits, such as alternating constipation and diarrhea. Abdominal pain is a late sign.)

A nurse is preparing a presentation for a local community group of older adults about colon cancer. Which of the following would the nurse include as the primary characteristic associated with this disorder? a) Frank blood in the stool b) Abdominal pain c) Abdominal distention d) A change in bowel habits

A (Crohn's disease is also known as regional enteritis and can occur anywhere along the GI tract, but most commonly at the distal ileum and in the colon. Infectious disease causes problems such as small bowel bacterial overgrowth leading to malabsorption. Disaccharidase deficiency leads to lactose intolerance. Postoperative malabsorption occurs after gastric or intestinal resection.)

Crohn's disease is a condition of malabsorption caused by which of the following pathophysiological processes? a) Inflammation of all layers of intestinal mucosa b) Infectious disease c) Gastric resection d) Disaccharidase deficiency

D (Oral fluids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement are prescribed to meet the nutritional needs, reduce inflammation, and control pain and diarrhea.)

Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following? a) Calorie restriction b) Low protein c) Iron restriction d) Low residue

D (The normal serum potassium level is 3.5 to 5 mEq/L. Hypokalemia can be severe if less than 2.5 mEq/L. A potassium result of 2.8 should be reported because it is significantly lower than normal. The other choices are normal levels.)

It is important for the nurse to monitor serum electrolytes in a patient with acute diarrhea. Select the electrolyte result that should be immediately reported. a) Calcium of 9 mg/dL b) Sodium of 136 mEq/L c) Chloride of 100 mEq/L d) Potassium of 2.8 mEq/L

B (Peritonitis decreases intestinal motility and causes intestinal distention. A classic sign of peritonitis is a sudden, diffuse, severe abdominal pain that intensifies in the area of the underlying causative disorder (such as appendicitis, diverticulitis, ulcerative colitis, or a strangulated obstruction). The client may also have rebound tenderness. Tenderness and pain in the right upper abdominal quadrant suggest cholecystitis. Jaundice and vomiting are signs of cirrhosis of the liver. Rectal bleeding or a change in bowel habits may indicate colorectal cancer.)

Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. The nurse also expects to find: a) tenderness and pain in the right upper abdominal quadrant. b) severe abdominal pain with direct palpation or rebound tenderness. c) rectal bleeding and a change in bowel habits. d) jaundice and vomiting.

A (Peritonitis is inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera. Peritonitis is typically a life-threatening emergency that requires prompt surgical intervention, and typically involves postoperative critical care monitoring due to the risk of sepsis, organ failure, and subsequent infections.)

Post appendectomy, a nurse should assess the patient for abdominal rigidity and tenderness, fever, loss of bowel sounds, and tachycardia, all clinical signs of: a) Peritonitis b) An abscess under the diaphragm. c) An ileus. d) A pelvic abscess.

A (Abdominal pain, a rigid boardlike abdomen, loss of bowel sounds, and signs and symptoms of shock occur with peritonitis. Peritonitis is typically a life-threatening emergency that requires prompt surgical intervention, and typically involves postoperative critical care monitoring due to the risk of sepsis, organ failure, and subsequent infections; thus, the nurse should notify the physician.)

The nurse is admitting a patient with a diagnosis of diverticulitis and assesses that the patient has a boardlike abdomen, no bowel sounds, and complains of severe abdominal pain. What is the nurse's first action? a) Notify the physician. b) Administer an opioid analgesic. c) Start an IV with lactated Ringer's solution. d) Administer a retention enema.

D (Constipation has many possible reasons; assessing the client's usual pattern of elimination is the first step in identifying the cause.)

The nurse is assessing a client for constipation. Which of the following is the first review that the nurse should conduct to identify the cause of constipation? Choose the correct option. a) Review the client's alcohol consumption. b) Review the client's current medications. c) Review the client's activity levels. d) Review the client's usual pattern of elimination.

D (Nausea is typically associated with appendicitis with or without vomiting. Pain is generally felt in the right lower quadrant. Rebound tenderness, or pain felt with release of pressure applied to the abdomen, may be present with appendicitis. Low-grade fever is associated with appendicitis.)

The nurse working in the ED is evaluating a patient for signs and symptoms of appendicitis. Which of the patient's signs/symptoms should the nurse include in the report to the physician on the patient's signs/symptoms of appendicitis? a) Left lower quadrant pain b) Pain when pressure is applied to the right lower quadrant of the abdomen c) High fever d) Nausea

A (A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Elderly, not middle-aged, clients are especially susceptible to appendix rupture.)

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? a) Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. b) The appendix may develop gangrene and rupture, especially in a middle-aged client. c) Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. d) Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.

D (A rigid, boardlike abdomen is a sign of peritonitis, a possibly life-threatening condition. Epigastric pain occurring 90 minutes to 3 hours after eating indicates a duodenal ulcer. Anorexia and periumbilical pain are characteristic of appendicitis. Risk of rupture is minimal within the first 24 hours, but increases significantly after 48 hours. A client with a large-bowel obstruction may have ribbonlike stools.)

Which client requires immediate nursing intervention? The client who: a) presents with ribbonlike stools. b) complains of anorexia and periumbilical pain. c) complains of epigastric pain after eating. d) presents with a rigid, boardlike abdomen.

A (Sudden, sustained pain, abdominal distention, and fever are symptoms of perforation in a client with intestinal obstruction. A decrease in blood pressure and decrease in urine output are symptoms of shock. Purulent drainage from the gluteal fold is not a symptom of perforation; it only indicates that the client has developed a condition of anorectal abscess.)

Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction? a) Sudden, sustained abdominal pain b) Decreased blood pressure c) Purulent drainage from the gluteal fold d) Decreased urine output

C (The client with peritonitis would typically exhibit a rigid, board-like abdomen, with absent bowel sounds, elevated pulse rate, and rapid, shallow respirations.)

Which of the following would a nurse expect to assess in a client with peritonitis? a) Decreased pulse rate b) Hyperactive bowel sounds c) Board-like abdomen d) Deep slow respirations