Hinkle Ch 48

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 suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis?

Sigmoidoscopy Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers.

Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?

Sudden, sustained abdominal pain

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 assisting a client to drain his continent ileostomy (Kock pouch). The nurse should insert the catheter how far through the nipple/valve?

2 in.

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 change in bowel habits

A community health nurse is performing a home visit to a 53-year-old patient who requires twice-weekly wound care on her foot. The patient mentions that she is currently having hemorrhoids, a problem that she has not previously experienced. What treatment measure should the nurse recommend to this patient?

A high-fiber diet with increased fruit intake

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

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

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 of the following laxatives should be used by a cardiac patient who should avoid straining?

Colace Colace can be used safely by patients who should avoid straining such as cardiac patients and those with anorectal disorders. Milk of Magnesia is a saline agent. Dulcolax is a stimulant. Mineral oil is a lubricant.

A client is being treated for diverticulosis. Which information should the nurse include in this client's teaching plan?

Drink at least 8 to 10 large glasses of fluid every day

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

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

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

Familial polyposis

The nurse is caring for a patient diagnosed with abdominal perforation. Which of the following is a clinical manifestation of this disease process?

Hypotension

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

Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following?

Low residue 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.

Which of the following is considered a bulk-forming laxative?

Metamucil

A 75-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. An emergency room nurse is obtaining assessment data from this patient. What assessment finding is characteristic of a small bowel obstruction?

Nausea and vomiting

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

Rectal bleeding

Which is a true statement regarding regional enteritis (Crohn's disease)?

The clusters of ulcers take on a cobblestone appearance.

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

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

anal fissure. 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.

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 The older client taking digoxin 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.

Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. The nurse also expects to find:

severe abdominal pain with direct palpation or rebound tenderness.