FA DAVIS - CH 30

The nurse is monitoring stools from different patients. Which findings would the nurse expect to observe? Select all that apply. 1. A patient with gallbladder disease has clay-colored stools. 2. A patient with steatorrhea has stools that float and are fluffy with a foul odor. 3. A patient with bleeding from the small intestine has bright red blood in the stools. 4. A patient with colon cancer has ribbon-shaped stools. 5. A patient with bleeding from the colon has melena.

1. A patient with gallbladder disease has clay-colored stools. 2. A patient with steatorrhea has stools that float and are fluffy with a foul odor. 4. A patient with colon cancer has ribbon-shaped stools. Rationales Option 1: Stools that are pale or clay colored indicate a lack of bile in the intestine, which may be due to liver or gallbladder disease. Option 2: Stool that appears fluffy, floats on water, and has a foul odor is due to abnormal content of undigested fat and is called steatorrhea. It may be due to disorders such as Crohn's disease. Option 3: Larger amounts of bright red blood will indicate bleeding or hemorrhage from the colon. Large amounts of maroon-colored blood indicate bleeding from the small intestine. Option 4: Ribbon-shaped stools may indicate compression on the colon by a tumor, which may be colon cancer. Option 5: Stools that are black and tarry with foul odor indicate bleeding from the stomach; the blood has been partially digested, giving it the black, tarry appearance that is known as melena.

The nurse is preparing to administer an enema. Which patient findings would cause the nurse to notify the health-care provider or charge nurse? Select all that apply. 1. Has a history of unstable angina 2. Is admitted with Crohn's disease 3. Observes a rectal fissure 4. Has infrequent hard stools 5. Observes severely bleeding hemorrhoids

1. Has a history of unstable angina 3. Observes a rectal fissure 4. Has infrequent hard stools 5. Observes severely bleeding hemorrhoids

The nurse would monitor which patients for diarrhea? Select all that apply. 1. One who eats ice cream and has lactose intolerance 2. One who has Clostridium difficile 3. One who has inflamed diverticula 4. One who is stressed about an upcoming surgery 5. One who is allergic to strawberries and does not eat strawberries

1. One who eats ice cream and has lactose intolerance 2. One who has Clostridium difficile 3. One who has inflamed diverticula 4. One who is stressed about an upcoming surgery Rationales Option 1: Some people are unable to digest lactose, a sugar found in milk and other dairy products. If they do ingest lactose-containing foods, it will usually cause them to have diarrhea. Option 2: One of the more severe opportunistic infections is Clostridium difficile, otherwise known as C. diff., which causes diarrhea. Option 3: Diverticulitis, inflammation of colon pouches, can cause diarrhea and severe cramping sufficient to force a visit to a health-care provider. Option 4: High levels of stress or anxiety, as well as other emotional problems, can cause increased peristalsis and intestinal mucus production, which may result in diarrhea. Option 5: If the patient ate the strawberries, then diarrhea could occur; but because the patient did not eat them, diarrhea will not occur.

A patient has a vagal response to administration of an enema. Which action by the nurse is priority? 1. Remove the tube from the rectum. 2. Place in high Fowler's position. 3. Leave the patient to go get help. 4. Slow the rate of the enema.

1. Remove the tube from the rectum. Rationales Option 1: The tube must be removed from the rectum. Option 2: Place the patient in the supine position. Option 3: Call for immediate assistance, but do not leave the patient. Option 4: The enema should be stopped.

The nurse wants to determine if peristalsis is occurring in a patient. Which piece of equipment should the nurse obtain? 1. Stethoscope 2. Thermometer 3. Blood pressure cuff 4. Enema bag

1. Stethoscope Rationales Option 1: Auscultation determines bowel sounds. As peristalsis moves the gastrointestinal contents and flatus through the colon, it results in gurgles, clicks, and tinkling sounds, known as bowel sounds. Option 2: Thermometer determines temperature. Option 3: A blood pressure cuff determines blood pressure and presence of Trousseau's sign. Option 4: An enema bag is used to administer an enema, not to determine peristalsis.

A patient is on a bowel training program. At which times would the nurse assist the patient to defecate? Select all that apply. 1. Upon awakening 2. Any time the patient states that he or she has to move bowels 3. After breakfast, lunch, and supper 4. After drinks a pitcher of water 5. Upon bedtime

1. Upon awakening 2. Any time the patient states that he or she has to move bowels 3. After breakfast, lunch, and supper Rationales Option 1: When the patient arises each day, assist the patient to the commode. Option 2: Any time the patient says that his or her bowels have to move, assist the patient to the toilet. Option 3: The patient should be assisted to the commode after each meal. Option 4: Although this may help with urination, it is not a time for defecation during bowel training. Option 5: Bedtime is not the time for defecation during bowel training.

The nurse would monitor which patients for diarrhea? Select all that apply. 1.One who eats ice cream and has lactose intolerance 2.One who has Clostridium difficile 3.One who has inflamed diverticula 4.One who is stressed about an upcoming surgery 5.One who is allergic to strawberries and does not eat strawberries

1.One who eats ice cream and has lactose intolerance 2.One who has Clostridium difficile 3.One who has inflamed diverticula 4.One who is stressed about an upcoming surgery Rationales Option 1: Some people are unable to digest lactose, a sugar found in milk and other dairy products. If they do ingest lactose-containing foods, it will usually cause them to have diarrhea. Option 2: One of the more severe opportunistic infections is Clostridium difficile, otherwise known as C. diff., which causes diarrhea. Option 3: Diverticulitis, inflammation of colon pouches, can cause diarrhea and severe cramping sufficient to force a visit to a health-care provider. Option 4: High levels of stress or anxiety, as well as other emotional problems, can cause increased peristalsis and intestinal mucus production, which may result in diarrhea. Option 5: If the patient ate the strawberries, then diarrhea could occur; but because the patient did not eat them, diarrhea will not occur.

Question 7. A patient is on a bowel training program. At which times would the nurse assist the patient to defecate? Select all that apply. 1.Upon awakening 2.Any time the patient states that he or she has to move bowels 3.After breakfast, lunch, and supper 4.After drinks a pitcher of water 5.Upon bedtime

1.Upon awakening 2.Any time the patient states that he or she has to move bowels 3.After breakfast, lunch, and supper Rationales Option 1: When the patient arises each day, assist the patient to the commode. Option 2: Any time the patient says that his or her bowels have to move, assist the patient to the toilet. Option 3: The patient should be assisted to the commode after each meal. Option 4: Although this may help with urination, it is not a time for defecation during bowel training. Option 5: Bedtime is not the time for defecation during bowel training.

The nurse is assigning the administration of an enema to the unlicensed assistive personnel (UAP). Which statement by the UAP indicates the UAP is safe to administer the enema? 1. "I will gently insert the tube upon resistance." 2. "I will insert the tubing toward the umbilicus." 3. "I will insert the tube at least 6 inches (15.2 cm) into the rectum." 4. "I will gently insert the tubing with the patient in the right side-lying position."

2. "I will insert the tubing toward the umbilicus." Rationales Option 1: Never force the enema tubing if resistance is met. Option 2: The UAP should direct the tip of the tubing toward the umbilicus to follow the natural direction of the sigmoid colon. Option 3: Never insert it farther than 4 to 6 inches (10.2 to 15.2 cm). Option 4: The patient should be in Sim's or left side-lying position.

A patient has a fecal impaction that requires digital removal and an oil retention enema. Which actions should the nurse take? Select all that apply. 1. Assign fecal impaction removal to the unlicensed assistive personnel (UAP). 2. Administer pain medication before the digital removal. 3. Monitor for vagal nerve stimulation. 4. Administer the oil retention enema after digital removal. 5. Check for heart problems before the digital removal.

2. Administer pain medication before the digital removal. 3. Monitor for vagal nerve stimulation. 5. Check for heart problems before the digital removal.

The nurse suspects a patient has occult bleeding and performs a guaiac test. Which actions should the nurse take? Select all that apply. 1. Put toilet paper in the specimen pan. 2. Obtain specimen from two different areas of the stool. 3. Watch for a bluish color, which is a positive result. 4. Place developer on opposite side of the card from the specimens. 5. Use sterile gloves.

2. Obtain specimen from two different areas of the stool. 3. Watch for a bluish color, which is a positive result. Rationales Option 1: Tell the patient that toilet tissue should not be placed in the specimen pan or bedpan, whichever is used, to prevent contamination of the specimen. Option 2: Select the specimen from two different areas of the stool, especially any part of stool that is red, maroon, black, or tarry in appearance. Option 3: The test results are positive for the presence of blood if the feces smears turn a blue or bluish-purple color, similar to the control color. The test results are negative if the smears do not turn blue. Option 4: According to specific kit instructions, apply the designated number of developer drops onto the opposite side of the card from the specimens, directly over each of the two feces smears. Option 5: Clean examination gloves are used.

Which information would the nurse share with a patient who wants to increase fiber in the diet? 1. Eat 35 to 40 g/day of fiber. 2. Slowly increase fiber intake over 7 to 10 days. 3. Increase caffeine intake with the fiber. 4. Decrease intake of fluid when eating fiber.

2. Slowly increase fiber intake over 7 to 10 days. Rationales Option 1: Teach the patient to increase the fiber in his or her diet to a minimum of 25 to 30 g/day. Option 2: Explain that the amount of fiber should be increased slowly over 7 to 10 days and that taking too much too quickly will cause excessive flatus. Option 3: Too much caffeine may also increase peristalsis and cramping, as well as production of excessive flatus. It is recommended that caffeine intake be limited to 300 mg daily. Option 4: Too much fiber without adequate fluids can contribute to constipation.

The nurse is obtaining a stool specimen for ova and parasite. Which technique should the nurse use? 1. Place specimen pan at the front of the toilet. 2. Take stool specimen from at least two areas of the feces. 3. Deliver to the laboratory within 1 hour of collection. 4. Avoid mixing urine with the stool but can mix if it occurs.

2. Take stool specimen from at least two areas of the feces. Rationales Option 1: Place the specimen pan under the rim of the toilet or bedside commode at the back to catch the feces. Option 2: Take the stool specimen from at least two areas of the feces, collecting any abnormal specimen findings such as blood, mucus, or visible parasites or eggs. This allows the laboratory to test any abnormalities in the stool. Option 3: Deliver the specimen to the laboratory within 15 minutes of collection so that it can be tested while it is fresh, while any ova or parasites that may be present in the specimen are still alive. Option 4: Instruct the patient to empty the bladder if necessary before defecation to avoid contamination of stool specimen with urine.

A patient is taking iron for low red blood cells. The nurse would expect the patient's feces to be which color? 1. Green 2. Red 3. Black 4. Tan

3. Black Rationales Option 1: Eating green foods such as spinach may result in greenish-black streaks in the feces. Option 2: Eating beets may result in red-tinted stools. Option 3: Ingestion of iron supplements normally causes stools to be very dark brown or black. Option 4: Normal stools can be tan.

The nurse is contributing to the community health program to parents of young children about bowel elimination. Which information should the nurse include? 1. Children develop bowel control around 5 years of age. 2. Infants have about six to eight bowel movements a day. 3. Children usually have about one to two stools a day. 4. Infants are prone to constipation.

3. Children usually have about one to two stools a day. Rationales Option 1: Children accomplish voluntary control of elimination between the ages of 2 and 3 years after their neuromuscular structures are developed. Option 2: Infants will normally have between three and six bowel movements daily. Option 3: The frequency of bowel movements usually decreases to one or two bowel movements per day. This pattern usually is maintained throughout adulthood. Option 4: Peristalsis decreases as the individual ages, making elderly individuals more prone to constipation, or hard stools that are difficult to pass.

A patient is having hard, infrequent stools. Which action should the nurse take? 1. Restrict fluid 2. Place on bedrest 3. Suggest eating yogurt 4. Decrease fiber intake

3. Suggest eating yogurt Rationales Option 1: Fluid should be encouraged. When fluid intake is inadequate, the water that has been ingested is absorbed from the bowel into the bloodstream in an attempt to prevent dehydration. Without enough water to keep the stools soft, they become hard and difficult to expel. Option 2: Bedrest will make the problem worse. Physical activity stimulates peristalsis. Option 3: The active bacteria in yogurt help to stimulate peristalsis, making it an excellent addition to the diet for prevention of constipation. Option 4: Fiber should be provided to add bulk to the stool. Inadequate fiber intake decreases stool mass as well as decreasing peristalsis, leading to development of constipation.

The nurse is caring for a patient who has a colostomy. Which action should the nurse take? 1. Determine the correct size by letting 3/8 inch of peristomal skin show. 2. Rinse the bag in hot water before reapplying. 3. Wash the stoma and skin with warm water and soap. 4. Change the wafer faceplate every 7 days.

3. Wash the stoma and skin with warm water and soap. Rationales Option 1: The correct size will fit around the stoma and allow only 1/16 to 1/8 inch of peristomal skin to show. Option 2: Some patients prefer to remove the bag and apply a new one; others prefer to empty the bag, rinse it in cool water, dry it, and reapply. Option 3: Use a soft washcloth, warm water, and mild soap to wash the stoma and skin, rinse thoroughly, and pat dry. Option 4: The faceplate is changed every 3 to 5 days or sooner if the adhesive backing begins to loosen from the skin.

The nurse assisted with a staff education program about bowel elimination. Which statement by a staff member indicates successful teaching? 1."The process of bowel elimination is feces." 2."Most of the digestion occurs in the stomach." 3."The sphincter between the stomach and the small intestine is the pyloric sphincter." 4."The normal flora interacts with the chyme to produce peristalsis or wavelike movements."

3. "The sphincter between the stomach and the small intestine is the pyloric sphincter." Rationales Option 1: The end waste product is known as feces. The process of bowel elimination is defecation. Option 2: Some absorption of water and alcohol occurs while food is in the stomach, but the stomach serves mostly as a reservoir. Option 3: The chyme passes through the outlet of the stomach called the pyloric sphincter and into the small intestine. Option 4: In the colon reside bacteria known as normal flora, whose purpose is to prevent infection and maintain health. The bacteria interact with the chyme, which produces a gas called flatus.

The nurse is collecting data about a patient's new stoma. Which finding would require the nurse to notify the health-care provider? 1.Edematous stoma 2.Red, shiny stoma 3.Dusky stoma 4.Moist stoma

3. Dusky stoma Rationales Option 1: The health-care provider does not need to be notified. Initially, there may be edema of the stoma, but the stoma should shrink to a small size over the first 2 to 3 weeks postsurgery. Option 2: A new stoma should be pink to red and shiny. The health-care provider does not need to be notified. Option 3: The health-care provider should be notified. Pallor, cyanosis, or a dusky color indicates impaired blood supply, and black depicts necrosis. Option 4: A moist stoma is a normal finding. The health-care provider does not have to be notified.

The nurse reinforces teaching with a patient who has an ileostomy. Which statement by the patient indicates a correct understanding of the teaching? 1. "I will be able to remove the pouch after several months." 2. "I will just lose stool through the ostomy." 3. "I will have semisoft, mushy fluid from the ostomy." 4. "I will clean the stool from my skin because it can be harmful."

4. "I will clean the stool from my skin because it can be harmful." Rationales Option 1: The effluent continually drains from the stoma, which requires that the patient constantly wear a pouch and empty it often. Option 2: A loss of a large amount of ileostomy drainage can lead to symptoms of malnutrition and electrolyte imbalance. Option 3: Effluent from an ileostomy is liquid because the majority of the water is not absorbed until it reaches the colon. Option 4: The effluent contains enzymes, making it very irritating to the skin surrounding the stoma.

The nurse is collecting data about a patient's bowel functioning. Which action should the nurse take? 1. Palpate the abdomen and then auscultate. 2. Listen to at least one of the four abdominal quadrants. 3. Inspect the abdomen last for distention. 4. Auscultate for at least 3 to 5 minutes if no bowel sounds are heard.

4. Auscultate for at least 3 to 5 minutes if no bowel sounds are heard. Rationales Option 1: Avoid palpating the abdomen until after the nurse has assessed the bowel sounds because palpation may stimulate bowel sounds that were not there naturally. Option 2: All four quadrants should be assessed. Option 3: Inspection is first, not last. Option 4: If the nurse thinks that bowel sounds are absent, be certain to listen for at least 3 to 5 minutes in each of the four quadrants before declaring this

The nurse is checking the intake and output record for several patients. Which finding would alert the nurse to a potential problem? 1.Intake 2500 mL and output 2300 mL 2. Intake 1500 mL and output 1800 mL 3.Had three bowel movements on Tuesday and two bowel movements on Wednesday 4.Had last bowel movement on Monday and it is now Thursday

4. Had last bowel movement on Monday and it is now Thursday

The nurse is collecting data from several patients who have diarrhea. Which patient would the nurse monitor most closely for dehydration? 1.Teenager 2.Young adult 3.Middle-aged adult 4.Older adult patient

4. Older adult patient Rationales Option 1: A teenager is not the most prone to dehydration. Option 2: Young adults can usually tolerate diarrhea better than older adults. Option 3: Middle-aged adults are not the most vulnerable to dehydration compared with the elderly. Option 4: Elderly patients, infants, and small children dehydrate much quicker than do young or middle-aged adults, so it is important to assess these patients with diarrhea for dehydration often.

A patient is having diarrhea. Which technique should the nurse use to clean the perineal area? 1.Use soap and water. 2.Use a cool washcloth. 3.Use alcohol wipes. 4.Use a patting motion to dry.

4. Use a patting motion to dry. Rationales Option 1: Soap is alkaline and therefore irritating to the skin. Option 2: The mechanical friction of using a washcloth can cause skin damage. Option 3: Alcohol is drying and irritating to excoriated skin. Option 4: Patting the skin when drying will not irritate the skin compared with rubbing.

The nurse is checking the intake and output record for several patients. Which finding would alert the nurse to a potential problem? 1.Intake 2500 mL and output 2300 mL 2.Intake 1500 mL and output 1800 mL 3.Had three bowel movements on Tuesday and two bowel movements on Wednesday 4.Had last bowel movement on Monday and it is now Thursday

4.Had last bowel movement on Monday and it is now Thursday Rationales Option 1: This would not alert the nurse to a potential problem. Intake should be equal or within 500 mL of output. Option 2: This is not a problem. Intake should be within 300 to 500 mL of output. Option 3: Some patients will normally have one bowel movement daily, whereas others may go several days between movements, and yet others may have several bowel movements each day. Option 4: The nurse must make certain the patient has a bowel movement at least every 3 days to prevent constipation.

The nurse is collecting data from several patients who have diarrhea. Which patient would the nurse monitor most closely for dehydration? 1.Teenager 2.Young adult 3.Middle-aged adult 4.Older adult patient

4.Older adult patient Rationales Option 1: A teenager is not the most prone to dehydration. Option 2: Young adults can usually tolerate diarrhea better than older adults. Option 3: Middle-aged adults are not the most vulnerable to dehydration compared with the elderly. Option 4: Elderly patients, infants, and small children dehydrate much quicker than do young or middle-aged adults, so it is important to assess these patients with diarrhea for dehydration often.