Med Surg Prep U Ch.48

Perforation of the appendix generally occurs within which timeframe of the onset of pain if no intervention is done?

24 hours *The major complication of appendicitis is perforation of the appendix. Perforation generally occurs 24 hours after the onset of pain if no intervention has occurred.

Which of the following clients would be at greatest risk for the development of an anorectal fistula?

A 35-year-old female with Crohn's disease *Clients with Crohn's disease have an increased risk for the development of anorectal abscesses and anorectal fistulae. Diverticulosis, irritable bowel syndrome, and colon polyps are not typically associated with anorectal fistulae

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 *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 caring for a client immediately following an appendectomy. The nurse should assign which nursing diagnosis the highest priority?

Acute pain *This client is most likely experiencing postoperative pain, so Acute pain should be the priority nursing diagnosis. Although the client is at risk for constipation and may require discharge teaching, these issues are lower priorities than pain. This client is more at risk for Deficient fluid volume rather than Excess fluid volume.

The nurse is performing a rectal assessment and notices a longitudinal tear or ulceration in the lining of the anal canal. The nurse documents the finding as which of the following?

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

A client with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation?

Assist client to increase dietary fiber. *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

Which of the following terms is used to refer to intestinal rumbling?

Borborygmus *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 follow statements provide accurate information regarding cancer of the colon and rectum?

Cancer of the colon and rectum is the second most common type of internal cancer in the United States *Cancer of the colon and rectum is the second most common type of internal cancer in the United States. Colon cancer affects more than twice as many people as does rectal cancer (94,700 for colon, 34,700 for rectum). The incidence increases with age (the incidence is highest in people older than 85). Colon cancer occurrence is higher in people with a family history 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?

Change in bowel habits *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.

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

The nurse is conducting discharge teaching for a patient with diverticulosis. Which of the following should the nurse include in the teaching?

Drink 8 to 10 glasses of fluid daily. *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 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?

Dry skin thoroughly after washing *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 performing a community screening for colorectal cancer. Which of the following characteristics should the nurse include in the screening?

Familial polyposis *Family history of colon cancer or familial polyposis is a risk factor for colorectal cancer. Being older than age 40 is a risk factor for colorectal cancer. A high-fat, high-protein, low-fiber diet is a risk factor for colorectal cancer. A history of skin cancer is not a recognized risk factor for colorectal cancer.

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 *For a client with an ostomy, maintaining skin integrity is a priority. The nurse should gently wash the area surrounding the stoma using a facecloth and mild soap. Scrubbing the area around the stoma can damage the skin and cause bleeding. The faceplate opening should be no more than 1/8? to 1/6? larger than the stoma. This size protects the skin from exposure to irritating fecal material. The nurse can create an adequate seal and prevent leakage of fecal material from under the faceplate by applying a thin layer of skin barrier and smoothing out wrinkles in the faceplate. Eliminating wrinkles in the faceplate also protects the skin surrounding the stoma from pressure.

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

High in fiber. *A high-fiber diet is prescribed to control diarrhea and constipation and is recommended for patients with IBS.

Diet therapy for patients diagnosed with IBS include which of the following?

High-fiber diet *A high-fiber diet is prescribed to help control diarrhea and constipation. Foods that are possible irritants such as caffeine, spicy foods, lactose, beans, fried foods, corn, wheat, alcohol should be avoided. Fluids should not be taken with meals because this results in abdominal distention.

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

Hypotension *Clinical manifestations include hypotension, increased temperature, tachycardia, and elevated ESR

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

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

A patient with irritable bowel syndrome has been having more frequent symptoms lately and is not sure what lifestyle changes may have occurred. What suggestion can the nurse provide to identify a trigger for the symptoms?

Keep a 1- to 2-week symptom and food diary to identify food triggers. *The nurse emphasizes and reinforces good dietary habits (e.g., avoidance of food triggers). A good way to identify problem foods is to keep a 1- to 2-week symptom and food diary

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?

Lack of free water intake *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

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?

Notify the physician. *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

A nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?

Polyps *Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren't preexisting conditions of colorectal cancer. Weight loss — not gain — is an indication of colorectal cancer.

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

Rectal bleeding *The most common symptom is rectal bleeding. Lower abdominal pain may also occur. Diarrhea and anorexia are clinical manifestations of ulcerative colitis

A nurse is caring for a client who had an ileo conduit 3 days earlier. The nurse examines the stoma site and determines that she should consult with the ostomy nurse. Which assessment finding indicates the need for further consultation?

Red, sensitive skin around the stoma site *Red, sensitive skin around the stoma site may indicate an ill-fitting appliance Beefy redness at a stoma site that isn't sensitive to touch is a normal assessment finding. Urine mixed with mucus is also a normal finding

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

Sudden, sustained abdominal pain *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

A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient?

Suggest fluid intake of at least 2 L per day *For constipation the nurse should suggest a fluid intake of at least 2L per day. The nurse should also offer prune or apple juice because they promote elimination. The nurse should encourage the patient to eat regular meals. Dieting or fasting can decrease stool volume and slow elimination. The nurse should instruct the patient to keep a record of food intake in case of diarrhea because this helps identify specific foods that irritate the GI tract

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?

White blood cell (WBC) count 22.8/mm3 *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 longitudinal tear or ulceration in the lining of the anal canal is termed a (an)

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.

A 43-year-old man is seen in the office where you work with complaints of severe pain and bleeding while having a bowel movement. Upon inspection, his healthcare provider notes a linear tear in the anal canal tissue. While reviewing with him the medical management for his condition, he asks you to repeat the name of the condition. The nurse will most likely tell him that he has been diagnosed with a ________

fissure *An anal fissure (fissure in ano) is a linear tear in the anal canal tissue. An anal fistula (fistula in ano) is a tract that forms in the anal canal. The condition described is known as a fissure. Hemorrhoids are dilated veins outside or inside the anal sphincter. The condition described is known as a fissure. A pilonidal sinus is an infection in the hair follicles in the sacrococcygeal area above the anus. The condition described is known as a fissure

Which client requires immediate nursing intervention? The client who

presents with a rigid, boardlike abdomen *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