PNE 105 Chapter 46: Caring for Clients with Disorders of the Lower GI Tract. Med-Surg.
A patient arrives in the emergency department with complaints of right lower abdominal pain that began 4 hours ago and is getting worse. The nurse assesses rebound tenderness at McBurney's point. What does this assessment data indicate to the nurse?
Appendicitis
A patient is suspected to have diverticulosis without symptoms of diverticulitis. What diagnostic test does the nurse anticipate educating the patient about prior to scheduling?
Colonoscopy Explanation: Diverticulosis is typically diagnosed by colonoscopy, which permits visualization of the extent of diverticular disease and biopsy of tissue to rule out other diseases. In the past, barium enema was the preferred diagnostic test, but it is now used less frequently than colonoscopy. CT with contrast agent is the diagnostic test of choice if the suspected diagnosis is diverticulitis; it can also reveal abscesses.
A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?
Contact the primary provider promptly and report these signs of perforation. Explanation: The client's change in status is suggestive of perforation, which is a surgical emergency. Obstruction does not have this presentation involving fever and abdominal rigidity. An enema would be strongly contraindicated. An order is needed for NG insertion and repositioning is not a priority.
Which characteristic is a risk factor for colorectal cancer?
Familial polyposis. Explanation: Family history of colon cancer or familial polyposis is a risk factor for colorectal cancer. Age older than 40 years and a high-fat, high-protein, low-fiber diet are risk factors for colorectal cancer. A history of skin cancer is not a recognized risk factor for colorectal cancer.
A client diagnosed with colon cancer presents with the characteristic symptoms of a left-sided lesion. Which symptoms are indicative of this disorder? Select all that apply.
Narrowing stools Constipation Abdominal distention
The nurse is conducting a gastrointestinal assessment. When the client reports the presence of mucus and pus in the stool, the nurse assesses for additional signs/symptoms of which disease/condition?
Ulcerative colitis. Explanation: The presence of mucus and pus in the stool 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 client has a 25-year history of ulcerative colitis and is in the midst of an exacerbation. The client has a history of experiencing severe LLQ pain and explosive diarrhea. What would be the client's preparation before the latest diagnostic colonoscopy?
tap water enema
A nurse is caring for a client with constipation whose primary provider has recommended senna for the management of this condition. The nurse should provide which of the following education points?
"Avoid taking the drug on a long-term basis." Explanation: Laxatives should not be taken on an ongoing basis in order to reduce the risk of dependence. Fluid should be increased, not limited, and there is no need to take each dose with a multivitamin. Senna does not need to be taken on an empty stomach.
Which of the following categories of laxatives draws water into the intestines by osmosis?
Saline agents (Milk of Magnesia) Explanation: Saline agents use osmosis to stimulate peristalsis and act within 2 hours of consumption. Bulk-forming agents mix with intestinal fluids, swell, and stimulate peristalsis. Stimulants irritate the colon epithelium. Fecal softeners hydrate the stool by surfactant action on the colonic epithelium, resulting in mixing of aqueous and fatty substances.
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. Explanation: 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.
A client's colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the client has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurse's most appropriate response to this observation?
Acknowledge the client's reluctance and initiate discussion of the factors underlying it. Explanation: If the client is reluctant to participate in ostomy care, the nurse should attempt to dialogue about this with the client and explore the factors that underlie it. It is presumptive to assume that the client's behavior is motivated by fear. Assessment must precede referrals and emphasizing the client's responsibilities may or may not motivate the client.
The nurse is caring for a client who is undergoing diagnostic testing for suspected malabsorption. When taking this client's health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis?
Foul-smelling diarrhea that contains fat Explanation: The hallmarks of malabsorption syndrome from any cause are diarrhea or frequent, loose, bulky, foul-smelling stools that have increased fat content and are often grayish (steatorrhea). Constipation and bloody bowel movements are not suggestive of malabsorption syndromes. Fever and a tender, rigid abdomen are associated with peritonitis.
The nurse is caring for a client with intussusception of the bowel. What does the nurse understand occurs with this disorder?
One part of the intestine telescopes into another portion of the intestine. Explanation: In intussusception of the bowel, one part of the intestine telescopes into another portion of the intestine. When the bowel twists and turns itself and obstructs the intestinal lumen, this is known as a volvulus. A hernia is when the bowel protrudes through a weakened area in the abdominal wall. An adhesion is a loop of intestine that adheres to an area that is healing slowly after surgery.
A client has a 10-year history of Crohn's disease and is seeing the physician due to increased diarrhea and fatigue. What is the primary treatment for Crohn's disease? Select all that apply. a.) regular antidiarrheal use b.) surgery c.) supportive d.) dietary
b.) supportive c.) dietary Explanation: The dietary approach varies. A high-fiber diet may be indicated when it is desirable to add bulk to loose stools. A low-fiber diet may be indicated in cases of severe inflammation or stricture. A high-calorie and high-protein diet helps replace nutritional losses from chronic diarrhea. The client may need nutritional supplements, depending on the area of the bowel affected. When the small intestine is inflamed, some clients experience lactose intolerance, requiring avoidance of lactose-rich foods.
A client has been brought into the ED via ambulance, reporting acute generalized abdominal pain, nausea, fever, and constipation. The healthcare provider suspects appendicitis, but testing has not been performed yet to make a definitive diagnosis. What will the nurse most likely do while initially caring for this client?
Explain to the client why analgesics are being withheld. Explanation: Analgesics may be withheld initially to avoid masking symptoms that may affect the diagnosis. Avoid multiple or frequent palpation of the abdomen; there is danger of causing the appendix to rupture. Perform the test for rebound tenderness at the end of the examination because a positive response causes pain and muscle spasm and makes it difficult to complete the rest of the assessment. Do not administer laxatives or enemas to a client who is experiencing fever, nausea, and abdominal pain, even though the client may complain of feeling constipated. Laxatives and cathartics may cause the appendix to rupture.
The nurse is performing a community screening for colorectal cancer. Which characteristic should the nurse include in the screening?
Familial polyposis. Explanation: Family history of colon cancer or familial polyposis is a risk factor for colorectal cancer. Age older than 40 years and a high-fat, high-protein, low-fiber diet are risk factors for colorectal cancer. A history of skin cancer is not a recognized risk factor for colorectal cancer.
A nurse is performing focused assessment on her clients. She expects to hear hypoactive bowel sounds in a client with:
paralytic ileus. Explanation: Bowel sounds are hypoactive or absent in a client with a paralytic ileus. Clients with Crohn's disease and gastroenteritis have hyperactive bowel sounds because of increased intestinal motility. A complete bowel obstruction causes absent bowel sounds below the obstruction and hyperactive sounds above the obstruction.
What is the most common cause of small-bowel obstruction?
Adhesions
A nurse applies an ostomy appliance to a patient who is recovering from ileostomy surgery. Which of the following interventions should the nurse utilize to prevent leakages from the appliance?
Ask the patient to remain inactive for 5 minutes. Explanation: When the nurse applies the ostomy appliance, he or she should ask the patient to remain inactive for 5 minutes to allow body heat to strengthen the adhesive bond. The adhesive faceplate should be pressed from the stomal edge outward to prevent the formation of wrinkles. A small amount of air should also be allowed to be trapped in the pouch; liquid feces will then drain to the bottom of the pouch, placing less tension on it.
An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform?
Assess the patient's food and fluid intake.
A client is admitted with a diagnosis of diverticulitis. The client has nausea, vomiting, and dehydration. Which sign requires immediate attention by the nurse?
Boardlike abdomen
The nurse is performing an abdominal assessment for a patient with diarrhea and auscultates a loud rumbling sound in the left lower quadrant. What will the nurse document this sound as on the nurse's notes?
Borborygmus. Explanation: Borborygmus is a rumbling noise caused by the movement of gas through the intestines, often associated with diarrhea.
In women, which of the following types of cancer exceeds colorectal cancer?
Breast. Explanation: In women, only incidences of breast cancer exceed that of colorectal cancer. In men, only incidences of prostate cancer and lung cancer exceed that of colorectal cancer.
A nurse is providing care for a client who has a diagnosis of irritable bowel syndrome (IBS). When planning this client's care, the nurse should collaborate with the client and prioritize what goal?
Client will accurately identify foods that trigger symptoms.
Which of the following is accurate regarding regional enteritis?
Exacerbations and remissions.
Which term refers to a protrusion of the intestine through a weakened area in the abdominal wall?
Hernia
Crohn's disease is a condition of malabsorption caused by which pathophysiological process?
Inflammation of all layers of intestinal mucosa
The nurse is assessing a patient with appendicitis. The nurse is attempting to elicit a Rovsing's sign. Where should the nurse palpate for this indicator of acute appendicitis?
Left lower quadrant Explanation: Rovsing's sign may be elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt in the right lower quadrant (see Fig. 48-3).
A positive Rovsing's sign is indicative of appendicitis. A nurse knows to assess for this indicator by palpating the:
Left lower quadrant.
As part of the management of constipation, the client is instructed to take 30 mL of mineral oil orally. How does mineral oil facilitate bowel evacuation?
Lubricates and softens fecal matter
Vomiting results in which of the following acid-base imbalances? a) Metabolic alkalosis b) Respiratory acidosis c) Respiratory alkalosis d) Metabolic acidosis
Metabolic alkalosis Explanation: Vomiting results in loss of hydrochloric acid (HCl) and potassium from the stomach, leading to a reduction of chlorides and potassium in the blood and to metabolic alkalosis.
Celiac sprue is an example of which category of malabsorption?
Mucosal disorders causing generalized malabsorption
The nurse is admitting a client with a diagnosis of diverticulitis and assesses that the client has a boardlike abdomen, no bowel sounds, and reports of severe abdominal pain. What is the nurse's first action?
Notify the health care provider.
Which actions would a nurse take when performing an assessment on a client undergoing surgical repair of a hernia? Select all that apply.
Obtain the client's allergy history. Ask whether the client is taking a corticosteroid. Obtain the client's smoking history.
Post appendectomy, a nurse should assess the patient for abdominal rigidity and tenderness, fever, loss of bowel sounds, and tachycardia, all clinical signs of:
Peritonitis. Explanation: 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.
When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report?
Rectal bleeding. Explanation: Internal hemorrhoids cause bleeding but are less likely to cause pain, unless they protrude through the anus. External hemorrhoids may cause few symptoms, or they can produce pain, itching, and soreness of the anal area
A client who has undergone colostomy surgery is experiencing constipation. Which intervention should a nurse consider for such a client?
Suggest fluid intake of at least 2 L/day.
Which of the following outcomes demonstrates the client's understanding of methods to relieve constipation?
The client exercises regularly four to six times a week.
Which outcome indicates effective client teaching to prevent constipation?
The client reports engaging in a regular exercise regimen.
A client's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this client's health problem?
The client's polyps constitute a risk factor for cancer. Explanation: Although most polyps do not develop into invasive neoplasms, they must be identified and followed closely. They are very common, but are not classified as a normal, age-related physiologic change. Diet will not help them resolve and they do not typically lead to obstructions.
Which is a true statement regarding regional enteritis (Crohn's disease)?
The clusters of ulcers take on a cobblestone appearance.
A nurse caring for a patient with colorectal cancer is preparing the patient for upcoming surgery. The nurse administers cephalexin (Keflex) to the patient and explains what rationale?
To reduce intestinal bacteria levels. Explanation: Antibiotics such a kanamycin (Kantrex), neomycin (Mycifradin), and cephalexin (Keflex) are administered orally the day before surgery to reduce intestinal bacterial. Preoperative antibiotics are not given to treat undiagnosed infections, reduce motility, or prevent abdominal distention.
A client admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this client?
Tofu
A client presents to the emergency department with complaints of acute GI distress, bloody diarrhea, weight loss, and fever. Which condition in the family history is most pertinent to the client's current health problem?
Ulcerative colitis Explanation: A family history of ulcerative colitis, particularly if the relative affected is a first-degree relative, increases the likelihood of the client having ulcerative colitis. Although hypertension has familial tendencies, the client's symptoms aren't related to hypertension. A family history of gastroesophageal reflux disease or appendicitis isn't a significant factor in the client history because these conditions aren't considered familial traits.
The nurse is assessing a client for constipation. Which review should the nurse CONDUCT first to identify the cause of constipation?
Usual pattern of elimination Explanation: Constipation has many possible causes and assessing the client's usual pattern of elimination is the first step in identifying the cause. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the client's current medications, diet, and activity levels.
Patients diagnosed with malabsorption syndrome may have vitamin and mineral deficiency. Patient who easily bleed have which of the following deficiencies?
Vitamin K Explanation: The chief result of malabsorption is malnutrition, manifested by weight loss and other signs of vitamin and mineral deficiency (e.g., easy bruising [vitamin K deficiency], osteoporosis [calcium deficiency], and anemia [iron, vitamin B12 deficiency]).
A client is admitted to the emergency department with reports right lower quadrant pain. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the health care provider immediately?
White blood cell (WBC) count 22.8/mm3
Which of the following will the nurse observe as symptoms of perforation in a client with an intestinal obstruction? Select all that apply. a) Sudden, sustained abdominal pain b) Sudden drop in body temperature c) Intermittent, severe pain d) Abdominal distention
a) Sudden, sustained abdominal pain d) Abdominal distention Explanation: 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 factor could lead to the formation of a hernia?
coughing
Which of the following is accurate regarding regional enteritis? a.) Severe diarrhea b.) Severe bleeding c.) No narrowing of the colon d.) Fistulas are common
d.) Fistulas are common Explanation: Fistulas are common with regional enteritis. There is narrowing of the colon, mild bleeding, and diarrhea is less severe than ulcerative colitis.
A client has been experiencing lower GI difficulties that have increased in severity, and the gastroenterologist is concerned that the client's bowel is not functioning properly. What function of the lower GI tract is most likely to be affected by the client's disorder?
water and electrolyte absorption
Which of the following signs would the nurse expect when assessing a client with suspected peritonitis? Select all that apply.
Abdomen feels rigid. Pulse rate is elevated.
What does the nurse recognize as important assessments on a 24-year-old client seen in the emergency room with complaints of abdominal pain? The diagnosis is "rule out appendicitis." Select all that apply.
Abdominal pain currently localized in RLQ Generalized abdominal pain for 24 hours WBC of 16,500 cells/mm3
After assessing a client with peritonitis, the nurse most likely would document the client's bowel sounds as:
Absent. Explanation: Since lack of bowel motility typically accompanies peritonitis, bowel sounds are absent. Therefore, the nurse will not observe mild, high-pitched, or hyperactive bowel sounds.
A client reports having increased incidence of constipation. What can cause constipation? insufficient fiber inactivity emotional stress All options are correct.
All options are correct (insufficient fiber, inactivity, emotional stress). Explanation: Constipation may result from insufficient dietary fiber and water, ignoring or resisting the urge to defecate, emotional stress, use of drugs that tend to slow intestinal motility, or inactivity. It may stem from several disorders, either in the GI tract or systemically.
A longitudinal tear or ulceration in the lining of the anal canal is termed a(n):
Anal fissure.
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 condition?
Anal fissure. Explanation: 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.
Which is the most common presenting symptom of colon cancer?
Change in bowel habits
A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer?
Change in bowel habits. Explanation: The most common presenting symptom associated with colorectal cancer is a change in bowel habits. The passage of blood is the second most common symptom. Symptoms may also include unexplained anemia, anorexia, weight loss, and fatigue. Hemorrhoids and bloating are atypical.
Which of the following is the most common presenting symptom of colon cancer?
Change in bowel habits. Explanation: 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.
The nurse is irrigating a client's colostomy when the client begins to report cramping. What is the appropriate action by the nurse?
Clamp the tubing and allow client to rest. Explanation: The nurse should clamp the tubing and allow the client to rest when the client begins to report cramping during colostomy irrigation. Once the cramping has stopped, the nurse can resume the irrigation.
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. Explanation: 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.
Which of the following laxatives should be used by a cardiac patient who should avoid straining?
Colace. Explanation: 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.
Which statement provides accurate information regarding cancer of the colon and rectum?
Colorectal cancer is the third most common site of cancer in the United States.
A nurse is reviewing the history and physical of a client admitted for a hemorrhoidectomy. Which predisposing condition does the nurse expect to see?
Constipation
A client is having a diagnostic workup for reports of frequent diarrhea, right lower abdominal pain, and weight loss. The nurse is reviewing the results of the barium study and notes the presence of "string sign." What does the nurse understand that this is significant of?
Crohn's disease Explanation: The most conclusive diagnostic aid for Crohn's disease has classically been a barium study of the upper GI tract that shows a "string sign" on an x-ray film of the terminal ileum, indicating the constriction of a segment of intestine.
An older adult client seeks help for chronic constipation. What factor related to aging can cause constipation in elderly clients?
Decreased abdominal strength. Explanation: Decreased abdominal strength, muscle tone of the intestinal wall, and motility all contribute to chronic constipation in the elderly. A decrease in hydrochloric acid causes a decrease in absorption of iron and vitamin B12, whereas an increase in intestinal bacteria actually causes diarrhea.
A nurse is assessing a client's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding?
Document that the stoma appears healthy and well perfused. Explanation: A healthy, viable stoma should be shiny and pink to bright red. This finding does not indicate that the stoma is blocked or that skin integrity is compromised.
The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse's best action?
Document these expected assessment findings. Explanation: Redness and slight bleeding are expected, so no further intervention or assessment is likely necessary.
What information should the nurse include in the teaching plan for a client being treated for diverticulosis?
Drink at least 8 to 10 large glasses of fluid every day. Explanation: The nurse should instruct a client with diverticulosis to drink at least 8 to 10 large glasses of fluid every day. The client 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, regular exercise should be encouraged if the client's current lifestyle is somewhat inactive.
A young woman has been brought into the ED via ambulance, complaining of acute generalized abdominal pain, nausea, fever, and constipation. The healthcare provider suspects appendicitis, but testing has not been performed yet to make a definitive diagnosis. You are the nurse caring for this client. Which of the following will you most likely do while initially caring for this client?
Explain to the client why analgesics are being withheld. Explanation: Analgesics may be withheld initially to avoid masking symptoms that may affect the diagnosis. Avoid multiple or frequent palpation of the abdomen—there is danger of causing the appendix to rupture. Perform the test for rebound tenderness at the end of the examination. A positive response causes pain and muscle spasm and makes it difficult to complete the rest of the assessment. Do not administer laxatives or enemas to a client who is experiencing fever, nausea, and abdominal pain, even though the client may complain of feeling constipated. Laxatives and cathartics may cause the appendix to rupture.
The nurse is caring for a patient who has had an appendectomy. What is the best position for the nurse to maintain the patient in after the surgery?
High Fowler's Explanation: After surgery, the nurse places the patient in a high Fowler's position. This position reduces the tension on the incision and abdominal organs, helping to reduce pain.
During a client's scheduled home visit, an older adult client has stated to the community health nurse that she has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following?
Increased fluid and fiber intake. Explanation: Hemorrhoid symptoms and discomfort can be relieved by good personal hygiene and by avoiding excessive straining during defecation. A high-residue diet that contains fruit and bran along with an increased fluid intake may be all the treatment that is necessary to promote the passage of soft, bulky stools to prevent straining. Antibiotics, regular use of suppositories, and NSAIDs are not recommended, as they do not address the etiology of the health problem.
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. Explanation: 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 statement should the nurse include in the program?
It is the third most common cancer in the United States. Explanation: 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 is suspected to have diverticulosis without symptoms of diverticulitis. What diagnostic test does the nurse anticipate educating the patient about prior to scheduling?
Keep a 1- to 2-week symptom and food diary to identify food triggers.
A client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes?
Maintaining fluid and electrolyte balance. Explanation: All of the listed focuses of care are important for the client with a small bowel obstruction. However, the client's risk of fluid and electrolyte imbalances is an immediate threat to safety, and is a priority in nursing assessment and interventions.
The nurse is caring for an older adult patient experiencing fecal incontinence. When planning the care of this patient, what should the nurse designate as a priority goal?
Maintaining skin integrity. Explanation: Fecal incontinence can disrupt perineal skin integrity. Maintaining skin integrity is a priority, especially in the debilitated or older adult patient.
The nurse is admitting a client with a diagnosis of diverticulitis and assesses that the client has a board-like abdomen, no bowel sounds, and reports of severe abdominal pain. What is the nurse's first action?
Notify the health care provider. Explanation: Abdominal pain, a rigid board-like 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 health care provider.
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?
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. Explanation: 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.
The nurse is monitoring a client's postoperative course after an appendectomy. The nurse's assessment reveals that the client has vomited, has abdominal tenderness and rigidity, and has tachycardia. The nurse reports to the physician that the client has signs/symptoms of which complication?
Peritonitis. Explanation: The nurse should report to the physician that the client has signs/symptoms of peritonitis. Signs/symptoms of a pelvic abscess include anorexia, chills, fever, diaphoresis, and diarrhea. Signs/symptoms of an ileus include absent bowel sounds, nausea, and abdominal distention. Signs/symptoms of hemorrhage include tachycardia, hypotension, anxiety, and bleeding.
A nurse is interviewing a client about past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
Polyps. Explanation: 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
A client's large bowel obstruction has failed to resolve spontaneously and the client's worsening condition has warranted admission to the medical unit. Which of the following aspect of nursing care is most appropriate for this client?
Preparing the client for surgical bowel resection
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 Explanation: 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.
A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has not had ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action?
Report signs and symptoms of obstruction to the health care provider. Explanation: It is important to report nausea and abdominal distention, which may indicate intestinal obstruction. This requires prompt medical intervention. Referral to the WOC nurse is not an appropriate short-term response, since medical treatment is necessary. Physical mobility will not normally resolve an obstruction. There is no need to collect a culture from the stoma because infection is unrelated to this problem.
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 Explanation: 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 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis?
Risk for Infection Related to Possible Rupture of Appendix. Explanation: The client with a diagnosis of appendicitis has an acute risk of infection related to the possibility of rupture. This immediate physiologic risk is a priority over nutrition and constipation, though each of these concerns should be addressed by the nurse. The pain associated with appendicitis is acute, not chronic.
A teenage client with a pilonidal cyst has been brought for care by her mother. The nurse who is contributing to the client's care knows that treatment will be chosen based on what risk?
Risk for infection Explanation: Pilonidal cysts frequently develop into an abscess, necessitating surgical repair. These cysts do not contribute to bowel incontinence, constipation, or impaired tissue perfusion.
Which category of laxatives draws water into the intestines by osmosis?
Saline agents (e.g., magnesium hydroxide)
A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis?
Sigmoidoscopy Explanation: Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal cancer.
A nurse caring for a patient with regional enteritis knows to assess for this most serious systemic complication. What is that complication?
Small bowel obstruction
A client 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 Explanation: 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 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. Explanation: 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
Which is a true statement regarding regional enteritis (Crohn's disease)?
The clusters of ulcers take on a cobblestone appearance. Explanation: 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.
An older adult has a diagnosis of Alzheimer disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the client's stools. What is the nurse's most appropriate intervention?
Toilet the client on a frequent, scheduled basis. Explanation: Because the client's fecal incontinence is most likely attributable to cognitive decline, frequent toileting is an appropriate intervention. Loperamide is unnecessary in the absence of diarrhea. Specific foods are not likely to be a cause of, or solution to, this client's health problem.
The presence of mucus and pus in the stools suggests which of the following conditions?
Ulcerative colitis Explanation: 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.
The presence of mucus and pus in the stools suggests which condition?
Ulcerative colitis Explanation: 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.
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 Explanation: Constipation has many possible reasons and assessing the client's usual pattern of elimination is the first step in identifying the cause. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the client's current medications, diet, and activity levels.
A client has a history of inflammatory bowel disease and is undergoing procedures to determine the best treatment for the current symptoms. What is believed to cause inflammatory bowel disease?
autoimmunity Explanation: The term IBD refers to several chronic digestive disorders believed to result from the immune system attacking the bowel
Diet therapy for clients diagnosed with irritable bowel syndrome (IBS) includes:
high-fiber diet. Explanation: A high-fiber diet is prescribed to help control constipation. Individuals experiencing diarrhea may be advised to eat a low-fiber diet. Foods that are possible irritants, such as caffeine, spicy foods, lactose, beans, fried foods, corn, wheat, and alcohol, should be avoided. Fluids should not be taken with meals because they cause abdominal distention.
A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation?
lack of free water intake. Explanation: A client who cannot swallow food cannot drink enough water to meet daily needs. Inadequate fluid intake is a common cause of constipation.
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. Explanation: 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.
When planning care for a client with a small-bowel obstruction, the nurse should consider the primary goal to be:
maintaining fluid balance. Explanation: Because a client with a small-bowel obstruction can't tolerate oral intake, fluid volume deficit may occur and can be life-threatening. Therefore, maintaining fluid balance is the primary goal. Pain relief and maintaining body weight don't reflect life-threatening conditions, and the client's normal bowel pattern can be reestablished after fluid volume is stabilized.
Which client requires immediate nursing intervention? The client who:
presents with a rigid, board-like abdomen. Explanation: A rigid, board-like 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.
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"?
stool consistency and client comfort
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"?
stool consistency and client comfort. Explanation: 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.
A nurse is teaching an older adult client about good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?
"I need to use laxatives regularly to prevent constipation." Explanation: 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 client presents with an infection in the area between the internal and external sphincters. In which chronic disease is this condition commonly seen?
Crohn's disease. Explanation: An anorectal abscess is common in clients with Crohn's disease.
Which of the following is considered a bulk-forming laxative?
Metamucil
A typical sign/symptom of appendicitis is:
nausea. Explanation: Nausea, with or without vomiting, is typically associated with appendicitis. Pain is generally felt in the right lower quadrant. Rebound tenderness, or pain felt upon the release of pressure applied to the abdomen, may be present with appendicitis. Low-grade fever is associated with appendicitis.
A client has been recently diagnosed with an anorectal condition. The nurse is reviewing interventions that will assist the client with managing his therapeutic regimen. Which of the following would not be included?
Encourage client to avoid exercise. Explanation: Activity promotes healing and normal stool patterns. These measures prevent infection and irritation. Sitz baths promote healing, decrease skin irritation, and relieve rectal spasms. Encouragement promotes compliance with therapeutic regimen and prevents complications.
A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has had not ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action?
Report signs and symptoms of obstruction to the health care provider.
Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?
Sudden, sustained abdominal pain
A client has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving his diet. When introducing the client to the use of laxatives, what teaching should the nurse emphasize?
The risk of becoming laxative-dependent. Explanation: Laxatives should not normally be used on an ongoing basis because of the risk of dependence. In most cases they have a minimal effect on electrolyte levels. A client who has increased activity and improved diet likely has an understanding of the usual causes of constipation. Excessive laxative use could lead to diarrhea or fecal incontinence, but for most clients the risk of dependence is more significant.
A client reports severe pain and bleeding while having a bowel movement. Upon inspection, the health care provider notes a linear tear in the anal canal tissue. The client is diagnosed with a:
fissure. Explanation: 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. Hemorrhoids are dilated veins outside or inside the anal sphincter. A pilonidal sinus is an infection in the hair follicles in the sacrococcygeal area above the anus.
A nurse is preparing a client with a long history of ulcerative colitis for first stage surgery to remove the colon. Which of the client's statements indicates that the client requires more preoperative education?
"I will have an ileostomy for the rest of my life."
The nurse is caring for four clients with diarrhea. Which client is most likely to be diagnosed with Crohn's disease?
A 24 year-old Caucasian eastern European Jewish female. Explanation: Clients who are more prone to this disorder include those with a family history of the disease, those who are white with a European and/or Jewish ancestry, and those who smoke. The other client's listed do not have these risk factors.
Mr. Munster, a client in the primary care office where you work, reports having increased incidence of constipation. You complete your assessment and discuss the potential causes with Mr. Munster. What can cause constipation? a) Emotional stress b) Insufficient fiber c) All options are correct. d) Inactivity
All options are correct. Explanation: Constipation may result from insufficient dietary fiber and water, ignoring or resisting the urge to defecate, emotional stress, use of drugs that tend to slow intestinal motility, or inactivity. It may stem from several disorders, either in the GI tract or systemically.
What is the primary nursing diagnosis for a client with a bowel obstruction?
Deficient fluid volume Explanation: Feces, fluid, and gas accumulate above a bowel obstruction. Then the absorption of fluids decreases and gastric secretions increase. This process leads to a loss of fluids and electrolytes in circulation. Therefore, Deficient fluid volume is the primary diagnosis. Deficient knowledge, Acute pain, and Ineffective tissue perfusion are applicable but not the primary nursing diagnosis.
Which is one of the primary symptoms of irritable bowel syndrome (IBS)?
Diarrhea. Explanation: The primary symptoms of IBS include constipation, diarrhea, or a combination of both. Pain, bloating, and abdominal distention often accompany changes in bowel pattern.
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. Explanation: The nurse should teach the client without peristomal skin irritation to dry the skin thoroughly after washing. Barrier powder, triamcinolone acetonide spray, and nystatin powder are used when the client has peristomal skin irritation and/or fungal infection.
A client has been recently diagnosed with an anorectal condition. The nurse is reviewing interventions that will assist the client with managing the therapeutic regimen. What would not be included?
Encourage the client to avoid exercise. Explanation: Activity promotes healing and normal stool patterns. Proper cleansing prevents infection and irritation. Sitz baths promote healing, decrease skin irritation, and relieve rectal spasms. Encouragement promotes compliance with therapeutic regimen and prevents complications.
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 Explanation: Endoscopy with biopsy of the mucosa is the best diagnostic tool for malabsorption syndrome.
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.
A nurse is planning discharge teaching for a 21-year-old client with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the client's coping after discharge?
The family's ability to provide emotional support. Explanation: Emotional support from the family is key to the client's coping after discharge. A 21-year-old would be expected to self-manage the prescribed medication regimen and the family would not be primarily responsible for monitoring the client's health status. It is highly beneficial if the family is willing and able to accommodate the client's dietary needs, but emotional support is paramount and cannot be solely provided by the client alone.
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?
Wound dehiscence has occurred. Explanation: 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).
A nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. What else would the nurse expect to find?
severe abdominal pain with direct palpation or rebound tenderness. Explanation: 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 (i.e., appendicitis, diverticulitis, ulcerative colitis, 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.
The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be
solid. Explanation: With a sigmoid colostomy, the feces are solid. With a descending colostomy, the feces are semimushy. With a transverse colostomy, the feces are mushy. With an ascending colostomy, the feces are fluid.
