prepu chapter 46
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.
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
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
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
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.
A longitudinal tear or ulceration in the lining of the anal canal is termed a(n):
anal fissure.
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.
Diet therapy for clients diagnosed with irritable bowel syndrome (IBS) includes:
high-fiber diet.
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.
A typical sign/symptom of appendicitis is:
nausea
Which client requires immediate nursing intervention? The client who:
presents with a rigid, boardlike abdomen.
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
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."
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.
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
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
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
A positive Rovsing's sign is indicative of appendicitis. A nurse knows to assess for this indicator by palpating the:
Left lower quadrant.
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
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 client's food and fluid intake.
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
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
Which is the most common presenting symptom of colon cancer?
Change in bowel habits
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.
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.
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 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 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.
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.
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
The nurse is conducting discharge teaching for a client with diverticulosis. Which instruction should the nurse include in the teaching?
Drink 8 to 10 glasses of fluid daily.
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
A patient is being treated for diverticulosis. Which information should the nurse include in this patient'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
Which of the following is accurate regarding regional enteritis?
Exacerbations and remissions
The nurse is performing a community screening for colorectal cancer. Which characteristic should the nurse include in the screening?
Familial polyposis
Which characteristic is a risk factor for colorectal cancer?
Familial polyposis
Which term refers to a protrusion of the intestine through a weakened area in the abdominal wall?
Hernia
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
Crohn's disease is a condition of malabsorption caused by which pathophysiological process?
Inflammation of all layers of intestinal mucosa
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.
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 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 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
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 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
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
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
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.
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
Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?
Sudden, sustained abdominal pain
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
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.
Which outcome indicates effective client teaching to prevent constipation?
The client reports engaging in a regular exercise regimen.
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
The nurse is assessing a client for constipation. To identify the cause of constipation, the nurse should begin by reviewing the client's:
usual pattern of elimination.
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