Chapter 48 (easy)
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? A. Tenesmus B. Borborygmus C. Peristalsis D. Loud bowel sounds
B R: Borborygmus is a rumbling noise caused by the movement of gas through the intestines, often associated with diarrhea.
When a nurse recommends the following laxative, she emphasizes that it should not be taken with meals. Choose the laxative. A. Colace B. Mineral Oil C. Dulcolax D. Metamucil
B R:Mineral oil should never be taken with meals because it can impair the absorption of fat-soluble vitamins and delay gastric emptying. Refer to Table 24-1 in the text.
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. Abdominal distention B. Abdominal pain C. A change in bowel habits D. Frank blood in the stool
C R: 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.
The nurse is monitoring a patient's postoperative course after an appendectomy. The nurse's assessment reveals that the patient has vomited, has abdominal tenderness and rigidity, and has tachycardia. The nurse's report to the physician is that the patient has signs/symptoms of which of the following complications? A. Hemorrhage B. Pelvic abscess C. Ileus D. Peritonitis
D R:The nurse should report to the physician that the patient 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.
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? A. Left lower quadrant B. Left upper quadrant C. Right lower quadrant D. Right upper quadrant
A R: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).
When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report? A. Soreness B. Rectal bleeding C. Itching D. Pain
B. R: 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.
The nurse caring for a patient with diverticulitis is preparing to administer the patient's medications. The nurse anticipates administration of which category of medications due to the patient's diverticulitis? A. Antispasmodic B. Anti-inflammatory C. Antiemetic D. Antianxiety
A R: The nurse anticipates administration of antispasmodic medication to decrease intestinal spasm associated with diverticulitis. The patient may also be ordered an opioid analgesic to relieve the associated pain. There is no indication that the patient needs antianxiety, antiemetic, or anti-inflammatory medications at this time.
The nurse is performing a community screening for colorectal cancer. Which of the following characteristics should the nurse include in the screening? A. Familial polyposis B. History of skin cancer C. Low-fat, low-protein, high-fiber diet D. Being younger than 40 years of age
A R: 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.
The nurse is assessing a client for constipation. To identify the cause of constipation, the nurse should begin by reviewing the client's: A. activity levels. B. alcohol consumption. C. current medications. D. usual pattern of elimination.
D R:Constipation has many possible reasons; assessing the client's usual pattern of elimination is the first step in identifying the cause.
The nurse is caring for a client with intussusception of the bowel. What does the nurse understand occurs with this disorder? A. The bowel protrudes through a weakened area in the abdominal wall. B. A loop of intestine adheres to an area that is healing slowly after surgery. C. The bowel twists and turns itself and obstructs the intestinal lumen. D. One part of the intestine telescopes into another portion of the intestine.
D R: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 with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation? A. Provide adequate quantity of food. B. Assist client to increase dietary fiber. C. Obtain medical and allergy history. D. Obtain complete food history.
B R: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.
Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. The nurse also expects to find: A. tenderness and pain in the right upper abdominal quadrant. B. rectal bleeding and a change in bowel habits. C. severe abdominal pain with direct palpation or rebound tenderness. D. jaundice and vomiting.
C R: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 (such as appendicitis, diverticulitis, ulcerative colitis, or 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.
Which client requires immediate nursing intervention? The client who: A. presents with ribbonlike stools. B. complains of anorexia and periumbilical pain. C. complains of epigastric pain after eating. D. presents with a rigid, boardlike abdomen.
D R: 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.
The nurse is caring for a patient with a suspected megacolon. The nurse anticipates that one of the findings on assessment will include which of the following? A. Diarrhea B. Dark, tarry stools C. Hemorrhoids D. Fecal incontinence
D R: The nurse should anticipate fecal incontinence as one of the assessment findings. Other possible assessment findings include constipation and abdominal distention.
Which of the following would a nurse expect to assess in a client with peritonitis? A. Board-like abdomen B. Decreased pulse rate C. Deep slow respirations D. Hyperactive bowel sounds
A R:The client with peritonitis would typically exhibit a rigid, board-like abdomen, with absent bowel sounds, elevated pulse rate, and rapid, shallow respirations.
The nurse is performing and documenting the findings of an abdominal assessment. When the nurse hears intestinal rumbling and the patient then experiences diarrhea, the nurse documents the presence of which of the following? A. Diverticulitis B. Tenesmus C. Azotorrhea D. Borborygmus
D R: 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.
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? A. Keep a 1- to 2-week symptom and food diary to identify food triggers. B. Begin an exercise regimen and biofeedback to determine if external stress is a trigger. C. Discontinue the use of any medication presently being taken to determine if medication is a trigger. D. Document how much fluid is being taken to determine if the patient is overhydrating.
A R: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.
Which of the following is one of the primary symptoms of irritable bowel syndrome (IBS)? A. Bloating B. Diarrhea C. Pain D. Abdominal distention
B R: The primary symptoms of IBS include constipation, diarrhea, or a combination of both. Pain, bloating, and abdominal distention often accompany changes in bowel pattern.
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? A. Appendicitis B. Crohn's disease C. Diverticulitis D. Ulcerative colitis
A R: In up to 50% of presenting cases of appendicitis, local tenderness is elicited at McBurney's point when pressure is applied (Black & Martin, 2012) (Fig. 48-3). Rebound tenderness (i.e., production or intensification of pain when pressure is released) may be present.
A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate? A. Scrubbing fecal material from the skin surrounding the stoma B. Gently washing the area surrounding the stoma using a facecloth and mild soap C. Maintaining wrinkles in the faceplate so it doesn't irritate the skin D. Cutting the faceplate opening no more than 2? larger than the stoma
B R: 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 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? A. Administer topical ointment to the rectal area to decrease bleeding. B. Test all stools for occult blood. C. Administer morphine (Duramorph PF) routinely, as ordered. D. Prepare the client for a gastrostomy tube placement.
B R: 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
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? A. Serum potassium 4.2 mEq/L B. White blood cell (WBC) count 22.8/mm3 C. Hematocrit 42% D. Serum sodium 135 mEq/L
B R: 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 client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? A. Right upper quadrant B. Right lower quadrant D. Left upper quadrant C. Left lower quadrant
B R: 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 client has noticed increased incidence of constipation since a broken ankle caused the client to discontinue taking a daily 3-mile walk. During client education, what does the nurse explain as the mechanical cause of this constipation? A. ingesting excessive fiber B. stool remaining in the large intestine too long C. no known cause D. drinking excessive water
B R: Whenever stool remains stationary in the large intestine, moisture continues to be absorbed from the residue. Consequently, retention of stool, for any number of reasons, causes stool to become dry and hard.
An elderly 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"? A. two bowel movements daily B. stool consistency and client comfort C. one bowel movement daily D. one bowel movement every other day
B R: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.
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? A. Replace the fluid with cooler water since it is probably too warm. B. Clamp the tubing and give the patient a rest period. C. Stop the irrigation and remove the tube. D. Inform the patient that it will only last a minute and continue with the procedure.
B R: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.
Diet therapy for patients diagnosed with IBS include which of the following? A. Spicy foods B. Fluids with meals C. High-fiber diet D. Caffeinated products
C R: 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.
Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction? A. Decreased blood pressure B. Purulent drainage from the gluteal fold C. Sudden, sustained abdominal pain D. Decreased urine output
C R: 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 client realizes that regular use of laxatives has greatly improved his bowel pattern. However, the nurse cautions this client against the prolonged use of laxatives for which reason? A. The client may develop arthritis or arthralgia. B. The client may lose his appetite. C. The client may develop inflammatory bowel disease. D. The client's natural bowel function may become sluggish.
D R: It is essential for the nurse to caution the client against the prolonged use of laxatives because it decreases muscle tone in the large intestine. Prolonged use of laxatives may cause the client's natural bowel function to become sluggish. Laxatives do not increase the risk of developing inflammatory bowel disease, arthritis, or arthralgia, nor do they cause a loss in appetite.
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? A. Dust with nystatin powder B. Apply Kenalog spray C. Apply barrier powder D. Dry skin thoroughly after washing
D R: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.
Teach the client how to do sitz baths at home using warm water three to four times each day. Encourage the client to follow diet and medication instructions. Instruct the client to cleanse perianal area with warm water. Encourage the client to avoid exercise. A. Teach the client how to do sitz baths at home using warm water three to four times each day. B. Encourage the client to follow diet and medication instructions. C. Instruct the client to cleanse perianal area with warm water. D. Encourage the client to avoid exercise.
D R: 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.
A patient with an ileostomy should avoid?
Enteric coated products R: Patients with an ileostomy should avoid enteric-coated products and some modified-release drugs, such as slow-release beads and layered tablets. This is because these products may pass through without being absorbed. Preparations such as slow-K (potassium chloride) leave a "ghost" of the wax matrix coating, but that does not indicate the drug has been unabsorbed. It is not essential for the patient to avoid antacids and antibiotics if they have been prescribed.
The nurse is reinforcing diet teaching for a patient diagnosed with IBS. The nurse instructs the patient to include which of the following in his diet? A. Caffeinated products B. Spicy foods C. Fluids with meals D. High-fiber diet
D R: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, and alcohol, should be avoided. Fluids should not be taken with meals because this results in abdominal distention.
Post appendectomy, a nurse should assess the patient for abdominal rigidity and tenderness, fever, loss of bowel sounds, and tachycardia, all clinical signs of: A. Peritonitis B. An ileus. C. A pelvic abscess. D. An abscess under the diaphragm.
A R: 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.
Which of the following is a true statement regarding regional enteritis (Crohn's disease)? A. The clusters of ulcers take on a cobblestone appearance. B. It has a progressive disease pattern. C. It is characterized by lower left quadrant abdominal pain. D. The lesions are in continuous contact with one another.
A R: 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.
After teaching a group of students about irritable bowel syndrome and antidiarrheal agents, the instructor determines that the teaching was effective when the students identify which of the following as an example of an opiate-related antidiarrheal agent? A. Loperamide (Imodium) B. Bisacodyl (Dulcolax) C. Kaolin and pectin (Kaopectate) D. Bismuth subsalicylate (Pepto-Bismol)
R: Loperamide (Imodium) and diphenoxylate with atropine sulfate (Lomotil) are examples of opiate-related antidiarrheal agents. Bismuth subsalicylate (Pepto-Bismol) and kaolin and pectin (Kaopectate) are examples of absorbent antidiarrheal agents. Biscodyl (Dulcolax) is a chemical stimulant laxative.
A client reports severe pain and bleeding while having a bowel movement. Upon inspection, the healthcare provider notes a linear tear in the anal canal tissue. The client is diagnosed with a: A. fissure. B. fistula. C. hemorrhoid. D. pilonidal cyst.
A R: 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.
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? A. Take a stool softener such as docusate sodium (Colace) daily. B. Take a mild laxative such as magnesium citrate when necessary. C. Administer a phospho-soda (Fleet) enema when necessary. D. Administer a tap-water enema weekly.
A R:Stool softeners taken daily promote absorption of liquid into the stool, creating a softer mass. They may be taken on a daily basis without developing a dependence. Dependence is an adverse effect of daily laxative use. Enemas used daily or on a frequent basis can also lead to dependence of the bowel on an external source of stimulation.
Crohn's disease is a condition of malabsorption caused by which of the following pathophysiological processes? A. Infectious disease B. Inflammation of all layers of intestinal mucosa C. Disaccharidase deficiency D. Gastric resection
B R: Crohn's disease, also known as regional enteritis, can occur anywhere along the GI tract, but most commonly at the distal ileum and in the colon. Infectious disease causes problems such as small bowel bacterial overgrowth leading to malabsorption. Disaccharidase deficiency leads to lactose intolerance. Postoperative malabsorption occurs after gastric or intestinal resection.
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? A. Supine with head of bed elevated 15 degrees B. High Fowler's C. Sims' left lateral D. Prone
B R: 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.
Which of the following is the most common symptom of a polyp? A. Abdominal pain B. Anorexia C. Rectal bleeding D. Diarrhea
C R: The most common symptom is rectal bleeding. Lower abdominal pain may also occur. Diarrhea and anorexia are clinical manifestations of ulcerative colitis.
A patient visited a nurse practitioner because he had diarrhea for 2 weeks. He described his stool as large and greasy. The nurse knows that this description is consistent with a diagnosis of: A. Inflammatory colitis. B. A disorder of the large bowel. C. Intestinal malabsorption. D. A small bowel disorder.
C R:Watery stools are characteristic of disorders of the small bowel, whereas loose, semisolid stools are associated more often with disorders of the large bowel. Large, greasy stools suggest intestinal malabsorption, and the presence of mucus and pus in the stools suggests inflammatory enteritis or colitis.
An elderly patient diagnosed with diarrhea is taking digoxin (Lanoxin). Which of the following electrolyte imbalances should the nurse be alert to? A. Hyperkalemia B. Hypernatremia C. Hyponatremia D. Hypokalemia
D R: The older person taking digitalis must be aware of how quickly dehydration and hypokalemia can occur with diarrhea. The nurse teaches the patient to recognize the symptoms of hypokalemia because low levels of potassium intensify the action of digitalis, leading to digitalis toxicity.
Which of the following is the most common presenting symptom of colon cancer? A. Change in bowel habits B. Weight loss C. Fatigue D. Anorexia
A R: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.
Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following? A. Calorie restriction B. Iron restriction C. Low protein D. Low residue
D R: 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.
A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma? A. "A burning sensation under the stoma faceplate is normal." B. "The stoma should appear dark and have a bluish hue." C. "At first, the stoma may bleed slightly when touched." D. "The stoma should remain swollen distal to the abdomen."
C R: The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown.
Which of the following is the most common symptom of a polyp? A. Abdominal pain B. Diarrhea C. Rectal bleeding D. Anorexia
C R: The most common symptom is rectal bleeding. Lower abdominal pain may also occur. Diarrhea and anorexia are clinical manifestations of ulcerative colitis.
A patient is being seen in the clinic for complaints of painful hemorrhoids. The nurse assesses the patient and observes the hemorrhoids are prolapsed but able to be placed back in the rectum manually. The nurse documents the hemorrhoids as what degree? A. Second degree B. First degree C. Third degree D. Fourth degree
C R: First degree hemorrhoids do not prolapse and protrude into the anal canal. Second degree hemorrhoids prolapse outside the anal canal during defecation but reduce spontaneously. Third degree hemorrhoids prolapse to the extent that they require manual reduction. Fourth degree hemorrhoids prolapse to the extent that they may not be reduced.
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? A. increased fiber B. lack of solid food C. lack of exercise D. lack of free water intake
D R: A client who cannot swallow food cannot drink enough water to meet daily needs. Inadequate fluid intake is a common cause of constipation.
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? A. Daily bowel movements B. Abdominal cramping when having a bowel movement C. Excess gas D. Change in bowel habits
D R: 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.
A nurse is caring for a client immediately following an appendectomy. The nurse should assign which nursing diagnosis the highest priority? A. Excess fluid volume B. Risk for constipation C. Deficient knowledge (postoperative care) D. Acute pain
D R: 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.
A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult? A. "I don't like oatmeal, so it doesn't matter that I can't have it." B. "I don't understand why this happened again; I didn't travel out of the country." C. "I don't understand this; I took the medication the doctor ordered and followed the diet." D. "I didn't eat anything I shouldn't have; I just ate roast beef on rye bread."
D R: The client stating that he ate roast beef on rye bread indicates the need for a dietary consult because rye bread contains gluten, which must be eliminated from the client's diet. The client stating that he's followed the ordered medication regimen and diet doesn't suggest that the client needs a dietary consult; a treatment regimen consisting of medications to improve symptoms and dietary modification is necessary to treat celiac disease. The client stating that he hasn't traveled outside of the country doesn't suggest that dietary concerns exist. The client saying that he can't have oatmeal shows an understanding of the dietary restrictions necessary with celiac disease.
Common clinical manifestations of Crohn's disease include: A. Nausea and vomiting. B. Obstruction and paralytic ileus. C. Edema and weight gain. D. Abdominal pain and diarrhea.
D R: The onset of symptoms is usually insidious in regional enteritis, with prominent lower right quadrant abdominal pain that is unrelieved by defecation and the presence of diarrhea.
