Med Surg Chapter 24
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 tells the nurse, "I am not having normal bowel movements." When differentiating between what are normal and abnormal bowel habits, what indicators are the most important?
The consistency of stool and comfort when passing stool
A client informs the nurse that he is taking a stimulant laxative in order to be able to have a bowel movement daily. What should the nurse inform the client about taking a stimulant laxative?
They can be habit forming and will require increasing doses to be effective
A man with severe ulcerative colitis has been informed by his health care provider that he will require a colectomy and an ileostomy. The patient has been told by his health care provider that he is candidate for a continent ileal reservoir (Kock pouch). The patient's nurse recognizes which of the following advantages to the use of a Kock pouch as an alternative to the creation of an ileal stoma?
The patient will not have to wear an external collection bag
A nurse is presenting an educational event to a local community group and is speaking about colorectal cancer. What would the nurse identify as a risk factor associated with colorectal cancer?
age greater than 50
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 recommended dietary approach to treat Crohn's disease?
dietary approach varies.
Which is the most common presenting symptom of colon cancer?
Change in bowel habits
When interviewing a client with internal hemorrhoids, what would the nurse expect the client to report?
Rectal bleeding
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.
In addition to teaching a client with constipation to increase dietary fiber intake to 25 g/day, which of the following would the nurse include as important?
Adding fiber-rich foods to the diet gradually
Which is one of the primary symptoms of irritable bowel syndrome (IBS)?
Diarrhea
A community health nurse is performing a home visit to a 53-year-old patient who requires twice-weekly wound care on her foot. The patient mentions that she is currently having hemorrhoids, a problem that she has not previously experienced. What treatment measure should the nurse recommend to this patient?
A high-fiber diet with increased fruit intake
A nurse is preparing a presentation for a local community group of older adults about colon cancer. What would the nurse include as the primary characteristic associated with this disorder?
A change in bowel habits
The nurse is caring for a patient admitted with symptoms of an anorectal infection. Cultures obtained from a rectal swab indicate that the patient has a viral infection. What medication will the nurse anticipate the health care provider to order for this anorectal infection?
Acyclovir (Zovirax)
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 61-year-old woman presented to a scheduled appointment with her nurse practitioner, stating, "I'm having a lot of trouble with constipation over the past few months." What action should the nurse first take in response to this patient's health complaint?
Assess the woman's typical bowel patterns and her expectations for bowel function.
A client reports constipation. Which nursing measure would be most effective in helping the client reduce constipation?
Assist client to increase dietary fiber.
Which of the following would a nurse expect to assess in a client with peritonitis?
Board-like abdomen
A client informs the nurse that he has been having abdominal pain that is relieved when having a bowel movement. The client states that the physician told him he has irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder?
Chronic constipation with sporadic bouts of diarrhea
The nurse is caring for a patient who is postoperative day 3 following bowel resection and the creation of a colostomy. While changing the dressing, the nurse notes the stoma is dusky in color. How should the nurse interpret this assessment finding?
Circulation to the stoma is compromised.
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.
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.
The nurse is performing a community screening for colorectal cancer. Which characteristic should the nurse include in the screening?
Familial polyposis
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
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
An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to?
Hypokalemia
A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, what would the nurse stress the importance of?
Increasing fluid intake to prevent dehydration
The nurse is aware that many of the diseases of the lower gastrointestinal tract can be identified by the characteristics of the patient's stool. What would voluminous, greasy stools suggest?
Intestinal malabsorption
A 75-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. An emergency room nurse is obtaining assessment data from this patient. What assessment finding is characteristic of a small bowel obstruction?
Nausea and vomiting
Clostridium difficile infection has been moving through an extended-care facility, and several of the elderly residents have been experiencing severe diarrhea. One particularly sick resident has told the nurse that he is now experiencing extreme fatigue and muscle cramps and that his heart feels like it occasionally "skips a beat." The nurse should facilitate a stat assessment of this resident's
Potassium levels
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
client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and board-like. What complication does the nurse determine may be occurring at this time?
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 16-year-old girl presents at the emergency department complaining of right lower quadrant pain and is diagnosed with appendicitis. When assessing this patient, what signs or symptoms should the nurse expect to find?
Rebound tenderness, McBurney's sign, low-grade fever
A nurse on a medical unit is receiving morning report on a patient who has been admitted to the unit for the treatment of peritonitis. When providing this patient's care, the nurse should prioritize assessments relevant to what problem?
Sepsis
The nursing educator is teaching a group of nurses about constipation and the elderly. What recommendation for this population should a nurse can make about treating chronic constipation?
Take a stool softener, such as docusate sodium (Colace), daily.
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.
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.
A client describes being constipated, but also experiencing abdominal cramping, pain, and urgent diarrhea. These symptoms occur more often when the client is nearing a deadline or is under emotional stress. What would be recommended to treat these symptoms? Select all that apply.
high-fiber diet psyllium
Diet therapy for clients diagnosed with irritable bowel syndrome (IBS) includes:
high-fiber diet.
Which client requires immediate nursing intervention? The client who:
presents with a rigid board like 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
The nurse teaches the client whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be
solid.
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
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? Serum potassium 4.2 mEq/L White blood cell (WBC) count 22.8/mm3 Serum sodium 135 mEq/L Hematocrit 42%
White blood cell (WBC) count 22.8/mm3
