48 chapter exam 1
Effie Geitgey, a 93-year-old retired waitress, obsesses about the regularity of her bowel movements, which is a common complaint among the residents of the long-term care facility where you practice nursing. During one of your education sessions, you reinforce the medically acceptable definition of "regularity." What is the actual measurement of "regular"? Stool consistency and client comfort are the proper measurements. One bowel movement daily One bowel movement every other day Two bowel movements daily
Stool consistency and client comfort are the proper measurements. 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.
The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to? Referred pain Rebound pain Rovsing's sign Cremasteric reflex
Rovsing's sign Explanation: When an examiner deeply palpates the left lower abdominal quadrant and the client feels pain in the RLQ, this is referred to as a positive Rovsing's sign and suggests acute appendicitis. Referred pain indicates pain in another area but is not necessarily manipulated by the examiner. Rebound pain is indicated when the pain of palpation is worse when the pressure is off of the site. The cremasteric reflex is a superficial reflex that is present in male patients.
Patients diagnosed with malabsorption syndrome may have vitamin and mineral deficiency. Patient who easily bleed have which of the following deficiencies? Vitamin K Calcium Iron B12
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]).
After assessing a client with peritonitis, the nurse most likely would document the client's bowel sounds as: Mild. High-pitched. Hyperactive. Absent.
Absent. 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.
When preparing a client for a hemorrhoidectomy, the nurse should take which action? Administer an enema as ordered. Administer oral antibiotics as ordered. Administer topical antibiotics as ordered. Administer analgesics as ordered.
Administer an enema as ordered. Explanation: When preparing a client for a hemorrhoidectomy, the nurse should administer an enema, as ordered, and record the results. After surgery, the client may require antibiotics and analgesics.
A 50-year-old woman is brought into the ED with symptoms suggestive of peritonitis. Nursing management would include all of the following, except? Analgesics are limited to avoid the formation of paralytic ileus. Accurate recording of input and output Insertion of nasogastric tube Insertion of urinary retention catheter
Analgesics are limited to avoid the formation of paralytic ileus. Explanation: Analgesics such as meperidine or IV morphine sulfate are ordered to relieve pain and promote rest. Because hypovolemia can occur from fluids leaking into the peritoneal cavity, I & O is monitored closely to assist in determining fluid replacement. A nasogastric tube is used to relieve abdominal distention by suctioning the accumulated gas and stagnant upper GI fluids. If hypovolemia is present, renal perfusion can become decreased, requiring close monitoring.
A patient informs the nurse that he has been having abdominal pain that is relieved when having a bowel movement. The patient states that the physician told him he has irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder? Weight loss due to malabsorption Blood and mucus in the stool Chronic constipation with sporadic bouts of diarrhea Client is awakened from sleep due to abdominal pain.
Chronic constipation with sporadic bouts of diarrhea Explanation: Most clients with IBS describe having chronic constipation with sporadic bouts of diarrhea. Some report the opposite pattern, although less commonly. Most clients experience various degrees of abdominal pain that defecation may relieve. Weight usually remains stable, indicating that when diarrhea occurs, malabsorption of nutrients does not accompany it. Stools may have mucus, but blood is not usually found because the bowel is not locally inflamed. The sleep is not disturbed from abdominal pain.
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? Inform the patient that it will only last a minute and continue with the procedure. Clamp the tubing and give the patient a rest period. Stop the irrigation and remove the tube. Replace the fluid with cooler water since it is probably too warm.
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.
A client is being treated for diverticulosis. Which of the following points should the nurse include in this client's teaching plan? Select all that apply. Do not suppress the urge to defecate. Drink at least 8 to 10 large glasses of fluid every day. Use laxatives or enemas at least once a week. Avoid daily exercise; indulge only in mild activity.
Do not suppress the urge to defecate. Drink at least 8 to 10 large glasses of fluid every day. Explanation: Avoid constipation. Do not suppress the urge to defecate. Consume at least 2 L/day (within limits of the client's cardiac and renal reserve) and include foods that are soft but have increased fiber, such as prepared cereals or soft-cooked vegetables, to increase the bulk of the stool and facilitate peristalsis, thereby promoting defecation. Avoid the use of laxatives or enemas except when recommended by the physician. Exercise regularly if the current lifestyle is somewhat inactive.
A patient with an ileostomy should avoid which of the following? Enteric-coated products Antacids and antibiotics Wax matrix coated products Nonlayered tablets
Enteric-coated products Explanation: 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 performing a community screening for colorectal cancer. Which of the following characteristics should the nurse include in the screening? Being younger than 40 years of age Low-fat, low-protein, high-fiber diet History of skin cancer Familial polyposis
Family history of colon cancer or familial polyposis is a risk factor for colorectal cancer. Being older than age 40 is a risk factor for colorectal cancer. A high-fat, high-protein, low-fiber diet is a risk factor for colorectal cancer. A history of skin cancer is not a recognized risk factor for colorectal cancer.
The nurse is caring for a patient diagnosed with abdominal perforation. Which of the following is a clinical manifestation of this disease process? Hypotension Subnormal temperature Bradycardia Normal erythrocyte sedimentation rate (ESR)
Hypotension Explanation: Clinical manifestations include hypotension, increased temperature, tachycardia, and elevated ESR.
A 68-year-old resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. She receives nutrition via a PEG tube. The client remains physically and socially active and has adapted well to the tube feedings. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. Which of the following is the most likely cause of this client's constipation? Lack of free water intake Lack of solid food Lack of exercise Increased fiber
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. Poor fluid intake is the most likely cause.
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? Loperamide (Imodium) Bismuth subsalicylate (Pepto-Bismol) Kaolin and pectin (Kaopectate) Bisacodyl (Dulcolax)
Loperamide (Imodium) Explanation: 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.
Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following? Low residue Low protein Calorie restriction Iron restriction
Low residue Explanation: 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.
During assessment of a patient for a malabsorption disorder, the nurse notes a history of abdominal pain and weight loss, marked steatorrhea, azotorrhea, and frequent glucose intolerance. Based on these clinical features, the nurse suspects a diagnosis of: Lactose intolerance. Celiac disease. Pancreatic insufficiency. Ileal dysfunction.
Pancreatic insufficiency. Explanation: These symptoms are consistent with a diagnosis of pancreatic insufficiency. Loss of ileal absorbing surface results in ileal dysfunction. A toxic response to gluten is characteristic of celiac disease, and a deficiency of intestinal lactase results in lactose intolerance. Refer to Table 24-2 in the text.
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 That the client has a bowel movement daily That the stool is formed and soft The client is able to fully evacuate with each bowel movement
The consistency of stool and comfort when passing stool Explanation: 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. People differ greatly in their bowel habits and normal bowel patterns range from three bowel movements per day to three bowel movements per week. It is important for the stool to be soft to pass without pain. The client may not be able to fully evacuate with a bowel movement; it may take time.
Which client requires immediate nursing intervention? The client who: complains of epigastric pain after eating. complains of anorexia and periumbilical pain. presents with a rigid, boardlike abdomen. presents with ribbonlike stools.
presents with a rigid, boardlike abdomen. Explanation: 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.
A patient presents to the emergency room with a possible diagnosis of appendicitis. The health care provider asks the nurse to assess for tenderness at McBurney's point. The nurse knows to palpate the area: Between the umbilicus and the left iliac crest. Between the umbilicus and the anterior superior iliac spine. In the left periumbilical area. In the upper right quadrant slightly below the diaphragm.
Between the umbilicus and the anterior superior iliac spine. Explanation: Local tenderness in the right lower quadrant is elicited at McBurney's point when pressure is applied between the umbilicus and the anterior superior iliac spine.
Which of the following is considered a stimulant laxative? Magnesium hydroxide (milk of Magnesia) Bisacodyl (Dulcolax) Mineral oil Psyllium hydrophilic mucilloid (Metamucil)
Bisacodyl (Dulcolax) Explanation: Dulcolax is a stimulant laxative. Milk of magnesia a saline agent. Mineral oil is a lubricant. Metamucil is a bulk forming agent.
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 Beginning a bowel program to establish continence Instituting a diet high in fiber and increase fluid intake Determining the need for surgical intervention to correct the problem
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 performing a rectal assessment and notices a longitudinal tear or ulceration in the lining of the anal canal. The nurse documents the finding as which of the following? Anorectal abscess Anal fistula Hemorrhoid Anal fissure
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.
A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding? Blood supply to the stoma has been interrupted. This is a normal finding 1 day after surgery. The ostomy bag should be adjusted. An intestinal obstruction has occurred.
Blood supply to the stoma has been interrupted. Explanation: An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion. The nurse should interpret this finding as an indication that the stoma's blood supply is interuppted, which may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding 1 day after surgery. Adjusting the ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn't change stoma color.
A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate? Cutting the faceplate opening no more than 2? larger than the stoma Gently washing the area surrounding the stoma using a facecloth and mild soap Scrubbing fecal material from the skin surrounding the stoma Maintaining wrinkles in the faceplate so it doesn't irritate the skin
Gently washing the area surrounding the stoma using a facecloth and mild soap Explanation: 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.
Celiac sprue is an example of which category of malabsorption? Infectious diseases causing generalized malabsorption Mucosal disorders causing generalized malabsorption Luminal problems causing malabsorption Postoperative malabsorption
Mucosal disorders causing generalized malabsorption Explanation: In addition to celiac sprue, regional enteritis and radiation enteritis are examples of mucosal disorders. Examples of infectious diseases causing generalized malabsorption include small bowel bacterial overgrowth, tropical sprue, and Whipple's disease. Examples of luminal problems causing malabsorption include bile acid deficiency, Zollinger-Ellison syndrome, and pancreatic insufficiency. Postoperative gastric or intestinal resection can result in development of malabsorption syndromes.