ch 41- GI
A nurse is performing focused assessment on her clients. She expects to hear hypoactive bowel sounds in a client with: complete bowel obstruction. gastroenteritis. paralytic ileus. Crohn's disease.
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.
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? Peristalsis Borborygmus Tenesmus Loud bowel sounds
Borborygmus Explanation: Borborygmus is a rumbling noise caused by the movement of gas through the intestines, often associated with diarrh
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. Increase the rate of administration. Change irrigation fluid to normal saline. Discontinue the irrigation immediately.
Clamp the tubing and allow client to rest.
Which is the most prominent sign of inflammatory bowel disease? Hyperactive bowel sounds and constipation Increased peristalsis and diarrhea Abdominal distention and constipation Intermittent pain and diarrhea Intermittent pain and diarrhea
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 is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult? "I didn't eat anything I shouldn't have; I just ate roast beef on rye bread." "I don't like oatmeal, so it doesn't matter that I can't have it." "I don't understand this; I took the medication the doctor ordered and followed the diet." "I don't understand why this happened again; I didn't travel out of the country."
"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread."
A client reports 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? If the client is drinking 8 glasses of water per day, it is all right to continue taking them. The laxative is safe to take with other medication the client is taking. The client should take a fiber supplement along with the stimulant laxative. They can be habit forming and will require increasing doses to be effective.
hey can be habit forming and will require increasing doses to be effective. Explanation: The nurse should discourage self-treatment with daily or frequent enemas or laxatives. Chronic use of such products causes natural bowel function to be sluggish. In addition, laxatives continuing stimulants can be habit forming, requiring continued use in increasing doses. Although the nurse should encourage the client to have adequate fluid intake, laxative use should not be encouraged. The laxative may interact with other medications the client is taking and may cause a decrease in absorption. A fiber supplement may be taken alone but should not be taken with a stimulant laxative.
Which characteristic is a risk factor for colorectal cancer? Familial polyposis History of skin cancer Low-fat, low-protein, high-fiber diet Age younger than 40 years
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 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 ." "Take this on an empty stomach to ensure maximum effect." "Limit your fluid intake temporarily so you don't get diarrhea." "Make sure to take a multivitamin with each dose."
"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 stom
Medical management of a patient with peritonitis includes fluid, electrolyte, and colloid replacement. The nurse knows to prepare the initial, most appropriate intravenous solution. Which of the following is the correct solution? D5W D10W 0.9% NS 0.45% of NS
0.9% NS Explanation: The administration of several liters of an isotonic solution is immediately prescribed. Hypovolemia occurs because massive amounts of fluid and electrolytes move from the intestinal lumen into the peritoneal cavity and deplete the fluid in the vascular space.
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? Anorectal abscess Hemorrhoid Anal fissure Anal fistula
Anal fissure
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? Unexplained weight gain Development of new hemorrhoids Change in bowel habits Abdominal bloating and flank pain
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.
A client informs the nurse of having abdominal pain that is relieved when having a bowel movement. The health care provider diagnosed the client with irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder?
Chronic constipation with sporadic bouts of diarrhea
A client informs the nurse of having abdominal pain that is relieved when having a bowel movement. The health care provider diagnosed the client with irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder? Weight loss due to malabsorption Chronic constipation with sporadic bouts of diarrhea Client is awakened from sleep due to abdominal pain. Blood and mucus in the stool
Chronic constipation with sporadic bouts of diarrhea Explanation: Most clients with irritable bowel syndrome (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.
A client with Crohn's disease is losing weight. For which reason will the nurse anticipate the client being prescribed parenteral nutrition? Insufficient oral intake Impaired ability to absorb food Unwilling to ingest nutrients orally Prolonged preoperative nutritional needs
Impaired ability to absorb food Explanation: A client with Crohn's disease will have an impaired ability to ingest or absorb food orally or enterally. Clients with severe burns, malnutrition, short-bowel syndrome, AIDS, sepsis, and cancer would need parenteral nutrition because of insufficient oral intake. Unwillingness to ingest nutrients orally would cause a client with a major psychiatric illness to need parenteral nutrition. Prolonged surgical nutritional needs such as what occurs after extensive bowel surgery or acute pancreatitis would necessitate the need for parenteral nutrition.
Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following? Iron restriction Low protein Calorie restriction Low residue
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.
Vomiting results in which of the following acid-base imbalances? Metabolic alkalosis Metabolic acidosis Respiratory acidosis Respiratory alkalosis
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. Reference:
Celiac disease (celiac sprue) is an example of which category of malabsorption?
Mucosal disorders causing generalized malabsorption
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 cancer
A client is being treated for prolonged diarrhea. Which foods should the nurse encourage the client to consume?
Potassium-rich foods Explanation: The nurse should encourage the client with diarrhea to consume potassium-rich foods. Excessive diarrhea causes severe loss of potassium. The nurse should also instruct the client to avoid high-fiber or fatty foods because these foods stimulate gastrointestinal motility. The intake of protein foods may or may not be appropriate depending on the client's status.
Which of the following is the most common symptom of a polyp? Rectal bleeding Diarrhea Anorexia Abdominal pain
Rectal bleeding Explanation: The most common symptom is rectal bleeding. Lower abdominal pain may also occur. Diarrhea and anorexia are clinical manifestations of ulcerative colitis.
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
The nurse is performing and documenting the findings of an abdominal assessment. When the nurse hears intestinal rumbling and the client then experiences diarrhea, the nurse documents the presence of which condition? Diverticulitis Borborygmus Tenesmus Azotorrhea
Borborygmus Explanation: Borborygmus is the intestinal rumbling caused by the movement of gas through the intestines that accompanies diarrhea. Tenesmus refers to ineffectual straining at stool. Azotorrhea refers to excess of nitrogenous matter in the feces or urine. Diverticulitis refers to inflammation of a diverticulum from obstruction (by fecal matter) resulting in abscess formation.
The nurse is comparing Crohn's disease (regional enteritis) with ulcerative colitis. Which of the following describes Crohn's disease? Diarrhea is more severe Its course is prolonged and variable Fistulas are rare Bleeding is common and severe
Its course is prolonged and variable
The instructor is teaching a group of students about irritable bowel syndrome (IBS) and antidiarrheal agents, the instructor determines that the teaching was effective when the students identify which of the following as an example of an antidiarrheal agent commonly administered for IBS? Loperamide Peppermint oil Dicyclomine Lubiprostone
Loperamide Explanation: Loperamide is an opiate-related antidiarrheal agent. Lubiprostone is used to treat constipation; it activates chloride channels in the gastrointestinal tract to increase gastrointestinal transit. Dicyclomine, a smooth muscle antispasmodic agent, is used to treat pain accompanying IBS. Peppermint oil may also be taken to ease discomfort.
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. Reference:
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 exercise increased fiber lack of free water intake lack of solid food
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 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? Hematocrit 42% Serum potassium 4.2 mEq/L Serum sodium 135 mEq/L White blood cell (WBC) count 22.8/mm3
White blood cell (WBC) count 22.8/mm3 Explanation: 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 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: 1- fissure. 2- fistula. 3- hemorrhoid. 4- pilonidal cyst.
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.
