Ch 41 - Intestinal & Rectal Disorders
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. The appendix may develop gangrene and rupture, especially in a middle-aged client. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. Explanation: A client with appendicitis is at Risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Elderly, not middle-aged, clients are especially susceptible to appendix rupture.
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 one bowel movement daily one bowel movement every other day two bowel movements daily
stool consistency and client comfort 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 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 Pelvic abscess Ileus Hemorrhage
Peritonitis Explanation: The nurse should report to the physician that the client 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.
A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis? Stool Hematest Carcinoembryonic antigen (CEA) Sigmoidoscopy Abdominal computed tomography (CT) scan
Sigmoidoscopy Explanation: Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal cancer.
The nurse is caring for an older adult client with enteritis who reports frequent diarrhea. Which assessment finding should the nurse anticipate? positive Rovsing sign metabolic acidosis hyperkalemia elevated neutrophils
metabolic acidosis Explanation: Diarrhea causes a bicarbonate deficit. With loss of the relative alkalinity of the lower GI tract, the relative acidity of the upper GI tract predominates, leading to metabolic acidosis. Loss of acid, which occurs with severe vomiting, may lead to metabolic alkalosis. Diarrhea leads to hypokalemia. Elevated neutrophils are associated with infection and not frequent diarrhea. Rovsing sign is associated with appendicitis.
The nurse is caring for a patient who has malabsorption syndrome with an undetermined cause. What procedure will the nurse assist with that is the best diagnostic test for this illness? Ultrasound Endoscopy with mucosal biopsy Stool specimen for ova and parasites Pancreatic function tests
Endoscopy with mucosal biopsy Explanation: Endoscopy with biopsy of the mucosa is the best diagnostic tool for malabsorption syndrome.
A nurse is reviewing lab results for a client with an intestinal obstruction, and infection is suspected. What would be an expected finding? leukocytosis; elevated hematocrit; low sodium, potassium, and chloride leukopenia, decreased hematocrit; low sodium, potassium, and chloride leukocytosis; metabolic alkalosis; elevated sodium, potassium, and chloride leukopenia; metabolic acidosis; elevated sodium, potassium, and chloride
leukocytosis; elevated hematocrit; low sodium, potassium, and chloride Explanation: Tests of serum electrolytes may indicate low levels of sodium, potassium, and chloride. Metabolic alkalosis is evidenced by arterial blood gas results. A complete blood count (CBC) shows an increased WBC count in instances of infection. The hematocrit level is elevated if dehydration develops.
The nurse is reviewing the laboratory test results of a client with Crohn disease. Which of the following would the nurse most likely find? Decreased white blood cell count Increased albumin levels Stool cultures negative for microorganisms or parasite Decreased erythrocyte sedimentation rate
Stool cultures negative for microorganisms or parasite Explanation: Stool cultures fail to reveal an etiologic microorganism or parasite, but occult blood and white blood cells (WBCs) often are found in the stool. Results of blood studies indicate anemia from chronic blood loss and nutritional deficiencies. The WBC count and erythrocyte sedimentation rate may be elevated, confirming an inflammatory disorder. Serum protein and albumin levels may be low because of malnutrition.
A client has been diagnosed with cancer in the descending colon. Which symptom(s) would the nurse expect the client to report? Select all that apply. narrowing of stools constipation black, tarry stools tenesmus diarrhea
narrowing of stools constipation black, tarry stools diarrhea Explanation: Abdominal pain and cramping, narrowing of stools, constipation or diarrhea, abdominal distension, and bright red blood in stools are symptoms associated with cancer in the descending colon. Black, tarry stools and tenesmus are symptoms associated with cancer in the ascending colon.
After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching? "I'll have to wear an external collection pouch for the rest of my life." "I should eat foods from all the food groups." "I'll need to drink at least eight glasses of water a day." "I'll have to catheterize my pouch every 2 hours."
"I'll have to wear an external collection pouch for the rest of my life." Explanation: The client requires additional teaching if he states that he'll have to wear an external collection pouch for the rest of his life. An internal collection pouch, such as the Kock pouch, allows the client to perform self-catheterization for ileal drainage. This pouch is an internal reservoir, eliminating the need for an external collection pouch. A well-balanced diet is essential for healing; the client need not include or exclude particular foods. The client should drink at least eight glasses of fluid daily to prevent calculi formation and urinary tract infection. Intervals between pouch drainings should be increased gradually until the pouch is emptied two to four times daily.
A client presents with an infection in the area between the internal and external sphincters. In which chronic disease is this condition commonly seen? Crohn disease diverticulosis ulcerative colitis irritable bowel syndrome
Crohn disease Explanation: An anorectal abscess is common in clients with Crohn disease.
A client is being treated for diverticulosis. Which points should the nurse include in this client's teaching plan? Select all that apply. Do not suppress the urge to defecate. Drink fluids, especially water and fluids that are sugar-free Limit high-fat meat and dairy products Engage in regular physical activity Limit high-fiber foods
Do not suppress the urge to defecate. Drink fluids, especially water and fluids that are sugar-free Limit high-fat meat and dairy products Engage in regular physical activity Explanation: The nurse should instruct the client tto avoid constipation, and therefore not to suppress or ignore the urge to defecate. The client should consume plenty of fluids, especially water and sugar-free fluids (within limits of the client's cardiac and renal reserve). They should eat a diet that limits high-fat meats and dairy products and includes fruits and vegetables, to increase the bulk of the stool and facilitate peristalsis, thereby promoting defecation. The nurse should encourage the client to engage in regular physical activity, including exercises that involve toning abdominal muscles.
After teaching a group of students about intestinal obstruction, the instructor determines that the teaching was effective when the students identify which of the following as a cause of a functional obstruction? Volvulus Intussusception Tumor Abdominal surgery
Abdominal surgery Explanation: In functional obstruction, the intestine can become adynamic from an absence of normal nerve stimulation to intestinal muscle fibers. For example, abdominal surgery can lead to paralytic ileus. Mechanical obstructions result from a narrowing of the bowel lumen with or without a space-occupying mass. A mass may include a tumor, adhesions (fibrous bands that constrict tissue), incarcerated or strangulated hernias, volvulus (kinking of a portion of intestine), intussusception (telescoping of one part of the intestine into an adjacent part), or impacted feces or barium.
A client is diagnosed with colon cancer, located in the lower third of the rectum. What does the nurse understand will be the surgical treatment option for this client? Colectomy Segmental resection Abdominoperineal resection A low colectomy
Abdominoperineal resection Explanation: A cancerous mass in the lower third of the rectum will result in an abdominoperineal resection with a wide excision of the rectum and the creation of a sigmoid colostomy. An encapsulated colorectal tumor may be removed without taking away surrounding healthy tissue. This type of tumor, however, may call for partial or complete surgical removal of the colon (colectomy). Occasionally, the tumor causes a partial or complete bowel obstruction. If the tumor is in the colon and upper third of the rectum, a segmental resection is performed. In this procedure, the surgeon removes the cancerous portion of the colon and rejoins the remaining portions of the GI tract to restore normal intestinal continuity.
A nurse is caring for a client admitted with symptoms of an anorectal infection; cultures indicate that the client has a viral infection. The nurse should anticipate the administration of what drug? Acyclovir Doxycycline Penicillin Metronidazole
Acyclovir Explanation: Acyclovir (Zovirax) is often given to clients with viral anorectal infections. Doxycycline (Vibramycin) and penicillin (penicillin G) are drugs of choice for bacterial infections. Metronidazole (Flagyl) is used for other infections with a bacterial etiology; it is ineffective against viruses.
The American Cancer Society recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should a nurse recommend? Carcinoembryonic antigen (CEA) test after age 50 Proctosigmoidoscopy after age 30 Annual digital examination after age 40 Barium enema after age 20
Annual digital examination after age 40 Explanation: The American Cancer Society recommends an annual digital examination after age 40 for the purpose of detecting colorectal cancer. The CEA test is performed on clients who have already been treated for colorectal cancer. It helps monitor a client's response to treatment as well as detect metastasis or recurrence. Proctosigmoidoscopy is recommended every 3 to 5 years for people older than age 50. Barium enema isn't a screening test.
The nurse caring for a client with diverticulitis is preparing to administer the client's medications. The nurse anticipates administration of which category of medication because of the client's diverticulitis? Antianxiety Antispasmodic Antiemetic Anti-inflammatory
Antispasmodic Explanation: The nurse anticipates administration of antispasmodic medication to decrease intestinal spasm associated with diverticulitis. The client may also be ordered an opioid analgesic to relieve the associated pain. There is no indication that the client needs antianxiety, antiemetic, or anti-inflammatory medications at this time.
A client reports constipation. Which nursing measure would be most effective in helping the client reduce constipation? Provide adequate quantity of food. Obtain medical and allergy history. Assist client to increase dietary fiber. Obtain complete food history.
Assist client to increase dietary fiber. Explanation: The nurse should assist the client to increase the dietary fiber in 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.
A client 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 which 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 drug is considered a stimulant laxative? Magnesium hydroxide Bisacodyl Mineral oil Psyllium hydrophilic mucilloid
Bisacodyl Explanation: Bisacodyl is a stimulant laxative. Magnesium hydroxide is a saline agent. Mineral oil is a lubricant. Psyllium hydrophilic mucilloid is a bulk-forming agent.
Which is the most common presenting symptom of colon cancer? Fatigue Change in bowel habits Anorexia Weight loss
Change in bowel habits Explanation: 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 symptoms.
An older adult client seeks help for chronic constipation. What factor related to aging can cause constipation in elderly clients? Increased intestinal motility Decreased abdominal strength Increased intestinal bacteria Decreased production of hydrochloric acid
Decreased abdominal strength Explanation: Decreased abdominal strength, muscle tone of the intestinal wall, and motility all contribute to chronic constipation in the elderly. A decrease in hydrochloric acid causes a decrease in absorption of iron and vitamin B12, whereas an increase in intestinal bacteria actually causes diarrhea.
Which is one of the primary symptoms of irritable bowel syndrome (IBS)? Diarrhea Pain Bloating Abdominal distention
Diarrhea Explanation: 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 nurse is caring for a client with cardiac disease. The client asks the nurse which medication is best for help with regular bowel movements. What is the best response by the nurse? Docusate Magnesium hydroxide Bisacodyl Mineral oil
Docusate Explanation: Docusate (Colace) can be used safely by patients who should avoid straining, such as cardiac clients. Magnesium hydroxide (Milk of Magnesia) is a saline agent. Bisacodyl (Dulcolax) is a stimulant laxative. Mineral oil is a lubricant laxative.
An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to? Hyperkalemia Hypokalemia Hyponatremia Hypernatremia
Hypokalemia Explanation: The older client taking digitalis must be aware of how quickly dehydration and hypokalemia can occur with diarrhea. The nurse teaches the client to recognize the symptoms of hypokalemia because low levels of potassium intensify the action of digitalis, leading to digitalis toxicity.
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.
A client is reporting problems with constipation. What dietary suggestion can the nurse inform the client may help facilitate the passage of stool? Increase the carbohydrate content of the diet. Increase dietary fat consumption. Increase dietary protein such as lean meats. Increase dietary fiber.
Increase dietary fiber. Explanation: Constipation may result from insufficient dietary fiber and water. A diet low in fiber predisposes people to constipation because the stools produced are small in volume and dry. Increasing the carbohydrate, fat, and protein content will not facilitate the passage of stool.
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 small bowel disorder. Intestinal malabsorption. Inflammatory colitis. A disorder of the large bowel.
Intestinal malabsorption. Explanation: 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.
The nurse is comparing Crohn's disease (regional enteritis) with ulcerative colitis. Which of the following describes Crohn's disease? Fistulas are rare Diarrhea is more severe Bleeding is common and severe Its course is prolonged and variable
Its course is prolonged and variable Explanation: The course of Crohn's disease is prolonged and variable whereas ulcerative colitis follows a pattern of exacerbations and remissions. In Crohn's disease, bleeding usually does not occur but tends to be mild when it does occur; fistulas are common, and diarrhea is less severe than it is with ulcerative colitis.
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? Right lower quadrant Left lower quadrant Right upper quadrant Left upper quadrant
Left lower quadrant Explanation: 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).
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 Increases the volume of intestinal contents Irritates nerve endings in the intestinal mucosa Decreases water retention of stool
Lubricates and softens fecal matter Explanation: Mineral oil is used to soften impacted stool in the management of constipation. It coats the surface of stool and intestine with a lubricant film to allow passage of stool through the intestine. Mineral oil also improves water retention of stool, thereby softening stool and facilitating bowel evacuation. Mineral oil does not work by irritating nerve endings in the intestinal mucosa. Saline cathartics, such as magnesium sulfate and citrate, increase the volume of intestinal content, thus stimulating evacuation.
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.
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. Black, tarry stools Narrowing stools Constipation Dull abdominal pain Abdominal distention
Narrowing stools Constipation Abdominal distention Explanation: Melena and dull abdominal pain are associated with right-sided lesions. The other symptoms are found with left-sided lesions.
The nurse is caring for a client with diarrhea. For which finding will the nurse suspect the diarrhea is caused by pancreatic insufficiency? Nocturnal diarrhea Voluminous greasy stools Oil droplets on the toilet water Blood, mucus, and pus in the stool
Oil droplets on the toilet water Explanation: Symptoms of diarrhea depend upon the cause and the severity of the diarrhea. Oil droplets on the toilet water may be suggestive of pancreatic insufficiency. Nocturnal diarrhea is associated with diabetic neuropathy. Voluminous greasy stools are associated with malabsorption. Blood, mucus, and pus in the stool is associated with inflammatory enteritis or colitis.
Clients with inflammatory bowel disease (IBD) are at significantly increased risk for which condition? Osteoporosis DVT Hypotension Pneumonia
Osteoporosis Explanation: Clients with IBD also have a significantly increased risk of osteoporotic fractures due to decreased bone mineral density. Clients are not at increased risk of DVT, hypotension, or pneumonia.
A nurse is preparing to provide care for a client whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the client's stools will have what characteristics? Watery with blood and mucus Hard and black or tarry Dry and streaked with blood Loose with visible fatty streaks
Watery with blood and mucus Explanation: The predominant symptoms of ulcerative colitis are diarrhea and abdominal pain. Stools may be bloody and contain mucus. Stools are not hard, dry, tarry, black or fatty in clients who have ulcerative colitis.
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: hyperkalemia. hypokalemia. hyponatremia. hypernatremia.
hypokalemia. Explanation: The older client taking digoxin must be aware of how quickly dehydration and hypokalemia can occur with diarrhea. The nurse teaches the client to recognize the symptoms of hypokalemia because low levels of potassium intensify the action of digitalis, leading to digitalis toxicity.
The nurse is recording the medications a client uses on a daily basis for a client who is scheduled to undergo surgery in the morning. Which daily medication has the potential to result in constipation? laxative multivitamin without iron NSAIDs acetaminophen
laxative Explanation: Constipation may also result from chronic use of laxatives ("cathartic colon") because such use can cause a loss of normal colonic motility and intestinal tone. Laxatives also dull the gastrocolic reflex.
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? Loud bowel sounds Borborygmus Tenesmus Peristalsis
Borborygmus Explanation: Borborygmus is a rumbling noise caused by the movement of gas through the intestines, often associated with 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 Apply barrier powder Apply triamcinolone acetonide spray Dust with nystatin powder
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 has been recently diagnosed with an anorectal condition. The nurse is reviewing interventions that will assist the client with managing the therapeutic regimen. What would not be included? Encourage the client to avoid exercise. Instruct the client to cleanse perianal area with warm water. 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.
Encourage the client to avoid exercise. Explanation: 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.
The nurse is performing a community screening for colorectal cancer. Which characteristic should the nurse include in the screening? Age younger than 40 years Low-fat, low-protein, high-fiber diet History of skin cancer Familial polyposis
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.
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 Lubiprostone Dicyclomine Peppermint oil
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.
The nurse is admitting a client with a diagnosis of diverticulitis and assesses that the client has a board-like abdomen, no bowel sounds, and reports of severe abdominal pain. What is the nurse's first action? Start an IV with lactated Ringer's solution. Notify the health care provider. Administer a retention enema. Administer an opioid analgesic.
Notify the health care provider. Explanation: Abdominal pain, a rigid board-like abdomen, loss of bowel sounds, and signs and symptoms of shock occur with peritonitis. 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; thus, the nurse should notify the health care provider.
It is important for the nurse to monitor serum electrolytes in a patient with acute diarrhea. Select the electrolyte result that should be immediately reported. Chloride of 100 mEq/L Sodium of 136 mEq/L Calcium of 9 mg/dL Potassium of 2.8 mEq/L
Potassium of 2.8 mEq/L Explanation: The normal serum potassium level is 3.5 to 5 mEq/L. Hypokalemia can be severe if less than 2.5 mEq/L. A potassium result of 2.8 should be reported because it is significantly lower than normal. The other choices are normal levels.
A nurse is caring for a client who had an ileal conduit 3 days earlier. The nurse examines the stoma site and determines that she should consult with the ostomy nurse. Which assessment finding indicates the need for further consultation? Beefy red stoma site Stoma site not sensitive to touch Red, sensitive skin around the stoma site Clear mucus mixed with yellow urine drained from the appliance bag
Red, sensitive skin around the stoma site Explanation: Red, sensitive skin around the stoma site may indicate an ill-fitting appliance beefy redness at a stoma site that isn't sensitive to touch is a normal assessment finding. Urine mixed with mucus is also a normal finding.
Which category of laxatives draws water into the intestines by osmosis? Saline agents (e.g., magnesium hydroxide) Bulk-forming agents (e.g., psyllium) Stimulants (e.g., bisacodyl) Fecal softeners (e.g., docusate)
Saline agents (e.g., magnesium hydroxide) Explanation: Saline agents use osmosis to stimulate peristalsis and act within 2 hours of consumption. Bulk-forming agents mix with intestinal fluids, swell, and stimulate peristalsis. Stimulants irritate the colon epithelium. Fecal softeners hydrate the stool by surfactant action on the colonic epithelium, resulting in a mixing of aqueous and fatty substances.
A client is diagnosed with Zollinger-Ellison syndrome. The nurse knows to assess the client for which characteristic clinical feature of this syndrome? Decreased intestinal lactose Folate deficiency Lymphadenopathy Steatorrhea
Steatorrhea Explanation: Hyperacidity in the duodenum inactivates pancreatic enzymes causing steatorrhea and ulcer diathesis.
Which is a true statement regarding regional enteritis (Crohn's disease)? It has a progressive disease pattern. It is characterized by pain in the lower left abdominal quadrant. The clusters of ulcers take on a cobblestone appearance. The lesions are in continuous contact with one another.
The clusters of ulcers take on a cobblestone appearance. Explanation: 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.
A client is being seen in the clinic for reports of painful hemorrhoids. The nurse assesses the client and observes the hemorrhoids are prolapsed but able to be placed back in the rectum manually. The nurse documents the hemorrhoids as what degree? First degree Second degree Third degree Fourth degree
Third degree Explanation: 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.
The nurse is caring for a client with a mechanical intestinal obstruction who is at risk for perforation. For which finding(s) should the nurse monitor the client? Select all that apply. sudden, sustained abdominal pain abdominal distention high-pitched bowel sounds above the obstructed area intermittent, severe pain fever
sudden, sustained abdominal pain abdominal distention fever Explanation: Abdominal distention, fever, and sudden, sustained abdominal pain are the symptoms of perforation in a client with intestinal obstruction. High-pitched bowel sounds above the obstructed area are consistent with a mechanical obstruction, not a perforation. The client may also experience severe intermittent cramping during a mechanical obstruction.
Which client would be at greatest risk for the development of an anorectal fistula? A 50-year-old male with diverticulosis A 35-year-old female with Crohn's disease A 42-year-old female with irritable bowel syndrome A 60-year-old male with polyps of the colon
A 35-year-old female with Crohn's disease Explanation: Clients with Crohn's disease have an increased risk for the development of anorectal abscesses and anorectal fistulae. Diverticulosis, irritable bowel syndrome, and colon polyps are not typically associated with anorectal fistulae.
A patient is admitted to the hospital after not having had a bowel movement in several days. The nurse observes the patient is having small liquid stools, a grossly distended abdomen, and abdominal cramping. What complication can this patient develop related to this problem? Appendicitis Rectal fissures Bowel perforation Diverticulitis
Bowel perforation Explanation: Megacolon is a dilated and atonic colon caused by a fecal mass that obstructs the passage of colon contents. Symptoms include constipation, liquid fecal incontinence, and abdominal distention. Megacolon can lead to perforation of the bowel.
A patient with IBD would be encouraged to increase fluids, use vitamins and iron supplements, and follow a diet designed to reduce inflammation. Select the meal choice that would be recommended for a low-residue diet. A peanut butter sandwich and fruit cup Broiled chicken with low-fiber pasta Salami on whole grain bread and V-8 juice A fruit salad with yogurt
Broiled chicken with low-fiber pasta Explanation: A low-residue, high-protein, and high-calorie diet is recommended to reduce the size and number of stools. Foods to avoid include yogurt, fruit, salami, and peanut butter.
The nurse is caring for a client with an ileostomy because of inflammatory bowel disease. Which assessment findings indicate to the nurse that the ileostomy is functioning as expected? Select all that apply. Stoma is pink and shiny Stoma is edematous and bleeding Formed stool in collection pouch Continuous liquid flows from the stoma Slight skin excoriation around the stoma
Stoma is pink and shiny Continuous liquid flows from the stoma Explanation: An ileostomy should be pink and shiny. The client with an ileostomy cannot establish regular bowel habits because the contents of the ileum are fluid and are discharged continuously. The stoma should not be edematous and bleeding. Formed stool in the collection pouch is a characteristic of a colostomy. Slight skin excoriation around the stoma indicates an infection or reaction to the collection appliance.
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? Small-bowel disease Ulcerative colitis Disorders of the colon Intestinal malabsorption
Ulcerative colitis Explanation: The presence of mucus and pus in the stool suggests ulcerative colitis. Watery stools are characteristic of small-bowel disease. Loose, semisolid stools are associated more often with disorders of the colon. Voluminous, greasy stools suggest intestinal malabsorption
A client has a 10-year history of Crohn disease and is seeing the physician due to increased diarrhea and fatigue. What is the recommended dietary approach to treat Crohn disease? dietary approach varies high-fiber diet low-fiber diet lactose-rich foods
dietary approach varies Explanation: The dietary approach varies. A high-fiber diet may be indicated when it is desirable to add bulk to loose stools. A low-fiber diet may be indicated in cases of severe inflammation or stricture. A high-calorie and high-protein diet helps replace nutritional losses from chronic diarrhea. The client may need nutritional supplements, depending on the area of the bowel affected. When the small intestine is inflamed, some clients experience lactose intolerance, requiring avoidance of lactose-rich foods.
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. fistula. hemorrhoid. 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.
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? Abdominal distention Frank blood in the stool A change in bowel habits Abdominal pain
A change in bowel habits Explanation: 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.
A client has developed an anorectal abscess. Which client is likely at risk for the development of this type of abscess? A client with Crohn's disease A client with hemorrhoids A client with colon cancer A client with diverticulosis
A client with Crohn's disease Explanation: An anorectal abscess is common in clients with Crohn's disease. The other disorders do not predispose the client to risk for anorectal abscess.
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? Colonoscopy Barium enema Flexible sigmoidoscopy CT scan
Colonoscopy Explanation: Diverticulosis is typically diagnosed by colonoscopy, which permits visualization of the extent of diverticular disease and biopsy of tissue to rule out other diseases. In the past, barium enema was the preferred diagnostic test, but it is now used less frequently than colonoscopy. CT with contrast agent is the diagnostic test of choice if the suspected diagnosis is diverticulitis; it can also reveal abscesses.
A patient is not having daily bowel movements and has begun taking a laxative for this problem. What should the nurse educate the patient about regarding laxative use? When taking the laxatives, plenty of fluid should be taken as well. The laxatives should be taken no more than 3 times a week or laxative addiction will result. Laxatives should not be routinely taken due to destruction of nerve endings in the colon. Laxatives should never be the first response for the treatment of constipation; natural methods should be employed first.
Laxatives should not be routinely taken due to destruction of nerve endings in the colon. Explanation: Laxative abuse, particularly the anthracene derivatives such as senna and cascara, can lead to destruction of the nerves of the colon that are essential for normal peristalsis (Apau, 2010a).
During assessment of a client 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, what diagnosis will the nurse suspect? 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.
The presence of mucus and pus in the stools suggests which condition? Small-bowel disease Ulcerative colitis Disorders of the colon Intestinal malabsorption
Ulcerative colitis Explanation: The presence of mucus and pus in the stools suggests ulcerative colitis. Watery stools are characteristic of small-bowel disease. Loose, semisolid stools are associated more often with disorders of the colon. Voluminous, greasy stools suggest intestinal malabsorption.
The nurse is assessing a client for constipation. Which factor should the nurse review first to identify the cause of constipation? Alcohol consumption Activity levels Usual pattern of elimination Current medications
Usual pattern of elimination Explanation: Constipation has many possible reasons and assessing the client's usual pattern of elimination is the first step in identifying the cause. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the client's current medications, diet, and activity levels.
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% White blood cell (WBC) count 22.8/mm3 Serum potassium 4.2 mEq/L Serum sodium 135 mEq/L
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 longitudinal tear or ulceration in the lining of the anal canal is termed a(n): 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.
The nurse working in the emergency department is caring for a client with signs and symptoms of appendicitis. Which order from the health care provider should the nurse question? administer an enema intravenous antibiotic therapy nothing by mouth (NPO) complete blood count
administer an enema Explanation: An enema is not administered in clients with symptoms associated with appendicitis because it can lead to perforation. Monitoring the complete blood cell count is necessary to identify infection. The client should receive nothing by mouth as surgery is required. Intravenous antibiotics may be ordered to prevent infection.
A 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? Constipation Paralytic ileus Peritonitis Accumulation of gas
Peritonitis Explanation: Lack of bowel motility typically accompanies peritonitis. The abdomen feels rigid and board-like as it distends with gas and intestinal contents. Bowel sounds typically are absent. The diagnosis of acute appendicitis correlates with the symptoms of rupture of the appendix and peritonitis. A paralytic ileus and gas alone do not produce these symptoms.
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 having a diagnostic workup for reports of frequent diarrhea, right lower abdominal pain, and weight loss. The nurse is reviewing the results of the barium study and notes the presence of "string sign." What does the nurse understand that this is significant of? Crohn's disease Ulcerative colitis Irritable bowel syndrome Diverticulitis
Crohn's disease Explanation: The most conclusive diagnostic aid for Crohn's disease has classically been a barium study of the upper GI tract that shows a "string sign" on an x-ray film of the terminal ileum, indicating the constriction of a segment of intestine.
The nurse is conducting discharge teaching for a client with diverticulosis. Which instruction should the nurse include in the teaching? Avoid unprocessed bran. Avoid daily exercise. Drink 8 to 10 glasses of fluid daily. Use laxatives weekly.
Drink 8 to 10 glasses of fluid daily. Explanation: The nurse should instruct a client with diverticulosis to drink at least 8 to 10 large glasses of fluid every day. The client should include unprocessed bran in the diet because it adds bulk, and should avoid the use of laxatives or enemas except when recommended by the physician. In addition, regular exercise should be encouraged if the client's current lifestyle is somewhat inactive.
A client is being treated for prolonged diarrhea. Which foods should the nurse encourage the client to consume? Protein-rich foods Potassium-rich foods High-fiber foods High-fat foods
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.
A client is recently diagnosed with Crohn's disease and is beginning treatment. What first-line treatment does the nurse expect that the client will be placed on to decrease the inflammatory response? Ciprofloxacin Methotrexate Azathioprine Sulfasalazine
Sulfasalazine Explanation: Considered first-line treatment for inflammatory bowel disease, 5-ASA drugs contain salicylate, which is bonded to a carrying agent that allows the drug to be absorbed in the intestine. These drugs work by decreasing the inflammatory response. Methotrexate or azathioprine are used when failure to maintain remission necessitates the use of an immune-modulating agent. Ciprofloxacin is used as an effective adjunct to treat the disease.
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. Administer topical ointment to the rectal area to decrease bleeding. Prepare the client for a gastrostomy tube placement. Administer morphine (Duramorph PF) routinely, as ordered.
Test all stools for occult blood. Explanation: 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
The nurse teaches the client whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be semi mushy. mushy. fluid. solid.
solid. Explanation: With a sigmoid colostomy, the feces are solid. With a descending colostomy, the feces are semi mushy. With a transverse colostomy, the feces are mushy. With an ascending colostomy, the feces are fluid.
Diet therapy for clients diagnosed with irritable bowel syndrome (IBS) includes: caffeinated products. spicy foods. high-fiber diet. fluids with meals.
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.
A nurse caring for a client with small-bowel obstruction should plan to implement which nursing intervention first? Administering pain medication Obtaining a blood sample for laboratory studies Preparing to insert a nasogastric (NG) tube Administering I.V. fluids
Administering I.V. fluids Explanation: The nurse should first administer I.V. infusions containing normal saline solution and potassium to maintain fluid and electrolyte balance. For the client's comfort and to assist in bowel decompression, the nurse should prepare to insert an NG tube next. A blood sample is then obtained for laboratory studies to help diagnose bowel obstruction and guide treatment. Blood studies usually include a complete blood count, serum electrolyte levels, and blood urea nitrogen level. Pain medication commonly is withheld until obstruction is diagnosed because analgesics can decrease intestinal motility.
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 don't understand this; I took the medication the doctor ordered and followed the diet." "I didn't eat anything I shouldn't have; I just ate roast beef on rye bread." "I don't understand why this happened again; I didn't travel out of the country." "I don't like oatmeal, so it doesn't matter that I can't have it."
"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread." Explanation: 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.
A nurse is caring for a client who has been admitted to the hospital with diverticulitis. What would be appropriate nursing diagnoses for this client? Select all that apply. Acute Pain Related to Increased Peristalsis and GI Inflammation Activity Intolerance Related to Generalized Weakness Bowel Incontinence Related to Increased Intestinal Peristalsis Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea Impaired Urinary Elimination Related to GI Pressure on the Bladder
Acute Pain Related to Increased Peristalsis and GI Inflammation Activity Intolerance Related to Generalized Weakness Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea Explanation: Clients with diverticulitis are likely to experience pain and decreased activity levels, and are at risk of fluid volume deficit. The client is unlikely to experience fecal incontinence and urinary function is not directly influenced.
What is the most common cause of small-bowel obstruction? Hernias Neoplasms Adhesions Volvulus
Adhesions Explanation: Adhesions are scar tissue that forms as a result of inflammation and infection. Adhesions are the most common cause of small-bowel obstruction, followed by tumors, Crohn's disease, and hernias. Other causes include intussusception, volvulus, and paralytic ileus.
A nurse is educating a client with a family history of colorectal cancer about sign(s) to immediately report to the health care provider. Which early sign(s) of colorectal cancer will the nurse inform the client to report? Select all that apply. Development of new hemorrhoids Abdominal bloating and flank pain Unexplained weight gain Change in bowel habits Occasional rectal bleeding
Change in bowel habits Occasional rectal bleeding Explanation: The most common presenting symptoms associated with colorectal cancer are a change in bowel habits and occasional bleeding. Later 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? 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 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 surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member? Social worker Staff nurse Clinical educator Enterostomal nurse
Enterostomal nurse Explanation: The surgeon should collaborate with the enterostomal nurse, who can address the client's concerns. The enterostomal nurse may schedule a visit with a client who has a colostomy to offer support to the client. The clinical educator can provide information about the colostomy when the client is ready to learn. The staff nurse and social worker aren't specialized in colostomy care, so they aren't the best choices for this situation.
A client underwent a continent ileostomy. Within which time frame should the client expect to empty the reservoir? At least once a day At least once every 2 days Two to three times daily Every 4 to 6 hours
Every 4 to 6 hours Explanation: Approximately 2 weeks after the continent ileostomy procedure, when the healing process has progressed to the point at which the catheter is removed from the stoma, the patient is educated how to drain the pouch. A catheter is inserted into the reservoir to drain the fluid. The length of time between drainage periods is gradually increased until the reservoir needs to be drained only every 4 to 6 hours and irrigated once each day.
Which of the following is accurate regarding regional enteritis? Fistulas are common Severe diarrhea Severe bleeding No narrowing of the colon
Fistulas are common Explanation: Fistulas are common with regional enteritis. There is narrowing of the colon, mild bleeding, and diarrhea is less severe than ulcerative colitis.
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 Wearing an appliance pouch only at bedtime Consuming a low-protein, high-fiber diet Taking only enteric-coated medications
Increasing fluid intake to prevent dehydration Explanation: Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can't absorb them after an ileostomy.
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.
Which of the following is considered a bulk-forming laxative? Metamucil Milk of Magnesia Mineral oil Dulcolax
Metamucil Explanation: Metamucil is a bulk-forming laxative. Milk of Magnesia is classified as a saline agent. Mineral oil is a lubricant. Dulcolax is a stimulant.
A client with a cyst has been brought for care. The nurse who is contributing to the client's care knows that treatment will be chosen based on what risk? Risk for infection Risk for bowel incontinence Risk for constipation Risk for impaired tissue perfusion
Risk for infection Explanation: Pilonidal cysts frequently develop into an abscess, necessitating surgical repair. These cysts do not contribute to bowel incontinence, constipation, or impaired tissue perfusion.
A client reports 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 should the nurse anticipate in the client's plan of care? Select all that apply. high-fiber diet psyllium low-residue diet anticholinergic agents hospitalization
high-fiber diet psyllium anticholinergic agents Explanation: The client's symptoms are consistent with irritable bowel syndrome (IBS). For the client's symptoms, the nurse should anticipate a high-fiber diet (30 to 40 g/day) or a bulk-forming agent, such as products containing psyllium, to regulate bowel elimination, which precludes a low-residue diet. The fiber draws water into constipated stool and adds bulk to watery stool. An anticholinergic, such as dicyclomine, has an antispasmodic effect if taken before meals. Most clients with IBS are not hospitalized.
A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, blood pressure of 100/80 mm Hg, pulse rate of 88 beats/minute, respiratory rate of 20 breaths/minute, temperature 100° F (37.8° C). What diagnosis will the nurse suspect for this client? inflammatory bowel disease (IBD) colorectal cancer diverticulitis liver failure
inflammatory bowel disease (IBD) Explanation: IBD is a collective term for several GI inflammatory diseases with unknown causes. The most prominent sign of IBD is mild diarrhea, which sometimes is accompanied by fever and abdominal discomfort. Colorectal cancer is usually diagnosed after the client complains of bloody stools; the client will rarely have abdominal discomfort. A client with diverticulitis commonly states he has chronic constipation with occasional diarrhea, nausea, vomiting, and abdominal distention. Jaundice, coagulopathies, edema, and hepatomegaly are common signs of liver failure.
A typical sign/symptom of appendicitis is: nausea. left lower quadrant pain. pain when pressure is applied to the right upper quadrant. high fever.
nausea. Explanation: Nausea, with or without vomiting, is typically associated with appendicitis. Pain is generally felt in the right lower quadrant. Rebound tenderness, or pain felt upon the release of pressure applied to the abdomen, may be present with appendicitis. Low-grade fever is associated with appendicitis.
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? tenderness and pain in the right upper abdominal quadrant jaundice and vomiting severe abdominal pain with direct palpation or rebound tenderness rectal bleeding and a change in bowel habits
severe abdominal pain with direct palpation or rebound tenderness Explanation: 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 (i.e., appendicitis, diverticulitis, ulcerative colitis, 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.
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? 0.9% NS D5W D10W 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.
Which characteristic is a risk factor for colorectal cancer? Age younger than 40 years Low-fat, low-protein, high-fiber diet History of skin cancer Familial polyposis
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.
The nurse in an extended-care facility reports that a resident has clinical manifestations of fecal incontinence. The health care provider orders a diagnostic study to rule out inflammation. Which study will the nurse prepare the client for? Anorectal manometry Transit study Flexible sigmoidoscopy Barium enema
Flexible sigmoidoscopy Explanation: The treatment of fecal incontinence depends on the cause. A rectal examination and other endoscopic examinations, such as a flexible sigmoidoscopy, are performed to rule out tumors, inflammation, or fissures. X-ray studies such as barium enema, computed tomography (CT), anorectal manometry, and transit studies may be helpful in identifying alterations in intestinal mucosa and muscle tone or in detecting other structural or functional problems.
A client has a 3 lumen central line inserted into the subclavian vein for parenteral nutrition. Which approach will the nurse take to maintain patency? Flush each port with normal saline in a 3 mL syringe once a day. Flush each port with sterile water in a 2 mL syringe every 8 hours. Flush each port with diluted heparin in a 10 mL syringe once a shift. Flush each port with normal saline in a 2-mL syringe every 12 hours.
Flush each port with diluted heparin in a 10 mL syringe once a shift. Explanation: Flushing is necessary daily when the catheter is not in use. Lumens are flushed with normal saline or diluted heparin (10 U/mL) after each intermittent infusion and after blood drawing; a 10-mL syringe is to be used. Smaller volume syringes are not to be used because the pressure from smaller syringes is potentially harmful to the catheter. A 3-mL syringe with normal saline should not be used. Sterile water is not used to flush the lumens of a central line. A 2-mL syringe should not be used to flush the lumen of a central line.
A patient diagnosed with IBS is advised to eat a diet that is: Sodium-restricted. High in fiber. Low in residue. Restricted to 1,200 calories/day.
High in fiber. Explanation: A high-fiber diet is prescribed to control diarrhea and constipation and is recommended for patients with IBS.
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 caring for a client with intussusception of the bowel. What does the nurse understand occurs with this disorder? The bowel twists and turns itself and obstructs the intestinal lumen. One part of the intestine telescopes into another portion of the intestine. The bowel protrudes through a weakened area in the abdominal wall. A loop of intestine adheres to an area that is healing slowly after surgery.
One part of the intestine telescopes into another portion of the intestine. Explanation: 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's large bowel obstruction has failed to resolve spontaneously and the client's worsening condition has warranted admission to the medical unit. Which of the following aspect of nursing care is most appropriate for this client? Administering bowel stimulants as ordered Administering bulk-forming laxatives as ordered Performing deep palpation as prescribed to promote peristalsis Preparing the client for surgical bowel resection
Preparing the client for surgical bowel resection Explanation: The usual treatment for a large bowel obstruction is surgical resection to remove the obstructing lesion. Administration of laxatives or bowel stimulants is contraindicated if the bowel is obstructed. Palpation would be painful and has no therapeutic benefit.
Which of the following is the most common symptom of a polyp? Rectal bleeding Abdominal pain Diarrhea Anorexia
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.
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? Right upper quadrant Right lower quadrant Left upper quadrant Left lower quadrant
Right lower quadrant Explanation: 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 presents to the ED with acute abdominal pain, fever, nausea, and vomiting. During the client's examination, the lower left abdominal quadrant is palpated, causing the client to report pain in the RLQ. This positive sign is referred to as ________ and suggests the client may be experiencing ________. Rovsing sign; acute appendicitis McBurney sign; acute appendicitis Rovsing sign; perforation McBurney sign; perforation
Rovsing sign; acute appendicitis 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 sign and suggests acute appendicitis.
A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which statement best indicates that the disease process is under control? The client exhibits signs of adequate GI perfusion. The client expresses positive feelings about himself. The client verbalizes a manageable level of discomfort. The client maintains skin integrity.
The client exhibits signs of adequate GI perfusion. Explanation: Adequate GI perfusion can be maintained only if Crohn's disease is controlled. If the client experiences acute, uncontrolled episodes of Crohn's disease, impaired GI perfusion may lead to a bowel infarction. Positive self-image, a manageable level of discomfort, and intact skin integrity are expected client outcomes, but aren't related to control of the disease.
A client has a newly created colostomy. After participating in counseling with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image? The client closes his or her eyes when the abdomen is exposed. The client avoids talking about the recent surgery. The client asks the spouse to leave the room. The client touches the altered body part.
The client touches the altered body part. Explanation: By touching the altered body part, the client recognizes the body change and establishes that the change is real. Closing his or her eyes, not looking at the abdomen when the colostomy is exposed, or avoiding talking about the surgery reflects denial, instead of acceptance of the change. Asking the spouse to leave the room signifies that the client is ashamed of the change and not coping with 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? Spinach Tofu Multigrain bagel Blueberries
Tofu Explanation: Nutritional management of inflammatory bowel disease requires ingestion of a diet that is bland, low-residue, high-protein, and high-vitamin. Tofu meets each of the criteria. Spinach, multigrain bagels, and blueberries are not low-residue.