Chapter 38: Bowel elimination part 4

Fecal impactions occur in which portion of the colon? a. Ascending b. Descending c. Transverse d. Rectum

ANS: D A fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled. It results from unrelieved constipation. Feces at this point in the colon contain the least amount of moisture. Feces found in the ascending, transverse, and descending colon still consist mostly of liquid and do not form a hardened mass.

The nurse is providing ancillary personnel with instructions regarding the proper methods to implement when caring for a client with a Clostridium difficile infection. Which of the following practices will have the greatest impact on containment of the bacteria and thus prevention of cross-contamination? 1. Frequent in-services on transmission modes of C. difficile 2. Practice of proper hand hygiene by all staff 3. Appropriate handling of contaminated linen 4. Stool cultures on all suspected carriers

ANS: 2 Poor hand hygiene and erratic disinfection practices result in the transmission of C. difficile. Stool cultures are useful in the diagnosis, not the prevention, of C. difficile. Although the other options are appropriate, they do not have the most impact on preventing the spread of these bacteria.

Which nursing action best reduces risk of excoriation to the mucosal lining of the nose from a nasogastric tube? a. Lubricating the nares with water-soluble lubricant b. Applying a small ice bag to the nose for 5 minutes every 4 hours c. Instilling Xylocaine into the nares once a shift d. Changing the tape holding the tube in place once a shift

ANS: A The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation. Ice is not applied to the nose. Ice may be applied externally to the throat if the patient reports a sore throat. Xylocaine requires a physician order and is used to treat sore throat, not nasal mucosal excoriation. Changing the tape should be done daily, not every shift.

A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse would expect which other assessment finding? a. Hypoactive bowel sounds b. Jaundice in sclera c. Decreased skin turgor d. Soft tender abdomen

ANS: A Three or more days with no bowel movement indicates hypomotility of the GI tract. Assessment findings would include hypoactive bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation.

15. The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately? a. Liquid consistency of stool b. Presence of blood in the stool c. Noxious odor from the stool d. Continuous output from the stoma

ANS: B Blood in the stool may indicate a problem with the surgical procedure, and the physician should be notified. All other options are expected findings for an ileostomy.

A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? a. This is probably a false negative; we should rerun the test. b. Do you take iron supplements? c. You should schedule a colonoscopy as soon as possible. d. Sometimes severe stress can alter stool color.

ANS: B Certain medications and supplements, such as iron, can alter the color of stool. The fecal occult test takes three separate samples over a period of time and is a fairly reliable test. A colonoscopy is health prevention screening that should be done every 5 to 10 years; it is not the nurses initial priority. Stress alters GI motility and stool consistency, not color.

A patient with a hip fracture is having difficulty defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in having a successful bowel movement? a. Administering laxatives to the patient b. Raising the head of the bed c. Preparing to administer a barium enema d. Withholding narcotic pain medication

ANS: B Lying in bed is an unnatural position; raising the head of the bed assists the patient into a more normal position that allows proper contraction of muscles for elimination. Laxatives would not give the patient control over bowel movements. A barium enema is a diagnostic test, not an intervention to promote defecation. Pain relief measures should be given; however, preventative action should be taken to prevent constipation.

The nurse knows that most nutrients are absorbed in which portion of the digestive tract? a. Stomach b. Duodenum c. Ileum d. Cecum

ANS: B Most nutrients are absorbed in the duodenum with the exception of certain vitamins, iron, and salt (which are absorbed in the ileum). Food is broken down in the stomach. The cecum is the beginning of the large intestine.

A nurse is preparing a patient for a magnetic resonance imaging scan. Which nursing action is most important? a. Ensuring that the patient does not eat or drink 2 hours before the examination b. Removing all of the patients metallic jewelry c. Administering a colon cleansing product 12 hours before the examination d. Obtaining an order for a pain medication before the test is performed

ANS: B No jewelry or metal products should be in the same room as an MRI machine because of the high-power magnet used in the machine. The patient needs to be NPO 4 to 6 hours before the examination. Colon cleansing products are not necessary for MRIs. Pain medication is not needed before the examination is performed.

The nurse administers a cathartic to a patient. The nurse determines that the cathartic has had a therapeutic effect when the patient a. Has a decreased level of anxiety. b. Experiences pain relief. c. Has a bowel movement. d. Passes flatulence.

ANS: C A cathartic is a laxative that stimulates a bowel movement. It would be effective if the patient experiences a bowel movement. The other options are not outcomes of administration of a cathartic.

The nurse is preparing to perform a fecal occult blood test. The nurse plans to properly perform the examination by a. Applying liberal amounts of stool to the guaiac paper. b. Testing the quality control section before collecting the specimen section. c. Reporting any abnormal findings to the provider. d. Applying sterile disposable gloves.

ANS: C Abnormal findings such as a positive test should be reported to the provider. A fecal occult blood test is a clean procedure; sterile gloves are not needed. A thin specimen smear is all that is required. The quality control section should be developed after it is determined whether the sample is positive or negative.

The nurse would anticipate which diagnostic examination for a patient with black tarry stools? a. Ultrasound b. Barium enema c. Upper endoscopy d. Flexible sigmoidoscopy

ANS: C Black tarry stools are an indication of ulceration or bleeding in the upper portion of the GI tract; upper endoscopy would allow visualization of the bleeding. No other option would allow upper GI visualization.

A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding would the nurse expect? a. Increased energy levels b. Distended abdomen c. Decreased serum bicarbonate d. Increased blood pressure

ANS: C Chronic diarrhea can result in metabolic acidosis, which is diagnostic of low serum bicarbonate. Patients with chronic diarrhea are dehydrated with decreased blood pressure. Diarrhea also causes loss of electrolytes, nutrients, and fluid, which decreases energy levels. A distended abdomen would indicate constipation.

A patient had an ileostomy surgically placed 2 days ago. Which diet would the nurse recommend to the patient to ease the transition of the new ostomy? a. Eggs over easy, whole wheat toast, and orange juice with pulp b. Chicken fried rice with stir fried vegetables and iced tea c. Turkey meatloaf with white rice and apple juice d. Fish sticks with macaroni and cheese and soda

ANS: C During the first week or so after ostomy placement, the patient should consume easy-to-digest low-fiber foods such as poultry, rice and noodles, and strained fruit juices. Fried foods can irritate digestion and can cause blockage. Foods high in fiber will be useful later in the recovery process but can cause blockage if the GI tract is not accustomed to digesting with an ileostomy.

The nurse should question which order? a. A normal saline enema to be repeated every 4 hours until stool is produced b. A hypertonic solution enema with a patient with fluid volume excess c. A Kayexalate enema for a patient with hypokalemia d. An oil retention enema for a patient using mineral oil laxatives

ANS: C Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hypokalemic (have low potassium). Normal saline enemas can be repeated without risk of fluid or electrolyte imbalance. Hypertonic solutions are intended for patients who cannot handle large fluid volume and are contraindicated for dehydrated patients. Because mineral oil laxatives and an oil retention enema have the same intended effect of lubricating the colon and rectum, an oil retention enema is not needed.

A nurse is caring for an older adult patient with fecal incontinence due to cathartic use. The nurse is most concerned about which complication that has the greatest risk for severe injury? a. Rectal skin breakdown b. Contamination of existing wounds c. Falls from attempts to reach the bathroom d. Cross-contamination into the upper GI tract

ANS: C The nurse is most concerned about the worst injury the patient could receive, which involves falling while attempting to get to the bathroom. To reduce injury, the nurse should clear the path and reinforce use of the call light. The question is asking for the greatest risk of injury, not the most frequent occurrence or the event most likely to occur.

The nurse provides knows that a bowel elimination schedule would be most beneficial in the plan of care for which patient? a. A 40-year-old patient with an ileostomy b. A 25-year-old patient with Crohns disease c. A 30-year-old patient with C. difficile d. A 70-year-old patient with stool incontinence

ANS: D A bowel elimination program is helpful for a patient with incontinence. It helps the person who still has neuromuscular control defecate normally. An ileostomy, Crohns disease, and C. difficile all relate to uncontrollable bowel movements, for which no method can be used to set up a schedule of elimination.

The nurse is caring for a patient with Clostridium difficile. Which of the following nursing actions will have the greatest impact in preventing the spread of bacteria? a. Monthly in-services about contact precautions b. Placing all contaminated items in biohazard bags c. Mandatory cultures on all patients d. Proper hand hygiene techniques

ANS: D Proper hand hygiene is the best way to prevent the spread of bacteria. Monthly in-services place emphasis on education, not on action. Biohazard bags are appropriate but cannot be used on every item that C. difficilecomes in contact with, such as a human. Mandatory cultures are expensive and unnecessary and would not prevent the spread of bacteria.

A patient has constipation and hypernatremia. The nurse prepares to administer which type of enema? a. Oil retention b. Carminative c. Saline d. Tap water

ANS: D Tap water enema would draw fluid into the system and would help flush out excess sodium. Oil retention would not address sodium problems. Carminative enemas are used to provide relief from distention caused by gas. A saline enema would worsen hypernatremia.

The nurse is instructing the client in stomal care for an incontinent ostomy. The nurse evaluates achievement of learning goals if the client uses: a. Triamcinolone acetamide (Kenalog) spray for a yeast infection b. Peroxide to toughen the periostomal skin c. A commercial deodorant around the stoma d. Alcohol to cleanse the stoma

ANS: a a. If a yeast infection occurs, thorough cleansing should be performed, followed by patting the area dry and applying a prescribed topical agent, such as triamcinolone acetonide (Kenalog) spray or nystatin (Mycostatin), to the affected region. b. The peristomal skin should be cleansed gently with warm tap water by using gauze pads or a clean washcloth. c. An ostomy deodorant may be placed into the pouch, not around the stoma. d. Alcohol should not be used to clean the stoma. The area may be cleaned with warm tap water.

In the nursing care plan for constipation, the nurse should have an intervention that addresses the number of grams of cellulose that are needed for normal bowel function. How many grams should be in the daily diet? A) 2030 g B) 4050 g C) 6070 g D) >80g

Ans: A Feedback: A person who consumes approximately 20 g to 30 g of dietary fiber from fruits, vegetables, and grains will most likely have sufficient bulk in the stools to allow for easy defecation.

When the nurse performs a Hemoccult test on a stool specimen, blood in the stool will change the color on the test paper to A) Blue B) Brown C) Green D) Red

Ans: A Feedback: Blue is a positive diagnostic finding, indicating the presence of blood in the stool sample.

The proliferation of Clostridium difficile causes A) Antibiotic-associated diarrhea B) Escherichia coli diarrhea C) Urinary Clostridium infection D) Anal yeast infection

Ans: A Feedback: Normal intestinal flora inhibit the growth of Clostridium difficile. When broad-spectrum antibiotics, especially third-generation cephalosporins, are administered, normal flora is altered and C. difficile can proliferate and release toxins that cause antibiotic-associated diarrhea.

An elderly woman who is incontinent of stool following a cerebrovascular accident will have the following nursing diagnosis A) Bowel incontinence related to loss of sphincter control as evidenced by inability to delay the urge to defecate B) Diarrhea related to tube feedings as evidenced by hyperactive bowel sounds and urgency C) Constipation related to physiologic condition involving the deficit in neurologic innervation as evidenced by fecal incontinence D) Fecal retention related to loss of sphincter control and diminished spinal cord innervation related to hemiparesis

Ans: A Feedback: The most appropriate nursing diagnosis addresses the patients fecal incontinence related to loss of sphincter control innervation.

When caring for a patient with a new colostomy, which assessment finding would be considered abnormal and need to be reported to the physician? A) The stoma is pink. B) The stoma has a small amount of bleeding. C) The stoma is prolapsed. D) The stoma is on the abdominal surface.

C Feedback: The stoma should be pink and remain on the abdominal surface. The mucosal tissue is fragile, so a small amount of bleeding may be normal. If the stoma is found to be prolapsed, the surgeon must be notified immediately.

The nurse would expect the least formed stool to be present in which portion of the digestive tract? a. Ascending b. Descending c. Transverse d. Sigmoid

ANS: A The path of digestion goes from the ascending, across the transverse, to the descending and finally passing into the sigmoid; therefore, the least formed stool would be in the ascending.

An active 25-year-old female client shared with the nurse that ever since she had gone on a high-protein low-carbohydrate diet she had suffered from constipation. The client states that the diet is working for her in terms of weight loss and would like to stay on it. The best response from the nurse is that the client should try: 1. Consuming more low-carbohydrate fiber-rich foods like broccoli, raspberries, blackberries, and asparagus 2. Taking a laxative when feeling constipated 3. Try a different diet with less tendency to cause constipation 4. Exercise more

ANS: 1 A low-fiber diet high in animal fats (e.g., meats, dairy products, eggs) can slow peristalsis, leading to constipation. By consuming fiber-rich low-carbohydrate foods, the client can still maintain weight loss while avoiding constipation. The client could develop a dependence on laxatives by using them on a regular basis. The client has expressed a desire to remain on the diet she is currently on, and it seems to be working to help her lose weight. Because client is already active, additional activity is not likely to have a profound effect on relieving the constipation.

A client who is 2 days postoperative reports feeling constipated to the nurse. The client has good bowel sounds in all four quadrants and has tolerated liquids well. Her pain is being controlled with an opioid analgesic. Which of the following interventions should the nurse try initially? 1. Let me get you some apple juice. 2. Ambulating may get your bowels moving. 3. I'll see about getting a different pain medication. 4. Your health care provider might prescribe an enema if I call.

ANS: 1 An increase in fluid intake with the use of fruit juices softens stool and increases peristalsis. The remaining interventions are not inappropriate, but they are not the initial intervention for such a complaint.

The client asks the nurse to recommend bulk-forming foods that may be included in the diet. Which of the following should be recommended by the nurse? 1. Whole grains 2. Fruit juice 3. Rare meats 4. Milk products

ANS: 1 Bulk-forming foods, such as grains, fruits, and vegetables, absorb fluids and increase stool mass. Fruit juice, rare meats, and milk products are not bulk-forming foods.

The greatest risk for injury for a client who has fecal incontinence is: 1. Perineal and rectal skin breakdown 2. The contamination of existing wounds 3. Falls resulting from attempts to reach the bathroom 4. Cross-contamination into the upper gastrointestinal tract

ANS: 1 Fecal incontinence is a potentially dangerous condition in terms of contamination and risk for skin ulceration. The greatest risk to the otherwise healthy individual is skin breakdown. Although the other options may be risk factors, they are not as great as that of skin breakdown.

The nurse is discussing food allergies with a group of mothers whose children are allergy prone. Which of the following statements made by the nurse best describes lactose intolerance? 1. If milk causes diarrhea, cramps, or gas, it might be an intolerance of lactose. 2. You dont have to be allergic to dairy for it to cause you problems. 3. Allergies to milk can be very dangerous, even life threatening. 4. Many children outgrow their intolerance of dairy lactose.

ANS: 1 Food intolerance is not an allergy, but a particular food that causes the body distress within a few hours of ingestion. The result is diarrhea, cramps, or flatulence. For example, people who drink cows milk who have these symptoms are not allergic to milk but lack the enzyme needed to digest the milk sugar lactose; they are lactose intolerant.

A client has undergone intestinal surgery and now has an incontinent ostomy. The use of which of the following products by the client indicates that the discharge learning goals have been achieved? 1. A powder for a yeast infection 2. Peroxide to toughen the peristomal skin 3. A commercial deodorant around the stoma 4. Alcohol to cleanse the stoma

ANS: 1 If a yeast infection occurs, thorough cleansing should be performed, followed by patting the area dry and applying a prescribed topical agent, such as triamcinolone acetonide (Kenalog) spray or nystatin (Mycostatin), to the affected region. The peristomal skin should be cleansed gently with warm tap water using gauze pads or a clean washcloth. An ostomy deodorant may be placed into the pouch, not around the stoma. Alcohol should not be used to clean the stoma. The area may be cleaned with warm tap water.

A client who was recently diagnosed with anemia and rheumatoid arthritis reports to the nurse that she has noticed that her stool is black, and she is concerned because there is a history of colon cancer in her family. Which of the following assessment questions is most likely to provide information regarding this clients bowel problem? 1. What medications are you currently on? 2. When did you have your last colonoscopy? 3. Does the arthritis severely impair your mobility? 4. Would you like to have the stool tested for occult blood?

ANS: 1 Ingestion of iron, commonly prescribed for certain types of anemia, causes discoloration of the stool (black), nausea, vomiting, constipation (diarrhea is less commonly reported), and abdominal cramps. The remaining options, although focusing on aspects of function that could result in constipation, are not focused on the most likely cause in this scenario.

32. The nurse is assessing a cognitively impaired older adult client and observes a leaking of liquid stool from the rectum. The nurses initial intervention for this client is to: 1. Determine if the client has been eating sufficiently, especially fiber-rich foods 2. Determine how long it has been since the client had a normal-size, formed stool 3. Perform a digital examination of the rectum to determine the presence of stool 4. Call the health care provider to get a prescription for an antidiarrheal medication

ANS: 1 When a continuous oozing of diarrhea stool occurs, suspect impaction. The liquid portion of feces located higher in the colon seeps around the impacted mass. An obvious sign of impaction is the inability to pass a stool for several days, despite the repeated urge to defecate. The digital examination should be performed after it has been determined that the client has been without a normal bowel movement for several days. Although the remaining options are not inappropriate, they would not be the initial intervention.

The nurse instructs the client that before the fecal occult blood test (FOBT) she may eat: 1. Whole wheat bread 2. A lean, T-bone steak 3. Veal 4. Salmon

ANS: 1 Whole wheat bread may be eaten before a fecal occult blood test. A lean, T-bone steak may cause false-positive results if eaten before a fecal occult blood test. Veal may cause false-positive results if eaten before a fecal occult blood test. Salmon may cause false-positive results if eaten before a fecal occult blood test.

A 44-year-old male client was placed on a daily low-dose aspirin regimen by his health care provider following a recent diagnosis of hypertension and periodic atrial fibrillation. The client is currently hospitalized with renal stones. As the nurse is admitting the client, he shares that he has been very tired. The nurse gathers additional data regarding his bowel habits. The client shares that he has recently had black, tarry stools. The nurse is most concerned that the client may have: 1. Colon cancer 2. A GI bleed from the aspirin therapy 3. Ongoing atrial fibrillation 4. Electrolyte imbalance

ANS: 2 Although the client could have any one of the items mentioned, it is most likely that the aspirin is causing a GI bleed. The loss of blood can cause the client to be fatigued. Aspirin is a prostaglandin inhibitor, which interferes with the formation and production of protective mucus and causes GI bleeding.

Which of the following statements made by a nurse discussing the effect of an antibiotic on the gastrointestinal system reflects the best understanding of the possible occurrence of diarrhea? 1. The GI tract naturally rids itself of bacterial toxins by increasing peristalsis, and that causes diarrhea. 2. The antibiotic is responsible for killing off the GI tracts normal bacterial, and diarrhea is the result. 3. For some, antibiotics irritate the mucous lining of the intestines, causing decreased absorption and diarrhea. 4. When you are taking an antibiotic, your body is fighting off an infection, and peristalsis is faster and so diarrhea occurs.

ANS: 2 Antibiotics inadvertently produce diarrhea by disrupting the normal bacterial flora in the GI tract. The remaining options are not necessarily true.

A client is caring for her husband who recently experienced a cerebral vascular accident. She tells the home care nurse that she has been very anxious lately about all the added responsibilities. She adds that she has not been sleeping well and has had several bouts of diarrhea. Which of the following statements by the nurse focuses on the most likely cause of the gastrointestinal problem? 1. Have you experienced increased gas and cramping in addition to the diarrhea? 2. You are under a lot of stress; that can affect your bowels and result in diarrhea. 3. I suggest you get some over-the-counter medication and keep it on hand to manage those bouts. 4. Have you been eating a well-balanced diet since you brought your husband home?

ANS: 2 During emotional stress the digestive process is accelerated, and peristalsis is increased. Side effects of increased peristalsis are diarrhea and gaseous distention. The remaining options are focused on the most likely cause of the problem, or they are focused on treatment, not cause.

An 8-month-old infant is hospitalized with severe diarrhea. The nurse knows that the major problem associated with severe diarrhea is: 1. Pain in the abdominal area 2. Electrolyte and fluid loss 3. Presence of excessive flatus 4. Irritation of the perineal and rectal area

ANS: 2 Excess loss of colonic fluid because of diarrhea can result in serious fluid and electrolyte or acid-base imbalances. Infants and older adults are particularly susceptible to associated complications. Pain from abdominal cramping may occur with diarrhea, but it is not the major problem associated with severe diarrhea. Excessive flatus is not the major problem associated with severe diarrhea. Because repeated passage of diarrhea stools exposes the skin of the perineum and buttocks to irritating intestinal contents, meticulous skin care and containment of fecal drainage are needed to prevent skin breakdown. The greatest danger of severe diarrhea is a fluid and electrolyte or acid-base imbalance.

The nurse knows that the client receiving enteral feedings is at risk for diarrhea. One of the measures that the nurse can take to minimize the risk for diarrhea in this client is: 1. Making sure to chill the canned feeding before administering 2. Using strict sanitation when administering the formula 3. Not deviating from the prescribed rate of delivery for the formula 4. Not diluting or changing the strength of the prescribed formula

ANS: 2 Interventions to prevent diarrhea include the following: administer canned formulas at room temperature, follow strict sanitation when preparing the formula, increase the rate slowly, administer the volume at a rate tolerable to your client, or if using a hypertonic solution, give the initial feeding at half strength and gradually increase the volume to allow the client to adjust to a hypertonic solution. Consult a dietitian when diarrhea occurs.

The health care provider has ordered a stool specimen for ova and parasites from the 43-year-old male client. The nurse knows that when collecting the specimen the stool must be: 1. Kept on ice 2. Kept warm 3. Collected using sterile technique 4. Free from urine

ANS: 2 It is important to avoid delays in sending specimens to the laboratory. Some tests such as measurement for ova and parasites require the stool to be warm. The specimen need not be collected using sterile technique, because the laboratory will not be testing the sample for bacteria, but it should be collected with good sanitation practices. Likewise, a small amount of urine should not alter the test results.

The client is to receive a Kayexalate enema. The nurse recognizes that this is used to: 1. Prevent further constipation 2. Remove excess potassium from the system 3. Reduce bacteria in the colon before diagnostic testing 4. Provide direct antidiarrheal medication to the intestine

ANS: 2 Kayexalate is a type of medicated enema used to treat clients with dangerously high serum potassium levels. This drug contains a resin that exchanges sodium ions for potassium ions in the large intestine. Kayexalate enemas are not used to treat or prevent constipation, and Kayexalate is not a diarrheal medication. Neomycin enemas, not Kayexalate enemas, may be used to reduce bacteria in the colon before diagnostic testing.

A 50-year-old male client is having a screening colonoscopy. The nurse instructs the client that: 1. No special preparation is required 2. Light sedation is normally used 3. No metallic objects are allowed 4. Swallowing of an opaque liquid is required

ANS: 2 Light sedation is required for a colonoscopy. Special preparation is required before a colonoscopy. Clear liquids are given the day before and then some form of bowel cleanser, such as GoLytely, is administered. Enemas until clear may also be ordered. There is no restriction of metallic objects for a colonoscopy, not does it require swallowing an opaque liquid.

Which of the following statements made by an older adult reflects the best understanding of the role of fiber regarding bowel patterns? 1. The more fiber I eat, the fewer problems I have with my bowels. 2. Whole grain cereal and toast for breakfast keeps my bowels moving regularly. 3. My wife makes whole grain muffins; they are really good and good for me too. 4. I use to have trouble with constipation until I started taking a fiber supplement.

ANS: 2 The bowel walls are stretched, creating peristalsis and initiating the defecation reflex. By stimulating peristalsis, bulk foods pass quickly through the intestines, keeping the stool soft. Ingestion of a high-fiber diet improves the likelihood of a normal elimination pattern if other factors are normal. The other options are not as specific about the role of fiber, or they fail to provide an example of a high-fiber food.

The nurse is caring for a patient who is confined to the bed. The nurse asks the patient if he needs to have a bowel movement 30 minutes after eating a meal because a. The digested food needs to make room for recently ingested food. b. Mastication triggers the digestive system to begin peristalsis. c. The smell of bowel elimination in the room would deter the patient from eating. d. More ancillary staff members are available after meal times.

ANS: B Peristalsis occurs only a few times a day; the strongest peristaltic waves are triggered by mastication of the meal. The intestine can hold a great deal of food. A patients voiding schedule should not be based on the staffs convenience.

While undergoing a soapsuds enema, the client complains of abdominal cramping. The nurse should: 1. Immediately stop the infusion 2. Lower the height of the enema container 3. Advance the enema tubing 2 to 3 inches 4. Clamp the tubing

ANS: 2 The nurse should lower the container if the client complains of abdominal cramping. Cramping may prevent the client from retaining all of the fluid, which would alter the effectiveness of the enema. If the nurse stops the infusion, the client will not receive all of the fluid, and the enema will be less effective. The nurse may slow the infusion until the abdominal cramping passes. The enema tubing should not be advanced further. The tubing may be clamped temporarily if fluid escapes around the rectal tube. The instillation should be slowed in the instance of abdominal cramping.

Upon auscultation of the clients abdomen, the nurse hears hyperactive bowel sounds (greater than 35 per minute). The nurse knows that this can indicate which of the following? 1. Paralytic ileus 2. Fecal impaction 3. Small intestine obstruction 4. Abdominal tumor

ANS: 3 Absent (no auscultated bowel sounds) or hypoactive sounds (less than five sounds per minute) occur with paralytic ileus, such as after abdominal surgery. High-pitched and hyperactive bowel sounds (35 or more sounds per minute) occur with small intestine obstruction and inflammatory disorders.

A nurse who is caring for postoperative clients on a surgical unit knows that for 24 to 48 hours postoperatively, clients who have undergone general anesthesia may experience: 1. Colitis 2. Stomatitis 3. Paralytic ileus 4. Gastrocolic reflex

ANS: 3 Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. This condition, called paralytic ileus, usually lasts about 24 to 48 hours. Colitis is inflammation of the colon. Stomatitis is inflammation of the mouth. The gastrocolic reflex is the peristaltic wave in the colon induced by entrance of food into the stomach. Colitis, stomatitis, and gastrocolic reflex are not caused by anesthetic used during surgery.

A 70-year-old client is discussing his recent difficulty with having regular bowel movements while on a cross-country bus tour with a senior citizens group. Which of the following assessment questions is directed toward the most likely cause of the problem? 1. Did the bus stop frequently so you could get up and walk around? 2. Did you eat enough fiber while you were on the trip? 3. Do you find using public restrooms unsettling? 4. Do you have any chronic bowel-related problems?

ANS: 3 Attempting to eliminate in a public restroom sometimes results in a temporary inability to defecate. This embarrassment may prompt clients to ignore the urge to defecate, which begins a vicious cycle of constipation and discomfort. Although the remaining options may affect bowel elimination, the situation of the scenario strongly suggests an emotional cause.

Which of the following clients is at greatest risk for serious complications when using the Valsalva maneuver to expel feces? 1. 25-year-old pregnant client 2. 66-year-old male with hypertrophied prostate disease 3. 44-year-old male client with glaucoma 4. 53-year-old female with stomach cancer

ANS: 3 Clients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk, such as cardiac irregularities and elevated blood pressure, with this maneuver and need to avoid straining to pass the stool. Although the Valsalva maneuver may contribute to hemorrhoids, this is not as serious as increasing the intraocular pressure of a client with glaucoma. The Valsalva maneuver is not contraindicated in a client with hypertrophied prostate disease or in a client with stomach cancer.

The mother of an 18-month-old male client shares with the nurse that she is trying to get her child to tell her when he needs to have a bowel movement. Which of the following statements is the most appropriate response from the nurse? 1. I'm sure that you will be glad to have your son out of diapers. 2. I once heard of a child who was totally potty-trained by the time he was a year old. 3. Development of neuromuscular control of the bowels doesnt normally occur until a child is between 2 and 3 year of age. 4. You will have to really be persistent about taking him to the bathroom frequently in order to be successful.

ANS: 3 Developmental changes affecting elimination occur throughout life. The infant is unable to control defecation because of a lack of neuromuscular development. This development usually does not take place until 2 to 3 years of age.

For clients with hypocalcemia, the nurse should implement measures to prevent: 1. Gastric upset 2. Malabsorption 3. Constipation 4. Fluid secretion

ANS: 3 Disorders of calcium metabolism contribute to difficulty with the passage of stools. The nurse should implement measures to prevent constipation in clients with hypocalcemia. Gastric upset, malabsorption, and fluid secretion are not caused by hypocalcemia.

The client is taking medications to promote defecation. Which of the following instructions should be included by the nurse in the teaching plan for this client? 1. Increased laxative use often causes hyperkalemia. 2. Salt tablets should be taken to increase the solute concentration of the extracellular fluid. 3. Emollient solutions may increase the amount of water secreted into the bowel. 4. Bulk-forming additives may turn the urine pink.

ANS: 3 Emollient solutions are stool softeners that may increase the amount of water secreted into the bowel. Laxative overuse can cause serious diarrhea that can lead to dehydration and hypokalemia. Salt tablets should not be taken to increase the solute concentration of extracellular fluid. Bulk-forming additives do not turn the urine pink. Phenolphthalein or danthron stimulant cathartics (e.g., Doxidan, Correctol, Ex-Lax) may cause pink or red urine.

The nurse is caring for a 19-year-old male client with a fractured left femur whose leg was pinned 36 hours ago and is now in traction. Which of the following stressors is mostly likely the cause of this clients difficulty related to constipation? 1. Pain related to the fracture and its repair 2. Anxiety regarding the serious nature of the injury 3. The need to defecate in an unfamiliar, awkward position 4. Poor fluid intake after the accident and ensuing surgery

ANS: 3 For the client immobilized in bed, defecation is often difficult. In a supine position it is impossible to contract the muscles used during defecation. If the clients condition permits, raise the head of the bed; this assists the client to a more normal sitting position on a bedpan, enhancing the ability to defecate. Although the other options may have some effect, the primary cause is most likely the emotional stress of not being able to assume the usual position for defecation.

A client is caring for her daughter, who recently suffered multiple fractures in an automobile accident. The client tells the home care nurse that she has been really down since all this happened. She adds that she has been constipated and not really interested in eating. Which of the following statements by the nurse focuses on the most likely cause of the gastrointestinal problem? 1. Actually, how long have you been constipated? 2. Are you eating fiber-rich foods like fruit and whole grains? 3. You may be depressed; emotional depression can cause constipation. 4. I suggest you get some over-the-counter mild laxative and see if that helps.

ANS: 3 If a person becomes depressed, the autonomic nervous system slows impulses, and peristalsis decreases, resulting in constipation. Although the other options are not incorrect, they are not the most likely cause for this particular client.

31. A client is reporting that the oral medication she was prescribed for her hypothyroidism does not seem to be helping. The client goes on to report that she has been experiencing tension-related headaches and constipation. She has been self-medicating with nonsteroidal antiinflammatory drugs (NSAIDs) and bulk laxatives. Which of the following assessment questions is most likely to provide information regarding this clients concern regarding her thyroid problem? 1. How long have you taken Synthroid? 2. What other medications are you currently on? 3. How long have you been taking a bulk laxative? 4. Have you developed any other gastrointestinal symptoms?

ANS: 3 Laxatives often influence the efficacy of other medications by altering the transit time (i.e., the time the medication remains in the GI tract and is available for absorption). The remaining options would have little bearing on the effectiveness of the hypothyroid medication unless the medication has not been taken long enough to reach therapeutic levels.

The nurse is counseling a 65-year-old female client on her use of mineral oil as a laxative. One of the most important things that the nurse can share with the client is how mineral oil can cause the decreased absorption of which of the following vitamins? 1. Vitamin C 2. Niacin 3. Vitamin D 4. Riboflavin

ANS: 3 Mineral oil, a common laxative, decreases fat-soluble vitamin absorption. Vitamin D is the only fat soluble vitamin listedthe others are all water-soluble.

Which of the following is an appropriate nursing intervention for a client with a nasogastric tube in place? 1. Tape the tube up and around the ear on the side of insertion. 2. Secure the tubing to the bed by the clients head. 3. Mark the tube where it exits the nose. 4. Change the tubing daily.

ANS: 3 Once placement is confirmed, a mark should be placed, either making a red mark or using tape, on the tube to indicate where the tube exits the nose. The mark or tube length is to be used as a guide to indicate whether displacement may have occurred. The tube should be taped to the nose, not to the ear. The tubing should be secured to the clients gown, not the bed. The tubing should not be changed daily, but it should be irrigated daily.

The appropriate amount of fluid to prepare for an enema to be given to an average-size school-age child is: 1. 150 to 250 mL 2. 250 to 350 mL 3. 300 to 500 mL 4. 500 to 750 mL

ANS: 3 The appropriate amount of fluid to prepare for an enema to be given to an average-size school-age child is 300 to 500 mL. An infant should receive 150 to 250 mL, a toddler should receive 250 to 350 mL, and an adolescent should receive 500 to 750 mL.

Which of the following would the nurse expect as a normal change in the bowel elimination as a person ages? 1. Absorptive processes are increased in the intestinal mucosa. 2. Esophageal emptying time is increased. 3. Changes in nerve innervation and sensation cause diarrhea. 4. Mastication processes are less efficient.

ANS: 4 An expected change in bowel elimination is decreased chewing and decreased salivation, resulting in less efficient mastication. There is decreased nutrient absorption of the small intestine in the older adult. Esophageal emptying slows, as a result of reduced motility, especially in the lower third of the esophagus. With decreased peristalsis and weakened musculature, the older adult is more prone to constipation. Duller nerve sensations may place the older adult at increased risk for fecal incontinence.

A client who recently underwent surgery and now has a colostomy is correctly instructed by the nurse that for the next few weeks the clients diet will include foods such as: 1. Vegetables 2. Fresh fruit 3. Whole grain breads 4. Poached eggs and rice

ANS: 4 During the first weeks after surgery, many health care providers recommend low-fiber diets because the bowel requires time to adapt to the diversion. Low-fiber foods include bread, noodles, rice, cream cheese, eggs (not fried), strained fruit juices, lean meats, fish, and poultry. Poached eggs and rice would be appropriate for this client. After the ostomy heals, the client is allowed to eat whole grains, fruits, and vegetables. High-fiber foods such as fresh fruits and vegetables help ensure a more solid stool needed to achieve success at irrigation. Ostomy clients may benefit from avoiding foods that cause gas and odor, including broccoli, cauliflower, dried beans, and Brussels sprouts.

The nurse is discussing food allergies with a group of mothers whose children are allergy prone. Which of the following statements made by a mother best describes lactose intolerance? 1. My child is allergic to milk; it makes her very gassy. 2. Dairy products require a special enzyme to be digested properly. 3. Being lactose intolerant means my child cant tolerate dairy products. 4. My child gets diarrhea from dairy products because she cant digest lactose.

ANS: 4 Food intolerance is not an allergy, but a particular food that causes the body distress within a few hours of ingestion. The result is diarrhea, cramps, or flatulence. For example, people who drink cows milk who have these symptoms are not allergic to milk but lack the enzyme needed to digest the milk sugar lactose; they are lactose intolerant. To be lactose intolerant (exhibiting the signs after ingesting dairy products) does not constitute a dairy allergy. The remaining options are not as specific as the answer.

The client has been admitted to an acute care unit with a diagnosis of biliary disease. The nurse suspects that the feces will appear: 1. Bloody 2. Pus filled 3. Black and tarry 4. White or clay colored

ANS: 4 Stool that is white or clay colored indicates an absence of bile. Bloody feces is not an indication of biliary disease. Pus-filled feces indicate infection. Black or tarry feces may indicate upper gastrointestinal (GI) bleeding or iron ingestion.

The nurse is discussing arteriosclerosis and the effects it has on the body with an older adult client. Although the most commonly recognized effect is on the cardiovascular system, the nurse should include which of the following statements regarding its effect on the gastrointestinal system to complete the discussion? 1. Circulatory problems make getting to the bathroom easily problematic. 2. The benefit you get from your food is also decreased by this condition. 3. The aging process that causes the vascular problems also causes elimination problems. 4. The problem it creates with blood flow also affects blood flow to the bowels and so affects elimination.

ANS: 4 Systemic changes in the function of digestion and absorption of nutrients result from changes in older clients cardiovascular and neurological systems, rather than their gastrointestinal system. For example, arteriosclerosis causes decreased mesenteric blood flow, thus decreasing absorption from the small intestine.

A client is to have a stool test for occult blood. The nurse is instructing the nursing assistant in the correct procedure for the test. The nursing assistant is correctly informed that: 1. Sterile technique is used for collection 2. Stool should be collected over a 3-day period 3. The specimen should be kept warm 4. A 1-inch sample of formed stool is needed

ANS: 4 Tests performed by the laboratory for occult blood in the stool and stool cultures require only a small sample. The nurse uses clean technique to collect about 1 inch of formed stool or 15 to 30 mL of liquid stool. Unlike testing for occult blood, tests for measuring the output of fecal fat require a 3- to 5-day collection of stool, and tests that measure for ova and parasites require the stool to be warm.

The 35-year-old pregnant client is concerned about constipation. When weighing the advantages and disadvantages of having a local anesthetic over a general anesthetic for a caesarian section, the nurse shares with the client that the local will cause less risk for constipation following surgery. The best reason that there is less constipation following this surgery is because: 1. The client will not have to be allowed nothing by mouth (NPO) before surgery 2. The client will be able to ambulate immediately following surgery 3. The client will be able to eat following surgery 4. Local or regional anesthetic often has little or no effect on bowel activity

ANS: 4 The client who receives a local or regional anesthetic is less at risk for elimination alterations because this often affects bowel activity minimally or not at all whereas general anesthetic agents used during surgery cause temporary cessation of peristalsis, which can result in constipation. The client will still need to remain NPO before a scheduled caesarian section in case she would need to receive a general anesthetic. The client will not be able to ambulate immediately after surgery because of loss of feeling in the lower extremities. Clients should be able to eat following nonbowel-related surgery whether or not they have undergone a general anesthetic or a local anesthetic.

An adult client reports to the nurse that she has been experiencing constipation recently and is interested in any suggestions regarding dietary changes she might make. Which of the following suggestions provided by the nurse is most likely to minimize the clients complaint? 1. Have you tried foods like prunes and bran? 2. You might find the new flavored bulk laxatives helpful. 3. What have you tried in the past that hasnt been helpful? 4. Increase your fluid intake; have some juice with breakfast.

ANS: 4 Unless there is a medical contraindication, an adult needs to drink six to eight glasses (1500 to 2000 mL) of noncaffeinated fluid daily. An increase in fluid intake with the use of fruit juices softens stool and increases peristalsis. Poor fluid intake increases the risk for constipation because of reabsorption of fluid in the colon, resulting in hard, dry stools. Although some of the options are food related, they are not as direct; a laxative is not a dietary change.

Which of the following statements by a client reporting constipation reflects the most informed understanding of interventions that will aid in assuming proper bowel mobility? 1. Could it be that I need to get more exercise, even here in the hospital? 2. Is it true that drinking coffee often helps stimulate the bowels to work? 3. I guess a little high-fiber cereal might help. Can you get me some from the cafeteria? 4. May I have a cup of decaffeinated tea in addition to my breakfast juice? That usually helps.

ANS: 4 Unless there is a medical contraindication, an adult needs to drink six to eight glasses (1500 to 2000 mL) of noncaffeinated fluid daily. An increase in fluid intake with the use of fruit juices softens stool and increases peristalsis. Poor fluid intake increases the risk for constipation because of reabsorption of fluid in the colon, resulting in hard, dry stools. Although the other options are not incorrect, the client does not seem to have past experience with these suggestions.

Which of the following statements made by an older adult reflects the best understanding of the role of fiber regarding good bowel health? 1. Fiber is very effective at cleaning out the bowels. 2. A high-fiber diet results in softer bowel movements. 3. Passing hard, dry stool is more uncomfortable and harder on the bowels. 4. The more fiber there is in my diet, the less risk I have of developing polyps.

ANS: 4 When there is no fiber to transport waste matter through the colon, it increases the risk for polyps. Although the other options are not incorrect, they do not address the most important barrier to good bowel health.

A patient is diagnosed with a bowel obstruction. The nurse chooses which type of tube for gastric decompression? a. Salem sump b. Dobhoff c. Sengstaken-Blakemore d. Small bore

ANS: A A bowel obstruction causes a backup into the gastric area; a nasogastric tube may be inserted to decompress secretions and gases from the gastrointestinal tract. The Salem sump has the width and functionality needed to both feed and suction, and it is ideal for a bowel obstruction. A Dobhoff tube is used for instillation of feedings. A Sengstaken-Blakemore tube is used to compress stomach contents to prevent hemorrhage. A small bore is intended for nutritional feedings only and does not have suction capacity.

A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? a. Grape and walnut chicken salad sandwich on whole wheat bread b. Broccoli and cheese soup with potato bread c. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing d. Turkey and mashed potatoes with brown gravy

ANS: A A healthy diet for the bowel should include foods high in bulk-forming fiber. Whole grains, fresh fruit, and fresh vegetables are excellent sources. Foods without much fiber and with high levels of fat can slow down peristalsis, causing constipation.

A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education? a. If I get a positive result, I have gastrointestinal bleeding. b. I should not eat red meat before my examination. c. I should schedule to perform the examination when I am not menstruating. d. I will need to perform this test three times if I have a positive result.

ANS: A A positive result does not mean GI bleeding; it could be a false positive from consuming red meat, some raw vegetables, or NSAIDs. Proper patient education is important for viable results. The patient needs to avoid certain foods to rule out a false positive. If the test is positive, the patient will need to repeat the test at least three times. Menses and hemorrhoids can also lead to false positives.

After a patient returns from a barium swallow, the nurses priority is to a. Encourage the patient to increase fluids to flush out the barium. b. Monitor stools closely for bright red blood or mucus, which indicates trauma from the procedure. c. Inform the patient that his bowel movements are radioactive, and that he should be sure to flush the toilet three times. d. Thicken all patient drinks to prevent aspiration.

ANS: A Encourage the patient to increase fluid intake to flush and remove excess barium from the body. Barium swallow is a noninvasive procedure for which no trauma would produce blood or mucus or increase aspiration risk. Barium is not a radioactive substance, so multiple flushes are not needed.

A nurse is educating a patient on how to irrigate an ostomy bag. Which statement by the patient indicates the need for further instruction? a. I can use a fleet enema to save money because it contains the same irrigation solution. b. Sitting on the toilet lets the irrigation sleeve eliminate into the bowl. c. I should never attempt to reach into my stoma to remove fecal material. d. Using warm tap water will reduce cramping and discomfort during the procedure.

ANS: A Enema applicators should never be used in the stoma because they can cause damage. A special coned irrigation device is used for ostomies. Irrigating a stoma into the toilet is an effective management technique. Fingers and other objects should not be placed into the stoma because they may cause trauma to the intestinal wall. Warm tap water will reduce cramping during irrigation.

A patient informs the nurse that she was using laxatives three times daily to lose weight. After stopping use of the laxative, the patient had difficulty with constipation and wonders if she needs to take laxatives again. The nurse educates the patient that a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. b. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis. c. Natural laxatives such as mineral oil are safer than chemical laxatives for relieving constipation. d. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced.

ANS: A Long-term laxative use can lead to constipation. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Natural laxatives like mineral oil come with their own set of risks, such as inability to absorb fat-soluble vitamins. Even if malnourished, the body will produce waste if substance is consumed.

Which of the following is not a function of the large intestine? a. Absorbing nutrients b. Absorbing water c. Secreting bicarbonate d. Eliminating waste

ANS: A Nutrient absorption is done in the small intestine. The other options are all functions of the large intestine.

While a cleansing enema is administered to an 80-year-old patient, the patient expresses the urge to defecate. What is the next priority nursing action? a. Positioning the patient in the dorsal recumbent position with a bed pan b. Assisting the patient to the bedside commode c. Stopping the enema cleansing and rolling the patient into right-lying Sims position d. Inserting a rectal plug to contain the enema solution

ANS: A Patients with poor sphincter control may not be able to hold in all of an enema solution. Positioning the patient on a bed pan in dorsal recumbent position will allow the nurse to continue to administer the enema. Having the patient get up to toilet is unsafe because the rectal tube can damage the mucosal lining. The purpose of the enema is to promote defecation; stopping it early may inhibit its effectiveness. Use of a rectal plug to contain the solution is inappropriate.

The nurse should place the patient in which position when preparing to administer an enema? a. Left Sims position b. Fowlers c. Supine d. Semi-Fowlers

ANS: A Side-lying Sims position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon. This helps to improve retention of the enema. Administering an enema in a sitting position may allow the curved rectal tube to scrape the rectal wall.

The nurse is assessing a patient 2 hours after a colonoscopy. Based on the procedure done, what focused assessment will the nurse include? a. Bowel sounds b. Presence of flatulence c. Bowel movements d. Nausea

ANS: A The nurse does want to hear the presence of bowel sounds; absent bowel sounds may indicate a complication from the surgery. Bowel movements and flatulence are not expected in the hours after surgery. The nurse does want to hear the presence of bowel movements. Nausea is not a problem following colonoscopy.

The nurse knows that the ideal time to change an ostomy pouch is a. Before eating a meal, when the patient is comfortable. b. When the patient feels that he needs to have a bowel movement. c. When ordered in the patients chart. d. After the patient has ambulated the length of the hallway.

ANS: A The nurse wants to change the ostomy appliance when as little output as necessary ensures a smooth procedure. Patients with ostomies do not feel the urge to defecate because the sensory portion of the anus is not stimulated. Changing the ostomy pouch is a nursing judgment decision. After a patient ambulates, stool output is increased.

The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which of the following outcomes would the nurse evaluate as successful for the patient to establish normal defecation? a. The patient reports eliminating a soft, formed stool. b. The patient has quit taking opioid pain medication. c. The patients lower left quadrant is tender to the touch. d. The nurse hears bowel sounds present in all four quadrants.

ANS: A The nurses goal is for the patient to be on opioid medication and to have normal bowel elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired outcome for the patient. Tenderness in the left lower quadrant indicates constipation and does not further address bowel elimination. Present bowel sounds indicate that the bowels are moving; however, they are not an indication of defecation.

An older adults perineal skin appears to be dry and thin with mild excoriation. When providing hygiene after a bowel movement, the nurse should a. Thoroughly scrub the skin with a wash cloth and hypoallergenic soap. b. Apply a skin protective lotion after perineal care. c. Tape an occlusive moisture barrier pad to the patients skin. d. Massage the skin with deep kneading pressure.

ANS: B Proper skin care and perineal cleaning require that the nurse gently clean the skin and apply a moistening barrier cream. Tape and occlusive dressings can damage skin. Excessive pressure and force are inappropriate and may cause skin breakdown.

A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate? a. Changing the skin barrier portion of the ostomy pouch daily b. Selecting a pouch that is able to hold excess output to reduce the frequency of pouch emptying c. Thoroughly scrubbing the skin around the stoma to remove excess stool and adhesive d. Measuring the correct size for the barrier device while leaving a 1/8-inch space around the stoma

ANS: B Selecting a pouch that holds a large volume of output will decrease the frequency of emptying the pouch and may ease patient anxiety about pouch overflow. The barrier device should be changed every few days unless it is leaking or is no longer effective. Peristomal skin should be gently cleansed; vigorous rubbing can cause further irritation or skin breakdown. Approximately 1/16 of an inch is present between the barrier device and the stoma. Excess space allows fecal matter to have prolonged exposure to skin, resulting in skin breakdown.

Which patient is most at risk for increased peristalsis? a. A 5-year-old child who ignores the urge to defecate owing to embarrassment b. A 21-year-old patient with three final examinations on the same day c. A 40-year-old woman with major depressive disorder d. An 80-year-old man in an assisted-living environment

ANS: B Stress can stimulate digestion and increase peristalsis. Ignoring the urge to defecate, depression, and age-related changes of the elderly are causes of constipation.

Which physiological change can cause a paralytic ileus? a. Chronic cathartic abuse b. Surgery for Crohns disease and anesthesia c. Suppression of hydrochloric acid from medication d. Fecal impaction

ANS: B Surgical manipulation of the bowel can cause a paralytic ileus. The other options are incorrect.

Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs that prevents ambulation? a. Elevate the head of the bed 45 degrees 60 minutes after breakfast. b. Use a mobility device to place the patient on a bedside commode. c. Give the patient a pillow to brace against the abdomen while bearing down. d. Administer a soap suds enema every 2 hours.

ANS: B The best way to promote normal defecation is to assist the patient into a posture that is as normal as possible while defecating. Using a mobility device promotes nurse and patient safety. Elevating the head of the bed would be appropriate if the patient were to void with a bed pan. However, the patients condition does not require use of a bed pan. Giving the patient a pillow may reduce discomfort, but this is not the best way to promote defecation. A soaps suds enema is indicated for a patient who needs assistance to stimulate peristalsis. It promotes non-natural defecation.

The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. What is the next priority nursing action? a. Preparing the patient for a second tap water enema b. Donning gloves for digital removal of the stool c. Positioning the patient on the left side d. Inserting a rectal tube

ANS: B When enemas are not successful, digital removal of the stool may be necessary occasionally to break up pieces of the stool or to stimulate the anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbalance. Positioning the patient on the left side does not promote defecation. A rectal tube is indicated for a patient with liquid stool incontinence but would not be applicable or effective for this patient.

The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately? a. Stoma is protruding from the abdomen. b. Stoma is moist. c. Stool is discharging from the stoma. d. Stoma is purple.

ANS: D A purple stoma may indicate strangulation or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude. Stool is an expected outcome of stoma placement.

A guaiac test has been ordered. The nurse knows that this is a test for a. Bright red blood. b. Dark black blood. c. Blood that contains mucus. d. Blood that cannot be seen.

ANS: D Fecal occult blood tests are used to test for blood that may be present in stool that cannot be seen by the naked eye. This is usually indicative of a GI bleed. All other options are incorrect.

A nurse is providing education to an elderly patient concerning ways to prevent constipation. Which diet choices would support that the education was successful? Select all that apply A) Hot tea with meals B) A turkey sandwich with whole-grain bread C) Prune juice with breakfast D) Ice cream with lunch and dinner E) Diet soda with lemon

Ans: A, B, C Feedback: A glass of prune juice is equivalent to more than one serving of the dried fruit, has high magnesium content, and is an excellent source of fluid to promote bowel elimination. Hot fluids, such as coffee, tea, or hot water with lemon juice, may also increase intestinal motility. High fiber foods such as whole-grain bread provide bulk for the stool. Ice cream and diet soda do not provide any preventative measures for constipation.

A patient is complaining of increased flatulence. Which of the following may be a cause of his flatulence? Select all that apply. A) Carbonated beverages B) Caffeinated beverages C) Smoking D) Drinking straws E) Rapid ingestion of food

Ans: A, C, D, E Feedback: Rapid ingestion of food, improper use of straws, smoking, and excessive carbonated beverages may all be causes of flatulence. Caffeinated beverages typically do not cause flatulence.

The nurse is assisting an elderly patient into position for a sigmoidoscopy. Which position would the nurse place the patient in? A) Right lateral B) Left lateral C) Prone D) Semi-Fowlers

Ans: B Feedback: The left lateral or knee to chest position is the most common position for sigmoidoscopies or colonoscopies. If the patient is not able to tolerate this position, Sims position may also be used. The right lateral, prone or semi-Fowlers positions are not routinely used for this procedure.

A patient reports constipation. Which of the following assessment questions should the nurse initially ask when completing the patients health history, including bowel habits? A) Do you have a daily bowel movement? B) How do you handle stress? C) Do you eat fiber foods every day? D) What medicines do you take?

Ans: B Feedback: This represents a broad opening statement that allows for greater subjective information. Chronic exposure to stress can slow bowel activity, resulting in decreased frequency of bowel movements.

The student nurse has completed a presentation to a group of senior citizens on colorectal screening. Which statement by a participant suggests a need for further education? A) I will need yearly screenings for colon cancer. B) I will have a fecal occult blood test done every 5 years. C) I will have a flexible endoscopic exam done every 5 years. D) My mother had colon cancer so I am at a greater risk for also developing colon cancer.

Ans: B Feedback: Yearly screenings, including a fecal occult blood test, should be done on all patients over the age of 50. A flexible endoscopic exam should be done every 5 years. A family history of colorectal cancer increases the risk of developing colorectal cancer.

The student nurse is preparing a presentation on bowel elimination. Which of the following would be a potential cause of diarrhea that the student should include? Select all that apply. A) Opioids B) Antibiotics C) Acute stress D) Depression E) Increased physical activity

Ans: B, C Feedback: Acute stress, anxiety, and antibiotic use can all cause diarrhea. Opioid use and depression can cause constipation. Increased physical activity can increase peristalsis but this does not necessarily cause diarrhea.

You are educating a new colostomy patient on gas-producing foods. Which of the following are gas-producing foods the patient may choose to avoid? A) Lettuce B) Rice C) Brussels sprouts D) Green peppers

Ans: C Feedback: Certain foods (e.g., cabbage, onions, legumes) often increase the amount of flatus produced in the intestine.

The student nurse is administering a large-volume enema to a patient. The patient complains of abdominal cramping. What should the student nurse do first? A) Increase the flow of the enema for approximately 30 seconds then decrease it to the prior flow rate. B) Stop the administration of the enema and notify the physician. C) Stop the administration of the enema momentarily . D) Increase the flow of the enema until all of the solution has been administered.

Ans: C Feedback: If the patient complains of abdominal discomfort or cramping, the nurse should momentarily stop the flow of solution. Increasing the flow of the enema may cause more cramping and discomfort. Cramping and discomfort are common complaints during enema administration so there is no need to notify the physician.

An elderly patient who is wheelchair bound following a cerebrovascular accident is being assessed by the nurse. The nurse notes the patient has seepage of stool from the anus. The nurse knows this is indicative of A) Constipation B) Diarrhea C) Fecal impaction D) Intestinal infection

Ans: C Feedback: Suspect a fecal impaction when there is a history of absence of a regular bowel movement for several days (3-5 days or more) followed by the passage of liquid or semi-liquid stool.

Which of the following diversions is considered a continent ostomy? A) Colostomy B) Ileostomy C) Ileoconduit D) Ileoanal

Ans: D Feedback: A continent fecal diversion is the ileoanal diversion. With this type of diversion, feces can be drained at the patients convenience rather than having it continually draining into an external pouch, as occurs in the traditional ileostomy or colostomy.

A patient has had abdominal surgery and in 72 hours develops abdominal distention and absence of bowel sounds with pain. The nurse suspects the patient has A) A wound infection B) Need of greater pain relief C) Increased activity D) Paralytic ileus

Ans: D Feedback: An obstruction that blocks the passage of flatus and intestinal chime or feces is a primary cause of abdominal distention. Paralytic ileus and abdominal tumors are types of bowel obstruction that produce distention.