ER* Prep-U: Chapter 47: Management of Patients With Intestinal and Rectal Disorders
A nurse is teaching an older adult client about good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required? a. "I should eat a fiber-rich diet with raw, leafy vegetables, unpeeled fruit, and whole grain bread." b. "I need to use laxatives regularly to prevent constipation." c. "I need to drink 2 to 3 liters of fluids every day." d. "I should exercise four times per week."
"I need to use laxatives regularly to prevent constipation." Explanation: The client requires more teaching if he states that he'll use laxatives regularly to prevent constipation. The nurse should teach this client to gradually eliminate the use of laxatives because using laxatives to promote regular bowel movements may have the opposite effect. A high-fiber diet, ample amounts of fluids, and regular exercise promote good bowel health.
A client reports constipation. Which nursing measure would be most effective in helping the client reduce constipation? a. Provide adequate quantity of food. b. Obtain medical and allergy history. c. Assist client to increase dietary fiber. d. 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.
Which is the most common presenting symptom of colon cancer? a. Fatigue b. Change in bowel habits c. Anorexia d. 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.
A client informs the nurse that he has been having abdominal pain that is relieved when having a bowel movement. The client states that the physician told him he has irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder? a. Weight loss due to malabsorption b. Blood and mucus in the stool c. Chronic constipation with sporadic bouts of diarrhea d. 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 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? a. Encourage the client to avoid exercise. b. Instruct the client to cleanse perianal area with warm water. c. Teach the client how to do sitz baths at home using warm water three to four times each day. d. 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.
Which of the following is considered a bulk-forming laxative? a. Metamucil b. Milk of Magnesia c. Mineral oil d. 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.
The presence of mucus and pus in the stools suggests which condition? a. Small-bowel disease b. Ulcerative colitis c. Disorders of the colon d. 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.
A client is admitted from the emergency department with complaints of severe abdominal pain and an elevated white blood cell count. The physician diagnoses appendicitis. The nurse knows the client is at greatest risk for: a. rupture of the appendix. b. ulceration of the appendix. c. inflammation of the gallbladder. d. emotional distress related to the pain.
rupture of the appendix. Explanation: The most severe complication of appendicitis is rupture of the appendix, which can lead to a life-threatening infection. Ulceration of the appendix and inflammation of the gallbladder aren't risks in appendicitis. Although the client may have emotional distress because of the pain, this factor isn't the greatest risk to the client.
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"? a. stool consistency and client comfort b. one bowel movement daily c. one bowel movement every other day d. 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 comparing Crohn's disease (regional enteritis) with ulcerative colitis. Which of the following describes Crohn's disease? a. Fistulas are rare b. Diarrhea is more severe c. Bleeding is common and severe d. 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.
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? a. The client exhibits signs of adequate GI perfusion. b. The client expresses positive feelings about himself. c. The client verbalizes a manageable level of discomfort. d. 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 informs the nurse that he is taking a stimulant laxative in order to be able to have a bowel movement daily. What should the nurse inform the client about taking a stimulant laxative? a. They can be habit forming and will require increasing doses to be effective. b. As long as the client is drinking 8 glasses of water per day, he can continue to take them. c. The laxative is safe to take with other medication the client is taking. d. The client should take a fiber supplement along with the stimulant laxative.
They can be habit forming and will require increasing doses to be effective. Explanation: The nurse should discourage self-treatment with daily or frequent enemas or laxatives. Chronic use of such products causes natural bowel function to be sluggish. In addition, laxatives continuing stimulants can be habit forming, requiring continued use in increasing doses. Although the nurse should encourage the client to have adequate fluid intake, laxative use should not be encouraged. The laxative may interact with other medications the client is taking and may cause a decrease in absorption. A fiber supplement may be taken alone but should not be taken with a stimulant laxative.
After assessing a client with peritonitis, how would the nurse most likely document the client's bowel sounds? a. Mild b. High-pitched c. Hyperactive d. Absent
Absent Explanation: Since lack of bowel motility typically accompanies peritonitis, bowel sounds are absent. Therefore, the nurse will not observe mild, high-pitched, or hyperactive bowel sounds.
In addition to teaching a client with constipation to increase dietary fiber intake to 25 g/day, which of the following would the nurse include as important? a. Avoiding bran cereals and beans in the diet b. Adding fiber-rich foods to the diet gradually c. Limiting fluid intake to 5 to 6 glasses per day d. Minimizing activity levels for at least 2 months
Adding fiber-rich foods to the diet gradually Explanation: The nurse instructs the client to add fiber-rich foods to the diet gradually to avoid bloating, gas, and diarrhea. It is essential for a client to include bran cereals and beans in the diet because they ease defecation. The nurse also instructs the client to increase fluids to 6 to 8 glasses per day to prevent hard, dry stools. The client should also develop a regular exercise program to increase peristalsis and promote bowel elimination.
What is the most common cause of small-bowel obstruction? a. Hernias b. Neoplasms c. Adhesions d. 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.
Which drug is considered a stimulant laxative? a. Magnesium hydroxide b. Bisacodyl c. Mineral oil d. 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 of the following would a nurse expect to assess in a client with peritonitis? a. Deep slow respirations b. Decreased pulse rate c. Hyperactive bowel sounds d. Board-like abdomen
Board-like abdomen Explanation: The client with peritonitis would typically exhibit a rigid, board-like abdomen, with absent bowel sounds, elevated pulse rate, and rapid, shallow respirations.
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? a. Loud bowel sounds b. Borborygmus c. Tenesmus d. Peristalsis
Borborygmus
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? a. Appendicitis b. Rectal fissures c. Bowel perforation d. 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. A peanut butter sandwich and fruit cup b. Broiled chicken with low-fiber pasta c. Salami on whole grain bread and V-8 juice d. 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 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? a. Inform the patient that it will only last a minute and continue with the procedure. b. Clamp the tubing and give the patient a rest period. c. Stop the irrigation and remove the tube. d. 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.
Which statement provides accurate information regarding cancer of the colon and rectum? a. Colorectal cancer is the third most common site of cancer in the United States. b. Rectal cancer affects more than twice as many people as colon cancer. c. The incidence of colon and rectal cancer decreases with age. d. Colon cancer has no hereditary component.
Colorectal cancer is the third most common site of cancer in the United States. Explanation: Cancer of the colon and rectum is the third most common site of new cancer cases in the United States. Colon cancer affects more than twice as many people as does rectal cancer (94,700 for colon, 34,700 for rectum). The incidence increases with age (the incidence is highest in people older than 85). Colon cancer occurrence is higher in people with a family history of colon cancer.
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? a. Crohn's disease b. Ulcerative colitis c. Irritable bowel syndrome d. 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.
An older adult client seeks help for chronic constipation. What factor related to aging can cause constipation in elderly clients? a. Increased intestinal motility b. Decreased abdominal strength c. Increased intestinal bacteria d. 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.
The nurse is preparing a client for a test that involves inserting a thick barium paste into the rectum with radiographs taken as the client expels the barium. What test will the nurse prepare the client for? a. Kidneys, ureters, bladder (KUB) b. Colonic transit studies c. Defecography d. Abdominal radiography
Defecography Explanation: In defecography, a thick barium paste is inserted into the rectum. Radiographs are taken as the client expels the barium to determine whether there are any anatomic abnormalities or problems with the muscles surrounding the anal sphincter. A KUB will not determine this. Colonic transit studies are used to determine how long it takes for food to travel through the intestines. Abdominal radiography will show the structure but does not determine the muscle ability surrounding the anal sphincter.
Which is one of the primary symptoms of irritable bowel syndrome (IBS)? a. Diarrhea b. Pain c. Bloating d. 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.
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? a. Ultrasound b. Endoscopy with mucosal biopsy c. Stool specimen for ova and parasites d. Pancreatic function tests
Endoscopy with mucosal biopsy Explanation: Endoscopy with biopsy of the mucosa is the best diagnostic tool for malabsorption syndrome.
A client underwent a continent ileostomy. Within which time frame should the client expect to empty the reservoir? a. At least once a day b. At least once every 2 days c. Three or four times daily d. Every 4 to 6 hours
Every 4 to 6 hours Explanation: 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. This prevents the accumulating effluent from spilling or causing infection.
Which characteristic is a risk factor for colorectal cancer? a. Age younger than 40 years b. Low-fat, low-protein, high-fiber diet c. History of skin cancer d. 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.
A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate? a. Cutting the faceplate opening no more than 2 inches larger than the stoma b. Gently washing the area surrounding the stoma using a facecloth and mild soap c. Scrubbing fecal material from the skin surrounding the stoma d. Maintaining wrinkles in the faceplate so it doesn't irritate the skin
Gently washing the area surrounding the stoma using a facecloth and mild soap Explanation: For a client with an ostomy, maintaining skin integrity is a priority. The nurse should gently wash the area surrounding the stoma using a facecloth and mild soap. Scrubbing the area around the stoma can damage the skin and cause bleeding. The faceplate opening should be no more than 1/8-inch to 1/6-inch larger than the stoma. This size protects the skin from exposure to irritating fecal material. The nurse can create an adequate seal and prevent leakage of fecal material from under the faceplate by applying a thin layer of skin barrier and smoothing out wrinkles in the faceplate. Eliminating wrinkles in the faceplate also protects the skin surrounding the stoma from pressure.
A patient diagnosed with IBS is advised to eat a diet that is: a. Sodium-restricted. b. High in fiber. c. Low in residue. d. 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.
An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to? a. Hyperkalemia b. Hypokalemia c. Hyponatremia d. 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 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. A small bowel disorder. b. Intestinal malabsorption. c. Inflammatory colitis. d. 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.
After 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? a. Loperamide b. Lubiprostone c. Dicyclomine d. 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.
Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following? a. Low residue b. Low protein c. Calorie restriction d. 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.
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? a. Lubricates and softens fecal matter b. Increases the volume of intestinal contents c. Irritates nerve endings in the intestinal mucosa d. 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.
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? a. Maintaining skin integrity b. Beginning a bowel program to establish continence c. Instituting a diet high in fiber and increase fluid intake d. 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.
Vomiting results in which of the following acid-base imbalances? a. Metabolic alkalosis b. Metabolic acidosis c. Respiratory acidosis d. 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.
Celiac disease (celiac sprue) is an example of which category of malabsorption? a. Infectious diseases b. Mucosal disorders causing generalized malabsorption c. Luminal problems causing malabsorption d. Postoperative malabsorption
Mucosal disorders causing generalized malabsorption Explanation: Celiac disease (celiac sprue, gluten-sensitive enteropathy) results from a toxic response to the gliadin component of gluten by the surface epithelium of the intestine; eventually, the mucosal villi of the small intestine become denuded and cannot function. Crohn's disease (regional enteritis) and radiation enteritis are other examples of mucosal disorders. Examples of infectious diseases causing generalized malabsorption include small-bowel bacterial overgrowth, tropical sprue, and Whipple disease. Examples of luminal problems causing malabsorption include bile acid deficiency, Zollinger-Ellison syndrome, and pancreatic insufficiency. Postoperative gastric or intestinal resection and cancer can result in development of a lymphatic malabsorption syndrome, in which there is interference with the transport of the fat by-products of digestion into the systemic circulation.
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. a. Black, tarry stools b. Narrowing stools c. Constipation d. Dull abdominal pain e. 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.
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? a. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. b. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. c. The appendix may develop gangrene and rupture, especially in a middle-aged client. d. 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.
The nurse is caring for a client with intussusception of the bowel. What does the nurse understand occurs with this disorder? a. The bowel twists and turns itself and obstructs the intestinal lumen. b. One part of the intestine telescopes into another portion of the intestine. c. The bowel protrudes through a weakened area in the abdominal wall. d. 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 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? a. Constipation b. Paralytic ileus c. Peritonitis d. 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.
Which of the following is the most common symptom of a polyp? a. Rectal bleeding b. Abdominal pain c. Diarrhea d. 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 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? a. Beefy red stoma site b. Stoma site not sensitive to touch c. Red, sensitive skin around the stoma site d. 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.
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? a. Right upper quadrant b. Right lower quadrant c. Left upper quadrant d. 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 ________. a. Rovsing's sign; acute appendicitis b. McBurney's sign; acute appendicitis c. Rovsing's sign; perforation d. McBurney's sign; perforation
Rovsing's 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's sign and suggests acute appendicitis.
A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis? a. Stool Hematest b. Carcinoembryonic antigen (CEA) c. Sigmoidoscopy d. 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.
A client is diagnosed with Zollinger-Ellison syndrome. The nurse knows to assess the client for which characteristic clinical feature of this syndrome? a. Decreased intestinal lactose b. Folate deficiency c. Lymphadenopathy d. Steatorrhea
Steatorrhea Explanation: Hyperacidity in the duodenum inactivates pancreatic enzymes causing steatorrhea and ulcer diathesis.
The nurse is reviewing the laboratory test results of a client with Crohn disease. Which of the following would the nurse most likely find? a. Decreased white blood cell count b. Increased albumin levels c. Stool cultures negative for microorganisms or parasite d. 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 who has undergone colostomy surgery is experiencing constipation. Which intervention should a nurse consider for such a client? a. Suggest fluid intake of at least 2 L/day b. Instruct the client to avoid prune or apple juice c. Assist the client regarding the correct diet or to minimize food intake d. Instruct the client to keep a record of food intake
Suggest fluid intake of at least 2 L/day Explanation: The nurse should suggest a fluid intake of at least 2 L/day to help the client avoid constipation. The nurse should also offer prune or apple juice because they promote elimination. The nurse should encourage the client to eat regular meals. Dieting or fasting can decrease stool volume and slow elimination. The nurse should instruct the client to keep a record of food intake in case of diarrhea, because this helps identify specific foods that irritate the gastrointestinal tract.
A client realizes that regular use of laxatives has greatly improved bowel patterns. However, the nurse cautions this client against the prolonged use of laxatives for which reason? a. The client may develop inflammatory bowel disease. b. The client may develop arthritis or arthralgia. c. The client's natural bowel function may become sluggish. d. The client may lose his or her appetite.
The client's natural bowel function may become sluggish. Explanation: It is essential for the nurse to caution the client against the prolonged use of laxatives because it decreases muscle tone in the large intestine. Prolonged use of laxatives may cause the client's natural bowel function to become sluggish. Laxatives do not increase the risk of developing inflammatory bowel disease, arthritis, or arthralgia, nor do they cause a loss in appetite.
A client realizes that regular use of laxatives has greatly improved his bowel pattern. However, the nurse cautions this client against the prolonged use of laxatives for which reason? a. The client may develop inflammatory bowel disease. b. The client may develop arthritis or arthralgia. c. The client's natural bowel function may become sluggish. d. The client may lose his appetite.
The client's natural bowel function may become sluggish. Explanation: It is essential for the nurse to caution the client against the prolonged use of laxatives because it decreases muscle tone in the large intestine. Prolonged use of laxatives may cause the client's natural bowel function to become sluggish. Laxatives do not increase the risk of developing inflammatory bowel disease, arthritis, or arthralgia, nor do they cause a loss in appetite.
Which is a true statement regarding regional enteritis (Crohn's disease)? a. It has a progressive disease pattern. b. It is characterized by pain in the lower left abdominal quadrant. c. The clusters of ulcers take on a cobblestone appearance. d. 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.
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? a. Small-bowel disease b. Ulcerative colitis c. Disorders of the colon d. 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.
The nurse is assessing a client for constipation. Which review should the nurse conduct first to identify the cause of constipation? a. Alcohol consumption b. Activity levels c. Usual pattern of elimination d. Current medications
Usual pattern of elimination Explanation: Constipation has many possible causes 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 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: a. fissure. b. fistula. c. hemorrhoid. d. 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 reviewing lab results for a client with an intestinal obstruction, and infection is suspected. What would be an expected finding? a. leukocytosis; elevated hematocrit; low sodium, potassium, and chloride b. leukopenia, decreased hematocrit; low sodium, potassium, and chloride c. leukocytosis; metabolic alkalosis; elevated sodium, potassium, and chloride d. 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.
A nurse is performing focused assessment on her clients. She expects to hear hypoactive bowel sounds in a client with: a. paralytic ileus. b. Crohn's disease. c. gastroenteritis. d. complete bowel obstruction.
paralytic ileus. Explanation: Bowel sounds are hypoactive or absent in a client with a paralytic ileus. Clients with Crohn's disease and gastroenteritis have hyperactive bowel sounds because of increased intestinal motility. A complete bowel obstruction causes absent bowel sounds below the obstruction and hyperactive sounds above the obstruction.
Which client requires immediate nursing intervention? The client who: a. complains of epigastric pain after eating. b. complains of anorexia and periumbilical pain. c. presents with a rigid, board-like abdomen. d. presents with ribbonlike stools.
presents with a rigid, board-like abdomen. Explanation: A rigid, board-like abdomen is a sign of peritonitis, a possibly life-threatening condition. Epigastric pain occurring 90 minutes to 3 hours after eating indicates a duodenal ulcer. Anorexia and periumbilical pain are characteristic of appendicitis. Risk of rupture is minimal within the first 24 hours, but increases significantly after 48 hours. A client with a large-bowel obstruction may have ribbonlike stools.
A nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. What else would the nurse expect to find? a. tenderness and pain in the right upper abdominal quadrant b. jaundice and vomiting c. severe abdominal pain with direct palpation or rebound tenderness d. 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.
The nurse teaches the client whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be: a. semi mushy. b. mushy. c. fluid. d. 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.
What symptoms of perforation might the nurse observe in a client with an intestinal obstruction? Select all that apply. a. sudden, sustained abdominal pain b. abdominal distention c. sudden drop in body temperature d. intermittent, severe pain
sudden, sustained abdominal pain abdominal distention Explanation: Abdominal distention, fever, and sudden, sustained abdominal pain are the symptoms of perforation in a client with intestinal obstruction.