NURS 327 chapter 47
A client with anorexia reports constipation. Which nursing measure would be most effective in helping the client reduce constipation?
Assist client to increase dietary fiber. Explanation: The nurse should assist the client to increase the dietary fiber in food because it helps reduce constipation. Providing an adequate quantity of food is necessary in maintaining sufficient nutrition and in sustaining normal body weight. Obtaining medical, allergy, and food history would provide valuable information, however, it would not help reduce constipation.
A 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?
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
Which of the following is the diagnostic of choice if the suspected diagnosis is diverticulitis?
Computed tomography scan Explanation: A computed tomography scan is the diagnostic of choice if the suspected diagnosis is diverticulitis; it can also reveal one or more abscesses. A barium enema or colonoscopy may be used to diagnosis diverticulosis. Magnetic resonance imaging would not be used to diagnose diverticulitis.
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
Obstruction of the appendix 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 monitoring a client's postoperative course after an appendectomy. The nurse's assessment reveals that the client has vomited, has abdominal tenderness and rigidity, and has tachycardia. The nurse reports to the physician that the client has signs/symptoms of which complication?
Peritonitis Explanation: The nurse should report to the physician that the client has signs/symptoms of peritonitis. Signs/symptoms of a pelvic abscess include anorexia, chills, fever, diaphoresis, and diarrhea. Signs/symptoms of an ileus include absent bowel sounds, nausea, and abdominal distention. Signs/symptoms of hemorrhage include tachycardia, hypotension, anxiety, and bleeding.
When interviewing a client with internal hemorrhoids, what would the nurse expect the client to report?
Rectal bleeding Explanation: Internal hemorrhoids cause bleeding but are less likely to cause pain, unless they protrude through the anus. External hemorrhoids may cause few symptoms, or they can produce pain, itching, and soreness of the anal area.
A client who has undergone colostomy surgery is experiencing constipation. Which intervention should a nurse consider for such a client?
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 nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. What else would the nurse expect to find?
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.
