Prep U--Ch. 47: Mgmt of Patients With Intestinal and Rectal Disorders
A client is admitted with acute pancreatitis. The nurse should monitor which laboratory values? a) decreased urine amylase level b) increased serum amylase and lipase levels c) increased calcium level d) decreased glucose level
increased serum amylase and lipase levels
An adolescent client scheduled for an emergency appendectomy is to be transferred directly from the emergency department to the operating room. Which statement by the client should the nurse interpret as most significant? a) "It hurts when you press on my stomach." b) "I feel like I am going to throw up." c) "All of a sudden it does not hurt at all." d) "The pain is centered around my navel."
"All of a sudden it does not hurt at all."
The mother of a 16-year-old girl calls the emergency department, suspecting her daughter's abdominal pain may be appendicitis. In addition to pain, her daughter has a temperature of 100° F (37.7° C) and has vomited twice. What should the nurse tell the mother? a) "It's most likely the flu because your daughter is too young to have appendicitis." b) "Give your daughter a laxative to rule out the possibility that constipation is causing the pain." c) "Gently press on the lower left quadrant of your daughter's abdomen to test for rebound tenderness." d) "Bring your daughter into the emergency department immediately before her appendix has a chance to rupture."
"Bring your daughter into the emergency department immediately before her appendix has a chance to rupture."
A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult? "I don't understand this; I took the medication the doctor ordered and followed the diet." "I didn't eat anything I shouldn't have; I just ate roast beef on rye bread." "I don't understand why this happened again; I didn't travel out of the country." "I don't like oatmeal, so it doesn't matter that I can't have it."
"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread."
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? 1. "I need to use laxatives regularly to prevent constipation." 2. "I need to drink 2 to 3 liters of fluids every day." 3. "I should exercise four times per week." 4. "I should eat a fiber-rich diet with raw, leafy vegetables, unpeeled fruit, and whole grain bread."
"I need to use laxatives regularly to prevent constipation."
A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. The nurse shuld tell the client: a) "The side effects of steroids outweigh their benefits to clients with ulcerative colitis." b) "Ulcerative colitis can be cured by the use of steroids." c) "Steroids are used in severe flare-ups because they can decrease the incidence of bleeding." d) "Long-term use of steroids will prolong periods of remission."
"Steroids are used in severe flare-ups because they can decrease the incidence of bleeding."
A child is admitted to the emergency department and diagnosed with a suspected ruptured appendix. The parents are anxious about the child's condition and ask the nurse what to expect for immediate treatment. What is the best response by the nurse? a) "We will place a referral to the social worker to help you through this." b) "We will modify pain management strategies to control the situation." c) "We will be preparing your child for emergency surgery." d) "The focus of treatment is the initiation of antibiotic therapy."
"We will be preparing your child for emergency surgery."
A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. Based on the diagnosis of acute pancreatitis the nurse will provide which explanation for the prescribed interventions? a) "I will be starting antibiotic therapy once the blood cultures are obtained." b) "I can offer you ibuprofen for pain with a small sip of water." c) "Activity is important, so you will be scheduled for physical therapy." d) "You are not allowed anything by mouth so that your pancreas can rest"
"You are not allowed anything by mouth so that your pancreas can rest"
A client is admitted for a transurethral resection of the prostate (TURP). Preoperative teaching will include which of the following information? a) "You will need to keep your abdominal incision clean and dry and cannot shower until the sutures are removed." b) "You will return from surgery and have a suprapubic catheter for 48 hours." c) "You will need to use a urinal and remain on bed rest for 24 hours after surgery." d) "You will return from surgery with a catheter in your bladder and fluid flowing into and out of it continuously."
"You will return from surgery with a catheter in your bladder and fluid flowing into and out of it continuously."
A client has developed an anorectal abscess. Which client is at most risk for the development of this type of abscess? 1. A client with hemorrhoids 2. A client with Crohn's disease 3. A client with diverticulosis 4, A client with colon cancer
A client with Crohn's disease
A community health nurse is performing a home visit to a 53-year-old patient who requires twice-weekly wound care on her foot. The patient mentions that she is currently having hemorrhoids, a problem that she has not previously experienced. What treatment measure should the nurse recommend to this patient? Daily application of topical antibiotics Decreased fluid intake Bathing, rather than showering, once per day A high-fiber diet with increased fruit intake
A high-fiber diet with increased fruit intake
A client develops chronic pancreatitis. What would be the appropriate home diet for a client with chronic pancreatitis? a) A high-calcium, soft diet distributed over three meals and an evening snack daily b) A low-fat, bland diet distributed over five to six small meals daily c) a low-protein, high-fiber diet distributed over four to five moderate-sized meals daily d) A diabetic exchange diet distributed over three meals and two snacks daily
A low-fat, bland diet distributed over five to six small meals daily
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) Avoid bran cereals and beans in the diet. b) Increasing intake of fluids, 3-4 glasses/day. c) Avoid a daily exercise regimen. d) Adding fiber-rich foods to the diet gradually.
Adding fiber-rich foods to the diet gradually.
A longitudinal tear or ulceration in the lining of the anal canal is termed a(n): a) Hemorrhoid b) Anorectal abscess c) Anal fistula d) Anal fissure
Anal fissure
The American Cancer Society recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should a nurse recommend? Carcinoembryonic antigen (CEA) test after age 50 Proctosigmoidoscopy after age 30 Annual digital examination after age 40 Barium enema after age 20
Annual digital examination after age 40
The nurse is performing and documenting the findings of an abdominal assessment. When the nurse hears intestinal rumbling and the client then experiences diarrhea, the nurse documents the presence of which condition? a) Azotorrhea b) Borborygmus c) Tenesmus d) Diverticulitis
Borborygmus
The nurse is performing an abdominal assessment for a patient with diarrhea and auscultates a loud rumbling sound in the left lower quadrant. What will the nurse document this sound as on the nurse's notes? Loud bowel sounds Borborygmus Tenesmus Peristalsis
Borborygmus
The nurse caring for a client with diverticulitis is preparing to administer the client's medications. The nurse anticipates administration of which category of medication because of the client's diverticulitis? 1. Antispasmodic 2. Anti-inflammatory 3. Antianxiety 4. Antiemetic
Antispasmodic
A client with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation? a) Assisting to increase dietary fiber. b) Providing an adequate quantity of food. c) Obtaining medications and allergy history. d) Obtain medical and food history.
Assisting to increase dietary fiber.
A nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer? a) Polyps b) Hemorrhoids c) Duodenal ulcers d) Weight gain
Polyps
Which of the following would a nurse expect to assess in a client with peritonitis? a) Hyperactive bowel sounds. b) Decreased pulse rate (HR). c) Slow, deep respirations. d) Board-like abdomen.
Board-like abdomen.
A nurse is preparing a presentation for a local community group of older adults about colon cancer. Which of the following would the nurse include as the primary characteristic associated with this disorder? a) Frank blood in stool b) Change in bowel habits c) Change in dietary habits d) Abdominal pain
Change in bowel habits
Which is the most common presenting symptom of colon cancer? Fatigue Change in bowel habits Anorexia Weight loss
Change in bowel habits
While listening to a client's chest, the nurse notes a rub during inspiration and expiration with a grating sound. When communicating to the health care provider, what should the nurse request in the SBAR communication? a) Chest x-ray b) Arterial blood gasses c) Broncodialator small volume nebulizer treatments d) Narcotic pain medications
Chest x-ray
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? 1. Blood and mucus in the stool 2. Chronic constipation with sporadic bouts of diarrhea 3. Weight loss due to malabsorption 4. Client is awakened from sleep due to abdominal pain.
Chronic constipation with sporadic bouts of diarrhea
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) Tell the client you are almost finished and to hold still for the next 1-2 minutes. b) Water should flow in over a 45 minute period. c) Allow only tepid fluid to enter the colon slowly. d) Clamp the tubing and give the patient a rest period.
Clamp the tubing and give the patient a rest period.
A nurse should expect to administer which medication to a client with gout? a) Aspirin b) Calcium gluconate c) Colchicine d) Furosemide
Colchicine
A 13-year-old girl is being evaluated for possible Crohn's disease. The nurse expects to prepare her for which diagnostic study? a) Genetic testing b) Myelography c) Cystoscopy d) Colonoscopy with biopsy
Colonoscopy with biopsy
Which statement provides accurate information regarding cancer of the colon and rectum? 1. Rectal cancer affects more than twice as many people as colon cancer. 2. Colorectal cancer is the third most common site of cancer in the United States. 3. Colon cancer has no hereditary component. 4. The incidence of colon and rectal cancer decreases with age.
Colorectal cancer is the third most common site of cancer in the United States.
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? Kidneys, ureters, bladder (KUB) Colonic transit studies Defecography Abdominal radiography
Defecography
What is the most appropriate nursing diagnosis for the client with acute pancreatitis? a) Excess fluid volume b) Decreased cardiac output c) Ineffective gastrointestinal tissue perfusion d) Deficient fluid volume
Deficient fluid volume
The nurse is caring for a 77-year-old patient diagnosed with Crohn's disease. What would be especially important to monitor this patient for? Pain Fluid overload Fatigue Dehydration
Dehydration
The nurse is conducting discharge teaching for a client with diverticulosis. Which instruction should the nurse include in the teaching? 1. Use laxatives weekly. 2. Drink 8 to 10 glasses of fluid daily. 3. Avoid daily exercise. 4. Avoid unprocessed bran.
Drink 8 to 10 glasses of fluid daily.
What information should the nurse include in the teaching plan for a client being treated for diverticulosis? a) Drink at least 8 to 10 large glasses of fluid every day b) Do not include unprocessed bran in the diet c) Regular use of laxatives and enemas at home d) Discourage regular exercise if pt. is inactive
Drink at least 8 to 10 large glasses of fluid every day
The nurse is teaching a client with an ostomy how to change the pouching system. Which information should the nurse include when teaching a client with no peristomal skin irritation? Dry skin thoroughly after washing Apply barrier powder Apply triamcinolone acetonide spray Dust with nystatin powder
Dry skin thoroughly after washing
Diet therapy for clients diagnosed with irritable bowel syndrome (IBS) includes: a) Encourage caffeine and alcohol consumption at mild to moderate levels. b) Encourage a high-fiber diet daily. c) Encourage increased consumption of spicy foods, lactose, fried foods, corn, and wheat. d) Increase p.o. fluids only with/during meals.
Encourage a high-fiber diet daily.
Which of the following is accurate regarding regional enteritis? Fistulas are common Severe diarrhea Severe bleeding Exacerbations and remissions
Exacerbations and remissions
The nurse is performing a community screening for colorectal cancer. Which characteristic should the nurse include in the screening? Age younger than 40 years Low-fat, low-protein, high-fiber diet History of skin cancer Familial polyposis
Familial polyposis
When providing discharge teaching for a client with uric acid calculi, the nurse would include an instruction to avoid which type of diet? a) Low calcium b) High purine c) Low oxalate d) High oxalate
High purine
An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to? Hyperkalemia Hypokalemia Hyponatremia Hypernatremia
Hypokalemia
A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, what would the nurse stress the importance of? Increasing fluid intake to prevent dehydration Wearing an appliance pouch only at bedtime Consuming a low-protein, high-fiber diet Taking only enteric-coated medications
Increasing fluid intake to prevent dehydration
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? a) Impaired gas exchange related to increased blood flow b) Excess fluid volume related to peripheral vascular disease c) Ineffective peripheral tissue perfusion related to venous congestion d) Risk for injury related to edema
Ineffective peripheral tissue perfusion related to venous congestion
Crohn's disease is a condition of malabsorption caused by which pathophysiological process? 1. Inflammation of all layers of intestinal mucosa 2. Infectious disease 3. Gastric resection 4. Disaccharidase deficiency
Inflammation of all layers of intestinal mucosa
Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following? Low residue Low protein Calorie restriction Iron restriction
Low residue
Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following? a) Low p.o. fluids. b) Low-protein diet. c) Low residue diet. d) High-calorie diet.
Low residue diet.
A nurse is providing dietary instructions to a client with a history of pancreatitis. Which of the following instructions would be most appropriate? a) Maintain a low-carbohydrate, low-fat diet. b) Maintain a high-fat, high-carbohydrate diet. c) Maintain a high-carbohydrate, low-fat diet. d) Maintain a high-fat, low-carbohydrate diet.
Maintain a high-carbohydrate, low-fat diet.
A client has an allergy to latex. What intervention would be of importance? a) Maintain standard precautions with powder free gloves. b) Use allergy free lotion to prevent skin breakdown. c) Determine if client is also allergic to kiwi and strawberries. d) Keep an epinephrine pen at the bedside.
Maintain standard precautions with powder free gloves.
Vomiting results in which of the following acid-base imbalances? Metabolic alkalosis Metabolic acidosis Respiratory acidosis Respiratory alkalosis
Metabolic alkalosis
A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition? a) Recording fluid intake and output b) Monitoring the client's weight every day c) Accelerating the infusion if it falls behind schedule d) Ensuring that the TPN tubing has an in-line filter
Monitoring the client's weight every day
The nurse is admitting a client with a diagnosis of diverticulitis and assesses that the client has a board-like abdomen, no bowel sounds, and reports of severe abdominal pain. What is the nurse's first action? Start an IV with lactated Ringer's solution. Notify the health care provider. Administer a retention enema. Administer an opioid analgesic.
Notify the health care provider.
The nurse is monitoring a client's postoperative course after an appendectomy. The nurse's assessment reveals that the client has vomited, has abdominal tenderness and rigidity, and has tachycardia. The nurse reports to the physician that the client has signs/symptoms of which complication? Peritonitis Pelvic abscess Ileus Hemorrhage
Peritonitis
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 reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. b) Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage. c) Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. d) The appendix may develop gangrene and rupture, especially in a middle-aged client.
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
Clients with inflammatory bowel disease (IBD) are at significantly increased risk for which condition? Osteoporosis DVT Hypotension Pneumonia
Osteoporosis
Post appendectomy, a nurse should assess the patient for abdominal rigidity and tenderness, fever, loss of bowel sounds, and tachycardia, all clinical signs of: a) Ulcerative colitis b) Peritonitis c) Diverticulitis d) Diverticulosis
Peritonitis
An adult with appendicitis has severe abdominal pain. Which action will be the most effective to assist the client to manage pain prior to surgery? a) Apply moist heat to the abdomen. b) Teach client to massage the painful area. c) Provide distraction with music. d) Place the client in semi-Fowler's position with the knees to the chest.
Place the client in semi-Fowler's position with the knees to the chest
An adolescent, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention is appropriate? a) Providing small, frequent meals b) Providing high-fiber snacks c) Administering digestive enzymes before meals as ordered d) Administering antibiotics with meals as ordered
Providing small, frequent meals
A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm his diagnosis? a) Recent weight loss and temperature elevation b) Presence of blood in the client's stool and recent hypertension c) Adventitious breath sounds and hypertension d) Presence of easy bruising and bradycardia
Recent weight loss and temperature elevation
Which of the following is the most common symptom of a polyp? Rectal bleeding Abdominal pain Diarrhea Anorexia
Rectal bleeding
A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which nursing measure is the highest priority for this client? a) Educate the client concerning changes occurring in the gallbladder as a result of pregnancy. b) Discuss nutritional strategies to decrease the possibility of heartburn. c) Support the client's use of acetaminophen to relieve pain. d) Refer the client to her health care provider for evaluation and treatment of the pain
Refer the client to her health care provider for evaluation and treatment of the pain
A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? Right upper quadrant Right lower quadrant Left upper quadrant Left lower quadrant
Right lower quadrant
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 Instruct the client to avoid prune or apple juice Assist the client regarding the correct diet or to minimize food intake Instruct the client to keep a record of food intake
Suggest fluid intake of at least 2 L/day
The health care provider prescribes sulfasalazine for the client with ulcerative colitis. Which instruction should the nurse give the client about taking this medication? a) Take the total dose at bedtime. b) Avoid taking it with food. c) Take it with a full glass (240 mL) of water. d) Stop taking it if urine turns orange-yellow.
Take it with a full glass (240 mL) of water.
A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care? a) Administering an ointment b) Testing all stools for occult blood. c) Administering an opioid pain medication. d) Preparing a client for a gastrostomy tube.
Testing all stools for occult blood.
The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms? a) The client is experiencing a reaction to meperidine. b) The client needs a muscle relaxant to promote rest. c) The client has a nutritional imbalance. d) The client may be developing hypocalcemia.
The client may be developing hypocalcemia.
A client tells the nurse, "I am not having normal bowel movements." When differentiating between what are normal and abnormal bowel habits, what indicators are the most important? The consistency of stool and comfort when passing stool That the client has a bowel movement daily That the stool is formed and soft The client is able to fully evacuate with each bowel movement
The consistency of stool and comfort when passing stool
A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? A. Trigeminal neuralgia B. Angina Pectoris C. Migraine Headache D. Bells Palsy
Trigeminal neuralgia
A client presents to the emergency department with reports of acute GI distress, bloody diarrhea, weight loss, and fever. A family history of which of the following would be significant to this client's diagnosis? a) Peptic ulcers b) Crohn's disease c) Ulcerative colitis d) Appendicitis
Ulcerative colitis
The nurse is assessing a client for constipation. To identify the cause of constipation, the nurse should begin by reviewing the client's: a) Usual pattern of elimination b) Medications c) Allergies d) Family history of constipation/GI issues
Usual pattern of elimination
The nurse is assessing a client for constipation. Which review should the nurse conduct first to identify the cause of constipation? Alcohol consumption Activity levels Usual pattern of elimination Current medications
Usual pattern of elimination
During the first few weeks after a cholecystectomy, the client should follow a diet that includes: a) a decreased intake of fruits, vegetables, whole grains, and nuts, to minimize pressure within the small intestine. b) ingestion of pancreatic enzymes with meals to replace the normal enzyme secretion that has been surgically altered. c) at least four servings daily of meat, cheese, and peanut butter to increase protein intake that aids incisional healing. d) a limited intake of fat distributed throughout the day so there is not an excessive amount in the intestine at any one time.
a limited intake of fat distributed throughout the day so there is not an excessive amount in the intestine at any one time.
An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first? a) a 20-year-old with first-degree burns on her hands and forearms b) a middle-aged man with no injuries who has rapid respirations and coughs c) a 10-year-old with a simple fracture of the humerus who is in severe pain d) a woman who is 5 months pregnant with no apparent injuries
a middle-aged man with no injuries who has rapid respirations and coughs
What is the MOST common cause of small-bowel obstruction? a) adhesions b) ulcers c) hernias d) tumors
adhesions
A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child's temperature is 104° F (40° C), and the apical pulse is 140 bpm. The white blood cell count is 16,000/mm3 (16,000 X 109/L). What is priority for nursing intervention? a) difficulty breathing b) potential for aspiration c) airway obstruction d) infection
airway obstruction
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) anorectal fistula b) anal fissure c) anal polyp d) hemorrhoids
anal fissure
A client reports severe pain and bleeding while having a bowel movement. Upon inspection, the health care provider notes a linear tear in the anal canal tissue. The client is diagnosed with a: fissure. fistula. hemorrhoid. pilonidal cyst.
fissure
Diet therapy for clients diagnosed with irritable bowel syndrome (IBS) includes: caffeinated products. spicy foods. high-fiber diet. fluids with meals.
high-fiber diet
The nurse caring for an older adult client diagnosed with diarrhea is administering and monitoring the client's medications. Because one of the client's medications is digitalis (digoxin), the nurse monitors the client closely for: hyperkalemia. hypokalemia. hyponatremia. hypernatremia.
hypokalemia
A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation? 1. lack of solid food 2. lack of exercise 3. increased fiber 4. lack of free water intake
lack of free water intake
A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation? lack of free water intake lack of solid food lack of exercise increased fiber
lack of free water intake
The nurse administers theophylline to a client. When evaluating the effectiveness of this medication, the nurse should assess the client for: a) suppression of the client's respiratory infection. b) decrease in bronchial secretions. c) thinning of tenacious, purulent sputum. d) less difficulty breathing
less difficulty breathing
Which symptom would the nurse most likely observe in a client with cholecystitis from cholelithiasis? a) nausea after ingestion of high-fat foods b) black stools c) elevated temperature of 103°F (39.4°C) d) decreased white blood cell count
nausea after ingestion of high-fat foods
A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and board-like. What complication does the nurse determine may be occurring at this time? Constipation Paralytic ileus Peritonitis Accumulation of gas
peritonitis
Which client requires immediate nursing intervention? The client who: complains of epigastric pain after eating. complains of anorexia and periumbilical pain. presents with a rigid, board-like abdomen. presents with ribbonlike stools.
presents with a rigid, board-like abdomen
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.
Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. The nurse also expects to find: 1. tenderness and pain in the right upper abdominal quadrant. 2. severe abdominal pain with direct palpation or rebound tenderness. 3. jaundice and vomiting. 4. rectal bleeding and a change in bowel habits.
severe abdominal pain with direct palpation or rebound tenderness.
An older adult client in a long term care facility is concerned about bowel regularity. During a client education session, the nurse reinforces the medically acceptable definition of "regularity." What is the actual measurement of "regular"? stool consistency and client comfort one bowel movement daily one bowel movement every other day two bowel movements daily
stool consistency and client comfort
A client is recovering from an abdominal-perineal resection. To promote wound healing after the perineal drains have been removed the nurse should encourage the client to: a) use a heating pad on the area. b) take sitz baths. c) shower daily. d) apply moist dressings to the area.
take sitz baths
A client with rheumatoid arthritis tells the nurse that she feels "quite alone" in adjusting to changes in her lifestyle. The nurse should respond by: a) telling the client about her community's arthritis support group. b) referring the client and her husband for counseling to decrease her sense of isolation. c) suggesting that the client develop a hobby to occupy her time. d) suggesting that the client discuss her feelings with her minister.
telling the client about her community's arthritis support group.
Which is an appropriate nursing goal for the client who has ulcerative colitis? The client: a) uses a heating pad to decrease abdominal cramping. b) maintains a daily record of intake and output. c) accepts that a colostomy is inevitable at some time in his life. d) verbalizes the importance of small, frequent feedings.
verbalizes the importance of small, frequent feedings.
Pancreatic enzyme replacements are prescribed for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect? a) with each meal and snack b) every 4 hours, at specified times c) in the morning and at bedtime d) three times daily between meals
with each meal and snack
Which statement indicates the client understands the lifestyle modifications required when managing ulcerative colitis? a) "I am allowed to have alcohol as long as I only drink wine." b) "I can eat popcorn for an evening snack." c) "I may have coffee with my meals." d) "I will have to stop smoking."
"I will have to stop smoking."
After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first? a) Administer epinephrine, as ordered, and prepare to intubate the client, if necessary. b) Administer the antidote for penicillin, as ordered, and continue to monitor the client's vital signs. c) Insert an indwelling urinary catheter and begin to infuse I.V. fluids, as ordered. d) Prepare to administer a corticosteroid IV.
Administer epinephrine, as ordered, and prepare to intubate the client, if necessary.
The nurse is talking with a group of clients who are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider? 1. Abdominal cramping when having a bowel movement 2. Daily bowel movements 3. Excess gas 4. Change in bowel habits
Change in bowel habits
The nurse in an extended-care facility reports that a resident has clinical manifestations of fecal incontinence. The health care provider orders a diagnostic study to rule out inflammation. The nurse would prepare the patient for which of the following? a) Flexible sigmoidoscopy b) X-ray studies (i.e., barium enema) c) Computed tomography (CT) scan d) Anorectal manometry and transit studies
Flexible sigmoidoscopy
The nurse is caring for a patient diagnosed with abdominal perforation. Which of the following is a clinical manifestation of this disease process? 1. Normal erythrocyte sedimentation rate (ESR) 2. Subnormal temperature 3. Hypotension 4. Bradycardia
Hypotension
A client is complaining of problems with constipation. What dietary suggestion can the nurse inform the client may help facilitate the passage of stool? Increase the carbohydrate content of the diet. Increase dietary fat consumption. Increase dietary protein such as lean meats. Increase dietary fiber.
Increase dietary fiber
Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution? a) pain b) fluid balance c) altered level of consciousness d) anaphylactic reaction
anaphylactic reaction
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. 1. Salami on whole grain bread and V-8 juice 2. A peanut butter sandwich and fruit cup 3. Broiled chicken with low-fiber pasta 4. A fruit salad with yogurt
Broiled chicken with low-fiber pasta
The nurse is performing a community screening for colorectal cancer. Which characteristic should the nurse include in the screening? a) Age under 40 years old. b) High-fat, high-protein, low-fiber diet. c) Familial polyposis (FHx of colon cancer). d) Familial history of basal cell carcinomas.
Familial polyposis (FHx of colon cancer).
A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is MOST appropriate? a) Cutting the faceplate opening no more than 2" larger than the stoma b) Scrubbing the area around the stoma c) Gently washing the area surrounding the stoma using a facecloth and mild soap d) Eliminating wrinkles in the faceplate
Gently washing the area surrounding the stoma using a facecloth and mild soap
When a client has an acute attack of diverticulitis, the nurse should first: a) encourage the client to drink a glass of water every 2 hr. b) prepare the client for a colonoscopy. c) assess the client for signs of peritonitis. d) encourage the client to eat a high-fiber diet.
assess the client for signs of peritonitis.
