Med Surg II – Chapt 48 – Management of Pts with Intestinal and Rectal Disorders – Flashcards
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The nurse is assigned to care for a patient 2 days after an appendectomy due to a ruptured appendix with resultant peritonitis. The nurse has just assisted the patient with ambulation to the bedside commode when the patient points to the surgical site and informs the nurse that "something gave way." What does the nurse suspect may have occurred?
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Wound dehiscence has occurred. Correct Explanation: Any suggestion from the patient that an area of the abdomen is tender or painful or "feels as if something just gave way" must be reported. The sudden occurrence of serosanguineous wound drainage strongly suggests wound dehiscence (see Chapter 19).
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A patient is being treated for diverticulosis. Which of the following information should the nurse include in this patient's teaching plan?
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Drink at least 8 to 10 large glasses of fluid every day Correct Explanation: The nurse should instruct a patient with diverticulosis to drink at least 8 to 10 large glasses of fluid every day. The patient should include unprocessed bran in the diet because it adds bulk and should avoid the use of laxatives or enemas except when recommended by the physician. In addition, the patient should exercise regularly if his or her current lifestyle is somewhat inactive
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What is the primary nursing diagnosis for a client with a bowel obstruction?
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Deficient fluid volume Explanation: Feces, fluid, and gas accumulate above a bowel obstruction. Then the absorption of fluids decreases and gastric secretions increase. This process leads to a loss of fluids and electrolytes in circulation. Therefore, Deficient fluid volume is the primary diagnosis. Deficient knowledge, Acute pain, and Ineffective tissue perfusion are applicable but not the primary nursing diagnosis.
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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?
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Borborygmus Correct Explanation: Borborygmus is a rumbling noise caused by the movement of gas through the intestines, often associated with diarrhea.
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Which of the following is the most common presenting symptom of colon cancer? a) Change in bowel habits b) Anorexia c) Fatigue d) Weight loss
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Change in bowel habits Correct 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 symptom.
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A young woman has been brought into the ED via ambulance, complaining of acute generalized abdominal pain, nausea, fever, and constipation. The healthcare provider suspects appendicitis, but testing has not been performed yet to make a definitive diagnosis. You are the nurse caring for this client. Which of the following will you most likely do while initially caring for this client? a) Frequently palpate the abdomen to assess for changes that might indicate the onset of a perforation. b) Begin your exam by performing the test for rebound tenderness. c) Administer a laxative to relieve the client's constipation. d) Explain to the client why analgesics are being withheld.
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Explain to the client why analgesics are being withheld. Explanation: Analgesics may be withheld initially to avoid masking symptoms that may affect the diagnosis. Avoid multiple or frequent palpation of the abdomen—there is danger of causing the appendix to rupture. Perform the test for rebound tenderness at the end of the examination. A positive response causes pain and muscle spasm and makes it difficult to complete the rest of the assessment. Do not administer laxatives or enemas to a client who is experiencing fever, nausea, and abdominal pain, even though the client may complain of feeling constipated. Laxatives and cathartics may cause the appendix to rupture.
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In women, which of the following types of cancer exceeds colorectal cancer? a) Lung b) Liver c) Breast d) Skin
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Breast Correct Explanation: In women, only incidences of breast cancer exceed that of colorectal cancer. In men, only incidences of prostate cancer and lung cancer exceed that of colorectal cancer.
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A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient? a) Suggest fluid intake of at least 2 L per day b) Assist the patient regarding the correct diet or to minimize food intake c) Instruct the patient to avoid prune or apple juice d) Instruct the patient to keep a record of food intake
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Suggest fluid intake of at least 2 L per day Correct Explanation: For constipation the nurse should suggest a fluid intake of at least 2L per day. The nurse should also offer prune or apple juice because they promote elimination. The nurse should encourage the patient to eat regular meals. Dieting or fasting can decrease stool volume and slow elimination. The nurse should instruct the patient to keep a record of food intake in case of diarrhea because this helps identify specific foods that irritate the GI tract.
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The nurse is conducting a community education program on colorectal cancer. Which of the following statements should the nurse include in the program? a) The incidence of colorectal cancer decreases with age. b) It is the third most common cancer in the United States. c) The lifetime risk of developing colorectal cancer is 1 in 10. d) There is no hereditary component to colorectal cancer.
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It is the third most common cancer in the United States. Explanation: Colorectal cancer is the third most common type of cancer in the United States. The lifetime risk of developing colorectal cancer is 1 in 20. The incidence increases with age (the incidence is highest in people older than 85). Colorectal cancer occurrence is higher in people with a family history of colon cancer.
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An elderly patient diagnosed with diarrhea is taking digoxin (Lanoxin). Which of the following electrolyte imbalances should the nurse be alert to? a) Hyponatremia b) Hypokalemia c) Hyperkalemia d) Hypernatremia
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Hypokalemia Correct Explanation: The older person taking digitalis must be aware of how quickly dehydration and hypokalemia can occur with diarrhea. The nurse teaches the patient to recognize the symptoms of hypokalemia because low levels of potassium intensify the action of digitalis, leading to digitalis toxicity.
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The nurse caring for an elderly patient diagnosed with diarrhea is administering and monitoring the patient's medications. Because one of the patient's medications is digitalis (digoxin [Lanoxin]), the nurse monitors the patient closely for which of the following? a) Hypokalemia b) Hypernatremia c) Hyperkalemia d) Hyponatremia
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Hypokalemia Correct Explanation: The older person taking digoxin must be aware of how quickly dehydration and hypokalemia can occur with diarrhea. The nurse teaches the patient to recognize the symptoms of hypokalemia because low levels of potassium intensify the action of digitalis, leading to digitalis toxicity.
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Vomiting results in which of the following acid-base imbalances? a) Metabolic alkalosis b) Respiratory acidosis c) Respiratory alkalosis d) Metabolic acidosis
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Metabolic alkalosis Correct 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.
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When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report? a) Soreness b) Rectal bleeding c) Itching d) Pain
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Rectal bleeding Correct 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
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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) Test all stools for occult blood. b) Administer morphine (Duramorph PF) routinely, as ordered. c) Prepare the client for a gastrostomy tube placement. d) Administer topical ointment to the rectal area to decrease bleeding.
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Test all stools for occult blood. Correct Explanation: Blood in the stools is one of the warning signs of colorectal cancer. The nurse should plan on checking all stools for both frank and occult blood. The blood in the stool is coming from the colon or rectum; administering an ointment wouldn't help decrease the bleeding. Preparing a client for a gastrostomy tube isn't appropriate when diagnosing colorectal cancer. Colorectal cancer is usually painless; administering opioid pain medication isn't needed
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A nurse applies an ostomy appliance to a patient who is recovering from ileostomy surgery. Which of the following interventions should the nurse utilize to prevent leakages from the appliance? a) Ask the patient to remain inactive for 5 minutes. b) Press the adhesive faceplate from the stomal edge inward c) Ensure that no air is trapped in the pouch d) Ensure that there are no holes in the pouch
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Ask the patient to remain inactive for 5 minutes. Explanation: When the nurse applies the ostomy appliance, he or she should ask the patient to remain inactive for 5 minutes to allow body heat to strengthen the adhesive bond. The adhesive faceplate should be pressed from the stomal edge outward to prevent the formation of wrinkles. A small amount of air should also be allowed to be trapped in the pouch; liquid feces will then drain to the bottom of the pouch, placing less tension on it.
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Which of the following will the nurse observe as symptoms of perforation in a client with an intestinal obstruction? Select all that apply. a) Sudden, sustained abdominal pain b) Sudden drop in body temperature c) Intermittent, severe pain d) Abdominal distention
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Sudden, sustained abdominal pain Correct Explanation: Sudden, sustained pain, abdominal distention, and fever are symptoms of perforation in a client with intestinal obstruction. A decrease in blood pressure and decrease in urine output are symptoms of shock. Purulent drainage from the gluteal fold is not a symptom of perforation; it only indicates that the client has developed a condition of anorectal abscess
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Patients diagnosed with malabsorption syndrome may have vitamin and mineral deficiency. Patient who easily bleed have which of the following deficiencies? a) Vitamin K b) Iron c) B12 d) Calcium
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Vitamin K Correct Explanation: The chief result of malabsorption is malnutrition, manifested by weight loss and other signs of vitamin and mineral deficiency (e.g., easy bruising [vitamin K deficiency], osteoporosis [calcium deficiency], and anemia [iron, vitamin B12 deficiency]).
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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
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Right lower quadrant Correct 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.
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The nurse is caring for a patient who has had an appendectomy. What is the best position for the nurse to maintain the patient in after the surgery? a) High Fowler's b) Sims' left lateral c) Prone d) Supine with head of bed elevated 15 degrees
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High Fowler's Explanation: After surgery, the nurse places the patient in a high Fowler's position. This position reduces the tension on the incision and abdominal organs, helping to reduce pain.
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Mr. Munster, a client in the primary care office where you work, reports having increased incidence of constipation. You complete your assessment and discuss the potential causes with Mr. Munster. What can cause constipation? a) Emotional stress b) Insufficient fiber c) All options are correct. d) Inactivity
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All options are correct. Correct Explanation: Constipation may result from insufficient dietary fiber and water, ignoring or resisting the urge to defecate, emotional stress, use of drugs that tend to slow intestinal motility, or inactivity. It may stem from several disorders, either in the GI tract or systemically.
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A client presents to the emergency department with complaints of acute GI distress, bloody diarrhea, weight loss, and fever. Which condition in the family history is most pertinent to the client's current health problem? a) Gastroesophageal reflux disease b) Hypertension c) Appendicitis d) Ulcerative colitis
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Ulcerative colitis Correct Explanation: A family history of ulcerative colitis, particularly if the relative affected is a first-degree relative, increases the likelihood of the client having ulcerative colitis. Although hypertension has familial tendencies, the client's symptoms aren't related to hypertension. A family history of gastroesophageal reflux disease or appendicitis isn't a significant factor in the client history because these conditions aren't considered familial traits.
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The presence of mucus and pus in the stools suggests which of the following conditions?
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Ulcerative colitis Correct 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.
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The nurse is caring for a client with intussusception of the bowel. What does the nurse understand occurs with this disorder?
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One part of the intestine telescopes into another portion of the intestine. 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.
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The nurse is conducting a gastrointestinal assessment. When the patient complains of the presence of mucus and pus in his stools, the nurse assesses for additional signs/symptoms of which of the following disease/conditions? a) Small-bowel disease b) Disorders of the colon c) Intestinal malabsorption d) Ulcerative colitis
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Ulcerative colitis Correct 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.
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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) Endoscopy with mucosal biopsy b) Ultrasound c) Stool specimen for ova and parasites d) Pancreatic function tests
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Endoscopy with mucosal biopsy Correct Explanation: Endoscopy with biopsy of the mucosa is the best diagnostic tool for malabsorption syndrome.
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After assessing a client with peritonitis, the nurse most likely would document the client's bowel sounds as: a) High-pitched. b) Mild. c) Hyperactive. d) Absent.
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Absent. Correct 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.
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The nurse is caring for four clients with diarrhea. Which client is most likely to be diagnosed with Crohn's disease? a) A 32 year-old female from Vietnam b) A 24 year-old Caucasian eastern European Jewish female c) A 46 year-old African American male d) A 63 year-old Hispanic female with a history of cancer of the vulva
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A 24 year-old Caucasian eastern European Jewish female Correct Explanation: Clients who are more prone to this disorder include those with a family history of the disease, those who are white with a European and/or Jewish ancestry, and those who smoke. The other client's listed do not have these risk factors.
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A client has been recently diagnosed with an anorectal condition. The nurse is reviewing interventions that will assist the client with managing his therapeutic regimen. Which of the following would not be included? a) Instruct client to cleanse perianal area with warm water. b) Encourage client to follow diet and medication instructions. c) Encourage client to avoid exercise. d) Teach client how to do sitz baths at home using warm water three to four times each day.
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Encourage client to avoid exercise. Correct Explanation: Activity promotes healing and normal stool patterns. These measures prevent infection and irritation. Sitz baths promote healing, decrease skin irritation, and relieve rectal spasms. Encouragement promotes compliance with therapeutic regimen and prevents complications.
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Which of the following laxatives should be used by a cardiac patient who should avoid straining? a) Mineral oil b) Milk of Magnesia c) Dulcolax d) Colace
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Colace Correct Explanation: Colace can be used safely by patients who should avoid straining such as cardiac patients and those with anorectal disorders. Milk of Magnesia is a saline agent. Dulcolax is a stimulant. Mineral oil is a lubricant.
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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) Beginning a bowel program to establish continence b) Determining the need for surgical intervention to correct the problem c) Instituting a diet high in fiber and increase fluid intake d) Maintaining skin integrity
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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.
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The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be a) solid. b) semimushy. c) mushy. d) fluid.
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solid. Correct Explanation: With a sigmoid colostomy, the feces are solid. With a descending colostomy, the feces are semimushy. With a transverse colostomy, the feces are mushy. With an ascending colostomy, the feces are fluid.
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When planning care for a client with a small-bowel obstruction, the nurse should consider the primary goal to be: a) reporting pain relief. b) maintaining body weight. c) maintaining fluid balance. d) reestablishing a normal bowel pattern.
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maintaining fluid balance. Correct Explanation: Because a client with a small-bowel obstruction can't tolerate oral intake, fluid volume deficit may occur and can be life-threatening. Therefore, maintaining fluid balance is the primary goal. Pain relief and maintaining body weight don't reflect life-threatening conditions, and the client's normal bowel pattern can be reestablished after fluid volume is stabilized.
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The nurse is assessing a patient with appendicitis. The nurse is attempting to elicit a Rovsing's sign. Where should the nurse palpate for this indicator of acute appendicitis? a) Left lower quadrant b) Right lower quadrant c) Right upper quadrant d) Left upper quadrant
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Left lower quadrant Explanation: Rovsing's sign may be elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt in the right lower quadrant (see Fig. 48-3).
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Which of the following categories of laxatives draws water into the intestines by osmosis? a) Fecal softeners (Colace) b) Saline agents (Milk of Magnesia) c) Bulk-forming agents (Metamucil) d) Stimulants (Dulcolax)
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Saline agents (Milk of Magnesia) Correct Explanation: Saline agents use osmosis to stimulate peristalsis and act within 2 hours of consumption. Bulk-forming agents mix with intestinal fluids, swell, and stimulate peristalsis. Stimulants irritate the colon epithelium. Fecal softeners hydrate the stool by surfactant action on the colonic epithelium, resulting in mixing of aqueous and fatty substances.
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A nurse is performing focused assessment on her clients. She expects to hear hypoactive bowel sounds in a client with:
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paralytic ileus. Correct 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.
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A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis? a) Carcinoembryonic antigen (CEA) b) Abdominal computed tomography (CT) scan c) Sigmoidoscopy d) Stool Hematest
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Sigmoidoscopy Correct 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.
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A nurse is caring for a client who had an ileo 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) Clear mucus mixed with yellow urine drained from the appliance bag b) Beefy red stoma site c) Stoma site not sensitive to touch d) Red, sensitive skin around the stoma site
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Red, sensitive skin around the stoma site Correct 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.
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A patient is suspected to have diverticulosis without symptoms of diverticulitis. What diagnostic test does the nurse anticipate educating the patient about prior to scheduling? a) CT scan b) Flexible sigmoidoscopy c) Barium enema d) Colonoscopy
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Colonoscopy Correct Explanation: Diverticulosis is typically diagnosed by colonoscopy, which permits visualization of the extent of diverticular disease and biopsy of tissue to rule out other diseases. In the past, barium enema was the preferred diagnostic test, but it is now used less frequently than colonoscopy. CT with contrast agent is the diagnostic test of choice if the suspected diagnosis is diverticulitis; it can also reveal abscesses.
