Digestion & Elimination Questions – Flashcards
Unlock all answers in this set
Unlock answersquestion
A 43-year-old client comes into the clinic complaining about a leg wound that is not healing properly. During the assessment, the nurse notes that the client is disheveled and malnourished. The client admits to not having a stable home. Which lab result corresponds with the nurse's initial assessment? A: Hematocrit is 52. B: Albumin is 2.0 g/dL. C: ALT and AST are 25 units/L. D: INR is 4.0.
answer
B: Albumin is 2.0 g/dL. Albumin levels measure the amount of protein in the body. Normal albumin levels range from 3-5 g/dL. Albumin levels of ;2.5 may indicate a malnourished individual. Deficiencies in protein may delay wound healing. An elevated hematocrit may indicate dehydration, the ALT and AST are within normal limits, and an elevated INR indicates an increased tendency to bleed with slow clotting times.
question
A client diagnosed with pancreatitis complains of an increase in vomiting over the past 24 hours. The client's eyes are sunken and skin turgor is poor. The nurse knows that which activity is the priority for this client? A: Instruct client to avoid trigger foods. B: Assess the client for low urinary output. C: Start IV fluids. D: Give the client MSO4 2mg IV every 6 hours.
answer
C: Start IV fluids. The priority is to bring the client's fluid and electrolyte status within balance. Treatment focuses on reducing pancreatic secretions by making the client NPO (nothing by mouth), providing supportive care (such as IV fluids), and eliminating causative factors after resolving inflammation.
question
A 33-year-old client complains of nausea without vomiting. All vital signs are stable and the client denies any other physical complaints. What is the best therapy the nurse can offer the client at this time? A: Withhold all foods and liquids B: Provide the client with an antiemetic. C: Provide the client with an opioid analgesic. D: Teach the client deep breathing techniques.
answer
D: Teach the client deep breathing techniques. Deep breathing techniques will help suppress the vomiting reflex. There is no reason to withhold all food and liquids because the client is not vomiting. Antiemetics and opioids are not indicated at this time.
question
An 18-year-old client is admitted to the neurology unit following a car accident 2 days ago. During an initial abdominal assessment, which abnormal finding does the nurse find that is consistent with a motor vehicle accident? A: Cullen's sign B: Soft, non-tender abdomen C: High-pitched bowel sounds D: Tympany
answer
A: Cullen's sign Cullen's sign is a superficial abdominal bruising around the umbilicus. It is usually caused by severe pancreatic symptoms or blunt force abdominal trauma. All other findings are normal abdominal assessments.
question
The client undergoing an Upper GI Series is diagnosed with duodenal polyps. The nurse performs what priority intervention after the test? A: Gives the client a mild sedative B: Tells the client to stop smoking C: Gives the client a laxative D: Tells the client to remain NPO for 24 hours
answer
C: Gives the client a laxative After an Upper GI Series, the priority intervention is to; ensure that the client eliminates the barium used to illuminate the stomach by taking laxatives and drinking fluids unless contraindicated.
question
A client diagnosed with cancer is undergoing chemotherapy. The chemotherapy makes the client feel "nauseas all the time," however the client only wants "natural remedies for my nausea." Which alternative therapy does the nurse suggest for this client? A: St. John's wort B: Ginger C: Gingko Biloba D: Spearmint leaves
answer
B: Ginger Ginger is an aromatic edible used frequently for the treatment of nausea. St. John's wort is used for depression, Gingko Biloba to improve memory, and spearmint leaves for stomach aches.
question
A Hispanic mother of a 2-month-old infant brought to the clinic for a well-baby check-up, asks the nurse why her baby cannot drink whole milk yet. What is the nurse's best response? A: "Your baby cannot swallow whole milk effectively because of a large tongue." B: "Your baby does not have sufficient enzymes to aid in the digestion of whole milk." C: "The eruption of your baby's first teeth will indicate a mature digestive system, and then your baby can drink whole milk." D: "Your baby can have whole milk now; no allergies have presented."
answer
B: "Your baby does not have sufficient enzymes to aid in the digestion of whole milk." Infants have a deficiency of the amylase, lipase, and trypsin enzymes. Enzymes from the pancreas will not be sufficient to aid in digestion until 4-6 months in age. The infant's tongue is large in comparison to the nasal and oral passages, but does not impede the swallowing reflex. By the age of 2, a child's digestive tract is generally mature; this does not follow the eruption of teeth.
question
A client is placed on enteral nutrition therapy following an oral surgery. What priority intervention by the nurse is the most appropriate? A: Elevate the HOB at least 30 degrees during feeding. B: Verify placement by inserting 30 ml of air into the feeding tube. C: Monitor the client for signs and symptoms of infection. D: Reinsert a new tube every 72 hours.
answer
A: Elevate the HOB at least 30 degrees during feeding. Aspiration and diarrhea are the most common complications of enteral feedings. Procedures and interventions that reduce the risk for aspiration include: Continuous infusion of the formula; Placing the feeding tube in the jejunum rather than the stomach; Elevating the head of the bed at least 30 degrees during feeding and for at least 1 hour after feeding; and dual-lumen tubes that allow gastric suction with simultaneous instillation of an enteral feeding into the jejunum. Placement is verified by x-ray, the client is not at risk for an infection, and the tube can remain in place until completion of the therapy unless contraindicated.
question
The nurse is teaching a group of clients about renal and gastrointestinal health. Upon completion of the class, the nurse asks the group to summarize what they have learned. What does the group identify as alterations that may affect elimination? (Select all that apply.) A: Halitosis B: Impaction C: Mobility D: Inflammation E: Bulimia
answer
B: Impaction C: Mobility D: Inflammation E: Bulimia Alterations in elimination may reflect impaired function of other body systems, side effects from medications, or improper levels of hydration or nutrition. Alterations that may affect elimination include changes in neurological function, increased/decreased food and fluid intake, changes in: respiratory and cardiovascular function; in liver and gallbladder function; in reproductive system; and in musculoskeletal function. Disease processes, especially disorders with an inflammatory process, can also alter urinary and bowel function. Halitosis does not impact or alter urinary or bowel function.
question
The nurse is assessing a client with suspected Acute Renal Failure (ARF). Which of the following would be consistent with ARF? (Select all that apply.) A: Urine output ; 30 ml/hr B: Hypotension C: Constipation D: Tachycardia E: Pain
answer
A: Urine output ; 30 ml/hr B: Hypotension C: Constipation D: Tachycardia Fluid intake should be directly proportional to fluid output. Increased or decreased food and fluid intake, as well as unhealthy food and drink choices, can alter urine and fecal volume and composition and contribute to elimination problems. Signs and symptoms of dehydration (fluid volume deficit), include dry mouth and skin, fatigue, thirst, decreased urine output, constipation, headache, dizziness, and tachycardia. Signs of fluid overload include edema, weight gain, shortness of breath, fluid intake greater than output, increased blood pressure.
question
A client presents to the emergency room with a persistent urge to urinate, burning upon urination, and pelvic pain. The nurse knows which treatment is most appropriate for the client's symptoms? A: Surgery B: Urethral dilation C: Increase fluid intake D: Analgesics
answer
C: Increase fluid intake The client is experiencing a urinary tract infection, which is caused by an invasion of microorganisms to the bladder, ureters, or kidneys. Clinical manifestations include a persistent urge to urinate, burning sensation during urination, cloudy, red, or strong-smelling urine, and pelvic or rectal pain. Treatment includes administration of antibiotics if infection is caused by bacterium, increased fluid intake, and/or cranberry juice to increase urine pH. Surgery, analgesics, and urethral dilation are not indicated for this client.
question
The nurse is caring for a 62-year-old client with urinary incontinence. Which statement made by the patient would indicate a need for further teaching? A: "I have to wear adult briefs when I go on outings." B: "I tend to have fewer problems when I laugh, sneeze, or am under stress." C: "I have more problems since I injured my spine." D: "I usually go to the bathroom 30 minutes after my meals during the day."
answer
B: "I tend to have fewer problems when I laugh, sneeze, or am under stress." Urinary incontinence is an involuntary leakage of urine that is associated with stress, incontinence related to urgency, and/or incontinence related to neurological deficits. In order to prevent accidents the client would have to wear briefs while out in public, should go to the bathroom 30 minutes after meals. A spinal injury would increase the client's chances of problems with urinary incontinence and the client might leak urine when sneezing, laughing, coughing, or lifting.
question
The nurse caring for Ms. Jones is reviewing the physician's orders. Which diagnostic tests would be the least invasive? A: Ultrasonic bladder scan B: IVP C: Colonoscopy D: Blood test
answer
A: Ultrasonic bladder scan Noninvasive tests include renal ultrasound, CT, MRI, andrenal scan. These tests are used to identify and evaluate kidney size and structure as well as renal or perirenal masses and obstructions. In addition, a renal scan may be used to evaluate kidney blood flow, perfusion, and urine production. Blood tests may be used to determine whether bowel problems have a systemic cause for bowel problems. A colonoscopy is often used to visualize the colon and rectum to discover polyps, cysts, or tumors; tissue samples may also be removed for biopsy.
question
The nurse is caring for a patient who has been discharged from the hospital. Which client statements would indicate to the nurse that further teaching is needed? (Select all that apply.) A: "I eat vegetables and fruits once per week." B: "I believe handwashing is important to prevent many illnesses." C: "I like to eat my steaks rare." D: "I usually urinate about twice per day if I'm lucky."
answer
C: "I like to eat my steaks rare." D: "I usually urinate about twice per day if I'm lucky." For clients with constipation, interventions include encouraging increased intake of fluid and fiber, as well as teaching clients about the impact of dietary choices on bowel elimination. Washing hands, using sterile gloves, and maintaining a closed urinary collection system decrease the incidence of ascending bladder contamination and subsequent UTI.
question
A male nurse is assessing a female Muslim client with urinary and bowel incontinence.Which is the most appropriate action by the nurse for this client? (Select all that apply.) A: Cover as much of the body as possible during assessment. B: Find a female nurse to explain all procedures in a manner the client will understand. C: Provide privacy when assessing the client. D: Allow time for questions from the patient/family. *find answer B wrong. Nothing in the question suggests that he can grab another nurse, its HIS pt.
answer
A: Cover as much of the body as possible during assessment. B: Find a female nurse to explain all procedures in a manner the client will understand. C: Provide privacy when assessing the client. Privacy is a major concern during a urinary and bowel assessment. If desired by the client, have a clinician of the same gender perform the assessment, particularly imperative for certain cultures, including Muslims and Orthodox Jews. Modesty, including covering as much of the body as possible, is especially important for Muslim women. Explain each assessment at an appropriate comprehension level before and as it is performed to help ease anxiety about the procedure.
question
A nurse caring for a 32-year-old client in acute renal failure administers peritoneal dialysis to help the client's kidneys resume a normal filtering process. Prior to and during the dialysis procedure, which action by the nurse is priority? A: Teaching Kegel exercises B: Administer pain medication C: Maintaining aseptic technique D: Provide adequate fluid intake
answer
C: Maintaining aseptic technique Aseptic technique is essential during any procedures that could introduce bacteria into the blood or urinary tract. Washing hands, using sterile gloves, and maintaining a closed urinary collection system decrease the incidence of ascending bladder contamination and subsequent UTI. Maintaining aseptic technique throughout dialysis procedures is necessary to prevent infection in grafts, fistulas, and catheters. Both hemodialysis and peritoneal dialysis must be performed at frequent intervals until the client's kidneys can resume the normal filtering function.
question
The nurse is teaching a client diagnosed with GERD about his diagnosis. Which client statements lead the nurse to believe that teaching has been effective? (Select all that apply.) A: "Losing weight will help alleviate my symptoms." B: "I have to make sure I sit up straight during and after meals." C: "I can put the head of my bed on blocks." D: "I can still drink orange juice and coffee with breakfast." E: "I have to eat more frequently to fill up faster."
answer
A: "Losing weight will help alleviate my symptoms." B: "I have to make sure I sit up straight during and after meals." C: "I can put the head of my bed on blocks." Gastroesophageal reflux may result from transient relaxation of the lower esophageal sphincter, an incompetent lower esophageal sphincter, or increased pressure within the stomach. Factors contributing to gastroesophageal reflux include increased gastric volume (e.g., after meals), positioning that allows gastric contents to remain close to the gastroesophageal junction (e.g., bending over, lying down), and increased gastric pressure (e.g., obesity or wearing tight clothing).
question
A Client complaining of acid reflux is ordered omeprazole (Prilosec) 20 mg PO BID. Which intervention by the nurse will help to further alleviate the client's symptoms? A: Tell the client to eat three meals per day. B: Tell the client to stop eating after 07:00 p.m. C: Tell the client to decrease smoking. D: Tell the client to sleep on two pillows.
answer
D: Tell the client to sleep on two pillows. Esophageal peristalsis and bicarbonate in salivary secretions normally clear and neutralize gastric juices in the esophagus. During sleep, however, and in clients with impaired esophageal peristalsis or decreased salivation, the esophageal mucosa is damaged by gastric juices, causing an inflammatory response. Sleeping with the head elevated can help alleviate and prevent acid build-up in the esophagus.
question
A mother brings her 2-year-old child to the clinic. The child is diagnosed with GERD. Which assessment noted by the nurse corresponds with the diagnosis? A: Wheezing on auscultation B: Poor suck reflex C: Three dental caries on back molars D: Chest pain
answer
A: Wheezing on auscultation Clinical manifestations of GERD in the pediatric population include coughing, difficulty swallowing, and asthma symptoms. The other answer choices do not apply to this situation.
question
A client with GERD complains of a burning pain in his chest after eating spicy and fatty foods. What is the priority nursing diagnosis for this client? A: Dysfunctional GI Motility B: Ineffective Teaching C: ineffective Health Nutrition D: Dysfunctional Breathing
answer
C: ineffective Health Nutrition In adults, heartburn generally is the chief complaint and usually occurs after meals, when bending over, or when reclining. Regurgitation of sour material into the mouth or difficulty and pain with swallowing may develop. Teaching the client about dietary and lifestyle changes can help reduce symptoms and long-term effects of the disorder if the client is compliant.
question
A client comes into the clinic exhibiting symptoms of GERD. The nurse knows that which diagnostic test will be ordered by the physician to establish a GERD diagnosis? A: EGD B: CT scan C: 24-hour ambulatory pH monitoring D: Barium swallow
answer
C: 24-hour ambulatory pH monitoring GERD often is diagnosed based on the client's symptom history and predisposing factors, such as smoking or caffeine use. Collaborative care focuses on diet and lifestyle changes. A 24-hour ambulatory pH monitoring may be performed to establish the diagnosis of GERD. A barium swallow is done to evaluate the esophagus, stomach, and upper small intestine. A CT scan and an EGD are not used to diagnose GERD.
question
The nurse teaches a client with GERD and her spouse about a variety of treatment strategies. The nurse knows teaching has been effective when the client makes which statement? A: "I guess I will stop wearing my skinny jeans." B: "I just started another job; I can handle it." C: "If I incorporate my trigger foods gradually into my diet, they won't affect me as much later." D: "I will elevate the foot of my bed to reduce abdominal pressure."
answer
A: "I guess I will stop wearing my skinny jeans." Individuals can prevent GERD symptoms by eating smaller, more frequent meals; avoiding or minimizing trigger foods; avoiding eating too close to bedtime; elevating the head of the bed; avoiding tight-fitting clothing around the abdomen or chest; avoiding smoking and alcohol consumption, and by maintaining near or ideal body weight.
question
The client experiencing recurrent episodes of GERD is taught by the nurse to limit intake of fatty, acidic foods, alcohol, and coffee. The nurse also expects the client to reduce reflux symptoms by performing which priority activity? A: Lie down for 30 minutes after a meal. B: Join a smoking cessation program C: Avoid all caffeinated products D: Stop eating after 7:00 p.m. *Nothing in this question suggests pt smokes.
answer
B: Join a smoking cessation program Relieving the discomfort associated with GERD is the priority of nursing care. Teaching focuses on preventing symptoms and long-term consequences of the disorder. Clients who smoke should be referred to a smoking cessation program because cigarette smoking interferes with healing and increases gastric acidity. Client education should also include long-term changes in lifestyle, such as limiting intake of fat, acidic foods, alcohol, and coffee in order to promote continued health and manage symptoms over time.
question
The nurse is assessing the abdomen of an adult. Which findings are normal findings of an adult abdominal? assessment? ?(Select all that? apply.) Abdomen has rounded contours. Skin nevi of consistent color are present. Dullness is percussed over abdomen. Dullness is percussed over bladder. Tympany is percussed over abdomen.
answer
Abdomen has rounded contours. Skin nevi of consistent color are present. Tympany is percussed over abdomen. Normal findings of an adult abdominal assessment include the abdomen has rounded? contours; tympany is percussed over? abdomen; and the presence of skin nevi of consistent color. Dullness percussed over the abdomen may indicate bowel obstruction or mass. Dullness percussed over the bladder may indicate an overdistended bladder.
question
A nurse educator is teaching a group of students about newborn digestion. Which statement will the nurse educator include in the? teaching? ?A: "The newborn's stomach is unable to absorb vital? nutrients." ?B: "The newborn's ability to form ketones is mature at? birth." ?C: "The newborn's liver can conjugate bilirubin at? birth." ?D: "The placenta provides nutrients and removal of waste products until? birth."
answer
?D: "The placenta provides nutrients and removal of waste products until? birth." The? newborn's digestive system is immature at birth because the placenta provides nutrients and removal of waste products until birth. The? newborn's stomach is able to absorb vital nutrients.? However, the? newborn's liver is immature and the newborn cannot conjugate bilirubin until after the first few weeks of life. The? newborn's ability to form ketones is immature at birth.
question
A nurse educator is teaching a group of students about alterations in digestion that have a genetic tendency. Which conditions should the educator include in the? lecture? ?(Select all that? apply.) Hepatitis Pancreatitis Celiac disease Pyloric stenosis Diarrhea
answer
Pancreatitis Celiac disease Pyloric stenosis Conditions that have familial tendencies include celiac? disease, pancreatitis, and pyloric stenosis. Hepatitis is not a condition of familial tendency and diarrhea is a manifestation of another? condition, not a primary disorder.
question
The nurse is caring for a client with prolonged diarrhea who is concerned that no treatments have been effective to stop the diarrhea. Which response is most appropriate by the nurse related to the? client's concern? ?A: "Your diarrhea is most likely caused by a food? allergy." ?B: "Diarrhea is not life? threatening, and you should not? worry." ?C: "The healthcare provider is an expert in gastrointestinal? disorders." ?D: "Diarrhea is a symptom of an underlying? illness, not an illness? itself."
answer
?D: "Diarrhea is a symptom of an underlying? illness, not an illness? itself." Diarrhea is a manifestation of an? illness, not a primary disorder. The healthcare provider needs to determine the underlying illness in order to resolve the? client's diarrhea successfully. Basing a response on the thought that diarrhea is not life threatening and the client should not worry dismisses the? client's concerns and is not therapeutic. Basing a response on the experience of the healthcare provider dismisses the? client's concerns and is also not therapeutic. Thinking that the? client's diarrhea is most likely caused by a food allergy is an assumption that may not be true. It also dismisses the? client's real? concern, that the diarrhea is not resolved.
question
A nurse is caring for a client diagnosed with intractable nausea and vomiting. Which independent nursing interventions help maintain fluid and electrolyte? balance? (Select all that? apply.) A: Administering antiemetics as ordered B: Discussing the need to avoid foods that produce nausea C: Teaching clients to restrict fluid intake for 1 hour before and after meals D: Teaching clients to seek additional medical help if unable to take in fluids E: Administering IV fluid replacement as ordered
answer
B: Discussing the need to avoid foods that produce nausea C: Teaching clients to restrict fluid intake for 1 hour before and after meals D: Teaching clients to seek additional medical help if unable to take in fluids Independent interventions which help to maintain fluid and electrolyte balance? include: discussing the need to avoid foods that produce? nausea; teaching clients to seek additional medical help if unable to take in? fluids; and teaching clients to restrict fluid intake for 1 hour before and after meals. The other interventions are? collaborative, not? independent, interventions.
question
The nurse is caring for a client who has swallowing problems. The healthcare provider has considered both enteral and parenteral nutrition for nutritional assistance to the client. The? client's spouse asks the nurse about the difference between these two therapies. Which statement by the nurse is the most? appropriate? A: ?"Enteral nutrition is achieved through a tube into the stomach or small intestine while parenteral nutrition is achieved through the? veins." ?B: "Parenteral nutrition is achieved through a tube into the stomach or small intestine while enteral nutrition is achieved through the? veins." ?C: "Enteral nutrition is used? short-term while parenteral nutrition is used? long-term." ?D: "Enteral nutrition provides only part of the? client's nutritional needs while parenteral nutrition provides all the? client's nutritional? needs."
answer
A: ?"Enteral nutrition is achieved through a tube into the stomach or small intestine while parenteral nutrition is achieved through the? veins." Enteral nutrition is achieved through a tube into the stomach or small? intestine; parenteral nutrition is achieved through the veins. Enteral nutrition may be used? short-term or long term and may provide part or all of the? client's nutritional needs.
question
The nurse is performing an assessment on an older adult male. The client tells the nurse that he has noticed that certain foods do not seem to taste the same as they did when he was younger and his mouth always seems dry. Which responses by the nurse are appropriate to include when teaching this client about lifespan changes of the digestive? system? ?(Select all that? apply.) ?A: "Saliva production? increases; however, medications cause dry? mouth." ?B: "Taste can become less acute due to the loss of taste buds of the? tongue." ?C: "Saliva production can? decrease, causing dry? mouth." ?D: "Taste can become less acute due to decreased nerve endings in the? mouth." ?E: "Taste can become less acute due to the natural atrophy of the? tongue."
answer
?C: "Saliva production can? decrease, causing dry? mouth." ?E: "Taste can become less acute due to the natural atrophy of the? tongue." The normal aging process can make taste less acute due to the natural atrophy of the tongue. Saliva production also can decrease with? age, causing dry mouth. Taste buds are not lost during aging. Medications may make a? client's mouth? dry; however, saliva production does not increase. Nerve endings in the mouth do not decrease with aging.
question
A nurse is caring for an adult? client, with a suspected hiatal? hernia, who will undergo a barium enema tomorrow to aid in diagnosing this condition. Which statement made by the nurse is most appropriate when preparing this client for a barium? swallow? Do not drink any fluids or eat any foods 4 hours prior to the procedure. Do you have an allergy to contrast ?dye? I will be giving you a laxative after the procedure Do not eat or drink any fluids for 4 hours after the procedure.
answer
I will be giving you a laxative after the procedure A barium swallow is also known as an upper GI series. This procedure is used to diagnose a hiatal hernia. The client will drink water and take laxatives after the procedure to help aid in the elimination of the barium. Contrast dye is not used in this procedure. Adult clients should not eat food or drink fluids for
question
Genetic Considerations with Digestion
answer
Crohn's Disease Glucose galactose malabsorption (GGM) ->diarrhea GERD - Gastroesophagus Reflux Disease
question
A nurse is caring for an adult client who has a vitamin deficiency. The client asks the nurse why? it's important to have adequate vitamin levels in the body. Which response by the nurse is the most? appropriate? A: ?"Vitamins assist in the digestion of? nutrients." B: ?"Vitamins promote resistance to bacterial? infection." ?C: "Vitamins are essential enzymes for the? body." ?D: "Vitamins support normal? growth, maintenance, and? repair."
answer
?D: "Vitamins support normal? growth, maintenance, and? repair." Vitamins are nutrients which are used by the body to support normal? growth, maintenance, and repair. Vitamins do not promote resistance to bacterial infection.? Enzymes, not? vitamins, assist in the digestion of nutrients. Vitamins are? nutrients, not enzymes.
question
A nurse is caring for a client with? hepatitis, cirrhosis, and pernicious anemia. What do these conditions have in? common? A: They are all alterations of gastric absorption. B: They all cause liver failure. C: They are all caused by liver disease. D: They are all alterations of gastric motility.
answer
A: They are all alterations of gastric absorption. ?Hepatitis, cirrhosis, and pernicious anemia are all alterations of gastric absorption. The other options are incorrect.
question
A nurse is caring for a client diagnosed with intractable nausea and vomiting. What independent nursing interventions help to maintain fluid and electrolyte? balance? ?(Select all that? apply.) A: Teaching the client to seek additional medical help if unable to take in fluids B: Teaching the client to restrict fluid intake for 1 hour before and after meals C: Discussing the need to avoid foods that produce nausea D: Administering IV fluid replacement as ordered E: Administering antiemetics as ordered
answer
A: Teaching the client to seek additional medical help if unable to take in fluids B: Teaching the client to restrict fluid intake for 1 hour before and after meals C: Discussing the need to avoid foods that produce nausea Independent interventions that help to maintain fluid and electrolyte balance include discussing the need to avoid foods that produce? nausea, teaching the client to seek additional medical help if unable to take in? fluids, and teaching the client to restrict fluid intake for 1 hour before and after meals. The other interventions are? collaborative, not independent interventions.
question
A community health nurse is providing teaching to a group of adults on the prevention of digestive disorders. Which statement will the nurse include in the? teaching? ?A: "Immunizations help prevent Crohn? disease." ?B: "Digestive disorders are all inherited and cannot be? prevented." ?C: "Immunizations help prevent Hepatitis? A." ?D: "Digestive disorders can be prevented by diligent hand? washing."
answer
?C: "Immunizations help prevent Hepatitis? A." Immunizations help prevent Hepatitis A. Preventive methods do exist for digestive disorders and are primarily based on lifestyle? choices, health? management, and identifying the cause of the disorders. Immunizations do not help to prevent Crohn disease. While hand washing is important in health promotion and? maintenance, this action does not prevent all digestive disease.
question
A nurse inserts a nasogastric feeding tube for a client with dysphagia. Once the tube is in? place, the client begins to retch and complains of nausea. What is the priority action by the nurse in response to the? client's manifestations? A: Administer antiemetic as prescribed B: Provide the client with small sips of water C: Instruct the client on relaxation techniques D: Reassess placement of the tube
answer
D: Reassess placement of the tube After inserting a nasogastric feeding? tube, if a client develops nausea or? retching, the nurse should reassess tube placement prior to performing any additional interventions. Instructing the client on relaxation techniques or administering an antiemetic may be? appropriate, but only after the tube placement has been reassessed. Providing small sips of water to a client with swallowing difficulties is inappropriate.
question
A nurse is caring for a client with a suspected bowel obstruction. What diagnostic test will aid in confirming this? diagnosis? Abdominal? X-ray Barium swallow Endoscopy Upper GI series
answer
Abdominal? X-ray The abdominal? X-ray will be used to diagnose a suspected bowel obstruction. An upper GI series? (also known as a barium? swallow) is conducted to diagnose esophageal? varices, inflammation,? ulcerations, hiatal? hernia, foreign? bodies, polyps,? diverticula, and tumors of the? esophagus, stomach, and duodenal bulb. An endoscopy directly visualizes the mucous membrane lining of the? esophagus, stomach, and duodenum.
question
Elimination is the process of secretion and excretion of waste products by the
answer
kidneys and intestines
question
(BPH) Benign Prostatic Hyperplasia
answer
noncancerous growth of prostate gland that blocks the flow of urine from the urethra, making it challenging to urinate.
question
A client underwent a transurethral resection of the prostate? (TURP) 24 hours ago. The nurse providing care for him would be especially vigilant in observing for which? complications? (Select all that? apply.) A: Hypertension B: Hypotension C: Decreased urinary output D: Large blood clots E: Hemorrhage
answer
B: Hypotension C: Decreased urinary output D: Large blood clots E: Hemorrhage hours after a? TURP, the client should be monitored closely for hemorrhage? (frankly bloody urine? output), the presence of large blood? clots, decreased urinary? output, increased bladder? spasms, decreased hemoglobin and? hematocrit, tachycardia, and hypotension. Hypertension would not be an expected complication.
question
The client has been prescribed dutasteride? (Avodart) for benign prostatic hyperplasia? (BPH). Which potential adverse effects would the nurse include in the medication teaching for this? medication? (Select all that? apply.) A: Decreased libido B: Decreased volume of ejaculate C: Renal insufficiency D: Gynecomastia E: Impotence
answer
A: Decreased libido B: Decreased volume of ejaculate E: Impotence Side effects of? 5-alpha reductase? inhibitors, such as dutasteride? (Avodart) and finasteride? (Proscar), may include? impotence, decreased? libido, and decreased volume of ejaculate. Gynecomastia and renal insufficiency are not side effects for these medications.
question
A client with mild benign prostatic hyperplasia? (BPH) tells the nurse that he prefers to do things "naturally" and doesn?'t want to take medication for his condition. He asks her if there are some things he can do to help his BPH without drugs. Which lifestyle changes used in the treatment for BPH would the nurse include in the response to the? client? (Select all that? apply.) A: Reducing stress B: Increasing dietary intake of foods high in potassium C: Avoiding drinking fluids within 2 hours of bedtime D: Exercising? regularly, including Kegel exercises E: Avoiding alcohol and caffeine
answer
A: Reducing stress C: Avoiding drinking fluids within 2 hours of bedtime D: Exercising? regularly, including Kegel exercises E: Avoiding alcohol and caffeine Lifestyle changes that may help clients with mild BPH include avoiding alcohol and? caffeine, exercising? regularly, including Kegel? exercises, avoiding drinking fluids within 2 hours of? bedtime, and reducing stress. Dietary intake of potassium is not related to BPH symptoms.
question
A client is admitted to the hospital for elective knee surgery to be performed the following day. The client tells the nurse that he has benign prostatic hyperplasia? (BPH). Which assessment findings support the diagnosis of? BPH? (Select all that? apply.) A: Urinary frequency B: Fever C: Increased time to void D: Nocturia E: Elevate white blood cell? (WBC) count
answer
A: Urinary frequency C: Increased time to void D: Nocturia (waking up to urinate at night) Clinical manifestations of BPH include weak urinary? stream, increased time to? void, hesitancy, incomplete bladder? emptying, postvoid? dribbling, frequency,? urgency, incontinence,? nocturia, dysuria, and bladder pain. Fever and an elevated WBC count are not signs of BPH.
question
An older adult client is admitted for a transurethral resection of the prostate? (TURP) to treat benign prostatic hyperplasia? (BPH). Which item in the client?'s health history placed him at risk for developing? BPH? A: Sedentary lifestyle B: Age C: More than one sexual partner D: Smoking history
answer
B: Age Age is the most common risk factor for BPH. Almost all men will develop BPH if they live long enough. There may be a racial component as? well, because Black and Hispanic men develop BPH earlier than White? men, but Asian men develop it later.? Smoking, sexual? history, and a sedentary lifestyle are not risk factors for developing BPH.
question
A client who has just undergone transurethral resection of the prostate? (TURP) has developed TURP? syndrome, according to the healthcare provider. Which findings during the nursing assessment support this? diagnosis? (Select all that? apply.) A: Decreased hematocrit B: Hypotension C: Hyponatremia D: Hypertension E: Confusion
answer
A: Decreased hematocrit C: Hyponatremia D: Hypertension E: Confusion TURP syndrome occurs when the client absorbs the irrigation fluids during and after surgery. Clinical manifestations are? hyponatremia, decreased? hematocrit, hypertension,? bradycardia, nausea, and confusion. If not treated? promptly, TURP syndrome may result in dysrhythmias? and/or seizures. Hypotension is not a manifestation of this syndrome.
question
Hyperplasia
answer
increase in number of cells
question
Risk Factors for BPH
answer
Age: After 40, more than 50% of men in their 60's, 90% of men in their 70's have it Presence of testes: men who have had them removed due to cancer do not have BPH Race: Black and Hispanic men experience earlier in life than white men. Asian men experience later in life
question
Manifestations of BPH include
answer
voiding storage urinary retention hydroureter (retention of urine) diverticula (sac like projections of mucosa) hydronephrosis (accumulation of urine in renal pelvis bc of obstruction)
question
Most frequently used diagnostic test for BPH is a Digital Rectal Examination (DRE)
answer
the healthcare provider inserts a gloved, lubricated finger into the clients rectum and palpates the prostate gland
question
Other diagnostic tests used to identify BPH:
answer
-UA - to assess for WBC and RBC & bacteria -UC - to assess for infxn -Urine flow rate test -Postvoid residual urine test (determines vol) -Uroflowmetry (to measure urine flow) -Prostate-specific antigen (PSA) level (screens for prostate cancer) -Cystoscopy (visualize bladder and urethra for blockage) -Creatinine Level (assess for kidney damage)
question
Nursing Dx for BPH
answer
Impaired urinary elimination Increased risk for infection Alterations in urinary retention Potential for urinary incontinence Alterations in comfort Potential for enhanced knowledge
question
Post Operative Interventions of BPH
answer
Assessing for TURP syndrome (hyponatremia, decreased hematocrit, hypertension, bradycardia, and confusion caused by absorption of irrigation fluid during and after surgery), which may lead to dysrhythmias and seizures if left untreated
question
The nurse is preparing a client for a transurethral needle ablation? (TUNA) for benign prostatic hyperplasia? (BPH). While reviewing the medical? record, the nurse notes that which findings support the rationale for this surgical procedure for the? client? (Select all that? apply.) A: It is easy to perform. B: It does not cause impotence. C: It is not expensive. D: It does not cause incontinence. E: It is minimally invasive.
answer
B: It does not cause impotence. D: It does not cause incontinence. E: It is minimally invasive. The TUNA is a minimally invasive surgery that uses? low-level radio frequency through twin needles to burn away a region of the enlarged prostate. The urethra is protected by a shield. This procedure improves urine flow through the urethra without causing impotence or incontinence. It is not necessarily easier to perform or less expensive than other procedures.
question
A client tells the nurse that he has had "problems with the prostateclose" for many years. Which clinical manifestations experienced by the client would necessitate the need for surgery for benign prostatic hyperplasia? (BPH)? (Select all that? apply.) A: Hematuria B: Nocturia C: Bladder stones D: Renal insufficiency secondary to BPH E: Urinary retention
answer
A: Hematuria C: Bladder stones D: Renal insufficiency secondary to BPH E: Urinary retention Candidates for prostate surgery are clients who have urinary? retention, hematuria, bladder? stones, and renal insufficiency secondary to BPH. Nocturia alone is not a reason to undergo surgery.
question
A client recently diagnosed with benign prostatic hyperplasia? (BPH) tells the nurse that the provider told him he can no longer take the decongestant medication he has routinely used for the sniffles. He asks the nurse to explain why he should avoid this medication. The nurse would base the response to the client on which? rationale? A: Increases risk of bladder cancer B: Causes urinary retention C: Causes an accelerated growth of the prostate D: Leads to impotence
answer
B: Causes urinary retention Several classes of medications can precipitate urinary retention in men with? BPH, including anticholinergics and? over-the-counter medications for the common? cold, such as decongestants. These medications do not lead to? impotence, growth of the? prostate, or increase the risk of bladder cancer.
question
The nurse is providing discharge instructions to a postoperative client who is being discharged to home with an indwelling urine catheter. Which will the nurse include in the teaching for this? client? (Select all that? apply.) A: Place powder around the bag to prevent odor. B: Place a soft cloth between the leg bag and thigh. C: Empty the leg bag every 3-4 hours. D: Change from a daytime leg bag to a larger drainage bag at night. E: Avoid strapping on the leg bag too tightly.
answer
B: Place a soft cloth between the leg bag and thigh. C: Empty the leg bag every 3-4 hours. D: Change from a daytime leg bag to a larger drainage bag at night. E: Avoid strapping on the leg bag too tightly. Changing to a larger bag at night permits gravity drainage and keeps urine from backing up in the bladder. If the leg bag is strapped on too? tightly, it can impede venous return in the leg. Placing a soft cloth between the bag and the thigh protects the skin and absorbs any wetness. Emptying the leg bag every 3- 4 hours prevents overfilling. Powder is not indicated. If there is a strong urine? smell, this should be reported to the? urologist, along with changes in urine? color, urine consistency and? amount, hematuria, frank? bleeding, or large blood clots.
question
A client with benign prostatic hyperplasia? (BPH) is scheduled for minimally invasive surgery for his condition. He is not convinced that he really needs this procedure. He asks the? nurse, "What?'s the worst that can happen if I don?'t have the ?procedure?" The nurse would base the response on which? complications? (Select all that? apply.) Detrusor hypertrophy Hydroureter Impotence Diverticula Hydronephrosis
answer
Hydroureter Diverticula Hydronephrosis Several complications may occur if the mass is not reduced in size. The bladder becomes more distended. Diverticula? (saclike projections of? mucosa) may appear on the bladder wall. The distention can cause hydroureter? (distention of the ureter with? urine) and hydronephrosis? (accumulation of urine in the renal? pelvis). These can all result in infection. Detrusor hypertrophy occurs in BPH to try to compensate for increased resistance to urine? flow, but it is not a complication of the mass. Impotence is not a factor.
question
The nurse is caring for a client who was recently remarried. He is being discharged today after having undergone prostate surgery. He asks the nurse? privately, with some? embarrassment, when he can resume sexual intercourse with his wife. Which response by the nurse is the most? appropriate? A: "You can resume sexual activity immediately" B: "You can resume sexual activity as soon as the catheter is removed" C: "You can resume sexual activity as soon as you are able to achieve an erection" D: "You can resume sexual activity 6 weeks after surgery"
answer
D: "You can resume sexual activity 6 weeks after surgery" In order to prevent? bleeding, sexual activity should not be resumed until 6 weeks after surgery. Another teaching point for the client? and/or partner is that after resuming? sex, the ejaculate will flow back into the bladder so the client will express little or no semen.
question
A client with urinary incontinence is scheduled for urodynamic testing. The client?'s family asks the nurse what this test is for. Which response by the nurse is the most? appropriate? A: To identify structural disorders contributing to incontinence B: To measure bladder strength and urinary sphincter health C: To determine how completely the bladder empties with voiding D: To evaluate detrusor muscle function
answer
B: To measure bladder strength and urinary sphincter health Urodynamic testing measures bladder strength and urinary sphincter health. Cystometrography is a diagnostic test done to evaluate detrusor muscle function. A cystoscopy identifies structural disorders contributing to incontinence. Postvoiding residual volume determines how completely the bladder empties with voiding.
question
The nurse is providing care to a client diagnosed with urinary incontinence. Which client statements support the nursing diagnosis of social? isolation? (Select all that? apply.) A: "I time my diuretic for early in the? day, so I can leave home later in the day and not have to visit the bathroom as often." B: "When I leave? home, I worry that I can?'t find a bathroom in time. C: "I have found ways to disguise the smell of urine while I am out of the house." D: "I have discovered a brand of absorbent undergarments that fit well." E: "I am so embarrassed when I wet myself. Even when I use absorbent? pads, I feel like I smell of urine'
answer
B: "When I leave? home, I worry that I can?'t find a bathroom in time. E: "I am so embarrassed when I wet myself. Even when I use absorbent? pads, I feel like I smell of urine' Embarrassment and odor and the fear of not being able to find a bathroom in time can lead to social isolation. Seeking out and using absorbent? products, use of odor? eliminators, and scheduling diuretics to provide adequate time to make frequent trips to the bathroom are coping strategies that a client may use to continue to participate in normal social activities.
question
The nurse is providing discharge education to a client diagnosed with urinary incontinence. Which client statement indicates the need for further education regarding preventive methods for urinary? incontinence? A: "I have decreased the amount of coffee I drink each day from eight cups to two" B: "I drink six to eight? 8-ounce glasses of water each day" C: "I have switched to a? low-fiber diet" D: "I have begun a smoking cessation program
answer
C: "I have switched to a? low-fiber diet" A? low-fiber diet is not indicated as a preventive method of decreasing urinary incontinence. The other client statements indicate understanding of the teaching session.
question
The nurse is providing care to older clients at a? long-term care facility. Many of the? nurse's clients experience urinary incontinence. Which factors place these clients at risk for urinary? incontinence? (Select all that? apply.) Stroke Depression More than two urinary tract infections? (UTIs) in a year Pelvic floor muscle exercises? (Kegel exercises) Age
answer
Stroke Depression More than two urinary tract infections? (UTIs) in a year Age Risk factors for urinary incontinence include? age, gender? (women are more susceptible than? men), obesity,? smoking, diabetes,? inactivity, pregnancy,? depression, neurologic disorders? (e.g., stroke), two or more UTIs per? year, and medications? (medications affecting the adrenergic? system, diuretics, and calcium channel? blockers). Kegel exercises decrease the risk of urinary incontinence.
question
The nurse is providing care to a client diagnosed with urinary retention. The healthcare provider prescribes pharmacologic therapy for the client. Which type of medication will the nurse include in the discharge teaching for this? client? Cholinergic medications Estrogen therapy Oxybutynin? (Ditropan, Ditropan? XL) Imipramine? (Tofranil)
answer
Cholinergic medications Cholinergic medications promote contraction of the detrusor muscle and emptying of the bladder. Imipramine? (Tofranil) contracts the smooth muscles of the bladder neck to treat incontinence. Oxybutynin? (Ditropan, Ditropan? XL) is used to treat urge incontinence and increase bladder capacity. Estrogen therapy is used to treat incontinence caused by postmenopausal atrophic vaginitis.
question
A client is admitted to a clinic with urinary retention caused by a functional problem. Which option is the likely cause of this client?'s condition? A: Anticholinergic medications B: Fecal impaction C: Benign prostatic hypertrophy D: Repeated urinary tract infections
answer
D: Repeated urinary tract infections Repeated urinary tract infections lead to scarring of? structure, which is a functional problem associated with urinary retention. Benign prostatic hypertrophy and fecal impaction are the causes of an obstruction that will lead to urinary retention. Anticholinergic medications are may cause? retention, but this is not a functional problem. Once the medication is stopped the urinary retention resolves.
question
Urinary Retention
answer
the inability to empty the bladder
question
Hydronephrosis
answer
accumulation of urine in the renal pelvis
question
Vesicoureteral reflux
answer
back flow of urine from the bladder to the kidneys
question
reversible causes of urinary incontinence
answer
polyuria exposure to irritants urinary retention stool impaction/constipation meds UTI's
question
Irreversible causes of urinary incontinence
answer
congenital disorders Nervous system disorders (stroke, trauma, MS, Parkinson)
question
Causes of Urinary incontinence
answer
BPH UTI's surgery meds conscious inhibition (waiting too long to void)
question
urinary incontinence is
answer
a symptom not a disorder the focus of a Dx is to determine the underlying cause
question
Simple diagnostic tests for urinary incontinence include
answer
bladder diary UA blood tests 24 hour urine sample stress test postvoiding residual vol
question
The nurse is providing care to a client who is prescribed a complete decompression of bladder using intermittent catheterization. Which explanation about this procedure to the family is the most? appropriate? A: ?"A diagnostic? uroflowmetry." ?B: "The postvoiding insertion of a catheter to determine the volume of urine retained in the? bladder." ?C: "A nonpharmachologic therapy for urinary? retention." ?D: "A diagnostic urodynamic? test."
answer
?C: "A nonpharmachologic therapy for urinary? retention." Complete decompression of bladder using intermittent catheterization or an indwelling catheter is a nonpharmachologic therapy for urinary retention. The postvoiding insertion of a catheter to determine the volume of urine retained in the bladder is used to determine how completely the bladder empties with voiding. Uroflowmetry is used to evaluate voiding patterns. Urodynamic testing measures bladder strength and urinary sphincter health.
question
The nurse is caring for a client at risk for urinary retention. Which clinical manifestations does the nurse document during the nursing assessment to support this? diagnosis? A: Nausea and vomiting B: Overflow voiding C: Hematuria D: Cool and clammy skin
answer
B: Overflow voiding The nurse should monitor the client for overflow voiding. This is a manifestation associated with urinary retention.? Cool, clammy? skin, nausea and? vomiting, and hematuria are not manifestations associated with urinary retention.
question
The nurse is providing care to a client diagnosed with urinary retention. Which medication on the? client's medical administration record would the nurse question for this? client? Ibuprofen Acetaminophen Bethanechol chloride Diphenhydramine hydrochloride
answer
Diphenhydramine hydrochloride The nurse would question the use of an? antihistamine, such as diphenhydramine? hydrocholoride, for a client with urinary retention. Bethanechol chloride is a medication used to treat urinary retention. Aceteminophen and ibuprofen can be administered safely for a client with urinary retention.
question
The nurse is providing care to a client with urinary incontinence who has been prescribed bladder training behavior modification. Which goal of therapy does the nurse include in the teaching session with the? client? A: To improve pelvic floor muscle strength by stopping the urine flow during voiding and holding for a few seconds B: To toilet the client at regular intervals? (e.g., every? 2-4 hours) C: To toilet the client on a schedule that corresponds with the normal pattern D: To gradually increase the bladder capacity by increasing the intervals between voiding and resisting the urge to void between scheduled times
answer
D: To gradually increase the bladder capacity by increasing the intervals between voiding and resisting the urge to void between scheduled times Bladder training increases the bladder capacity by increasing the intervals between voiding and resisting the urge to void between scheduled times. Habit training is toileting on a schedule that corresponds with the normal pattern. Scheduled voiding is toileting at regular intervals. Kegel exercise is a technique that is done to identify the pelvic muscles for pelvic floor muscle.
question
The nurse is educating the parents of a? preschool-age child about the causes of nocturnal enuresis. Which statements are appropriate for the nurse to include in the teaching session with the? parents? (Select all that? apply.) A: ?Bed-wetting is more common in girls than boys. B: Your child may be constipated. Constipation is a known cause for? bed-wetting. C: Many children wet the bed due to difficulties in arousal from sleep. D: This is caused by an overproduction of urine at night. E: Your child is just being lazy.
answer
B: Your child may be constipated. Constipation is a known cause for? bed-wetting. C: Many children wet the bed due to difficulties in arousal from sleep. D: This is caused by an overproduction of urine at night. Nocturnal enuresis occurs more often in boys. It can be the result of overproduction of urine at? night, difficulties in arousal from? sleep, and constipation. There is no indication that nocturnal enuresis is caused by the child being too lazy to get up out of bed at night to urinate.
question
The nurse reviews the medical chart for a client who is experiencing urinary incontinence. The healthcare provider?'s admission assessment identifies that the incontinence is related to an overactive detrusor muscle. Based on the provider?'s note, which type of urinary incontinence is this client? experiencing? Functional Urge Overflow Stress
answer
Urge Urge incontinence is related to an overactive detrusor? muscle, which increases bladder pressure. Stress incontinence is related to pelvic muscle relaxation and a weak urethra and surrounding? tissues, which cause decreased urethral resistance. Overflow incontinence is related to a lack of normal detrusor muscle? function, which causes the bladder to overfill and increases bladder pressure. Functional incontinence is related to the inability to respond to the need to urinate.
