Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders My Nursing Test Banks

Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. The nurse is collecting data from a newly admitted patient. Which finding should the nurse identify as a risk factor for constipation?
a. The patient does not like milk or milk products.
b. The patient has had hemorrhoids for the past 5 years.
c. The patient had part of the stomach removed 10 years ago because of ulcers.
d. The patient has a history of breast cancer treated with chemotherapy 3 years ago.
____ 2. The nurse is contributing to a patients plan of care. For which patient would the nursing diagnosis of Risk for Constipation be most appropriate?
a. A 37-year-old taking NSAIDs for bursitis
b. A 59-year-old taking narcotics for chronic pain control
c. A 74-year-old taking antibiotics for a urinary tract infection
d. A 67-year-old taking anticoagulant therapy for a history of deep vein thrombosis
____ 3. The nurse is caring for a patient who reports feeling constipated, yet passes frequent small liquid stools. Which action should the nurse take?
a. Check the patient for a fecal impaction.
b. Administer an antidiarrheal medication.
c. Explain that liquid stools indicate diarrhea.
d. Check the abdomen for rebound tenderness.
____ 4. The nurse notes that a patient with a history of a myocardial infarction is straining during defecation. Which response by the nurse is best?
a. Be careful, you might get a headache when you push so hard.
b. It is important that you not strain because it could cause damage to your heart.
c. Your blood pressure gets very low when you strain like that and you could faint.
d. Chronic constipation often causes a dilated colon, so it is good that you are staying empty.
____ 5. A patient with a colostomy says, My pouch blows up like a balloon when I pass gas. What is an appropriate response by the nurse?
a. Make a tiny pinhole in the top of the pouch to let air out.
b. Empty the gas like you would if the pouch was full of stool.
c. Peel back a tiny corner of the skin barrier to allow gas to escape.
d. Remove the pouch and put on a new one when it gets too full of gas.
____ 6. The nurse is reinforcing teaching provided to a patient with acute diarrhea. Which statement indicates the patient understands the most common cause for this health problem?
a. Excessive fluid intake.
b. Excessive fiber in the diet.
c. Viral or bacterial infection.
d. Inflammatory bowel disease.
____ 7. The nurse is providing discharge teaching to a patient with diarrhea. Which patient statement indicates that teaching has been effective?
a. It is important that I increase fluid intake to prevent dehydration.
b. I am at increased risk for a ruptured bowel, so I must remain on bedrest.
c. I should tell future health-care workers that Ive been diagnosed with obstipation.
d. My risk for a urinary tract infection is very high, so I should call the doctor if I have a pain.
____ 8. The nurse is caring for a patient who has diarrhea. Which nursing action is the highest priority?
a. Provide perineal skin care.
b. Auscultate the abdomen daily.
c. Encourage oral fluid replacement.
d. Provide analgesics for abdominal pain.
____ 9. The nurse is reinforcing patient teaching on the best way to prevent transmission of infectious diarrhea. Which patient statement indicates correct understanding of the teaching?
a. Wear a mask and gown.
b. Avoid sharing eating utensils.
c. Keep the perineal area clean and dry.
d. Wash hands frequently and after toileting.
____ 10. The nurse is contributing to the plan of care for a patient with gluten enteropathy (celiac disease). What should the nurse recommend be eliminated from the diet of the patient?
a. Red meats
b. Milk and milk products
c. Fresh fruits and vegetables
d. Wheat, rye, oats, and barley
____ 11. The nurse is collecting data from a patient who is reporting abdominal pain. Which symptom suggests that the patient is experiencing appendicitis?
a. Suprapubic pain
b. Midepigastric pain
c. Substernal pain that radiates to the back
d. Pain in the right lower abdominal quadrant
____ 12. The nurse suspects appendicitis in a patient complaining of abdominal pain. Which assessment finding should cause the nurse to notify the physician?
a. The patient burps after drinking a glass of water.
b. Tympanic, hollow sounds are heard on percussion.
c. Bowel sounds are hyperactive in the upper quadrants.
d. Palpation of the abdomen is positive for rebound tenderness.
____ 13. The nurse is caring for a patient with an inflamed appendix. Which complication is most likely to occur if the appendix ruptures?
a. Colitis
b. Enteritis
c. Hepatitis
d. Peritonitis
____ 14. The nurse is monitoring a patient recovering from an emergency appendectomy. Which finding should be reported to the physician immediately?
a. Pain at the operative site
b. Absence of bowel sounds
c. Abdomen rigid on palpation
d. 3-centimeter spot of bloody drainage on dressing
____ 15. A patient is to be started on clear liquids after an appendectomy. Which food should the nurse identify as being a clear liquid?
a. Oatmeal.
b. Ice cream.
c. Cranberry juice.
d. Graham crackers.
____ 16. The nurse is caring for a patient who is being screened for diverticulosis. Which patient statement indicates understanding of conditions that predispose to diverticulosis?
a. Colon cancer.
b. Chronic diarrhea.
c. Chronic constipation.
d. Diet high in red meats.
____ 17. A patient asks what causes diverticulitis. How should the nurse respond?
a. The lining of your colon is irritated and inflamed.
b. You have little pouches in your colon that are inflamed.
c. You have little outpouchings that occur in weak areas of the colon.
d. The visceral and parietal membranes in your abdomen are inflamed.
____ 18. The nurse is teaching a patient with diverticulosis how to avoid complications. Which patient statement indicates that teaching has been effective?
a. I will avoid milk and milk products.
b. I should avoid very hot and spicy foods.
c. I will increase fluids and fiber in my diet.
d. I should cook vegetables thoroughly before eating.
____ 19. The nurse is caring for a patient with an exacerbation of Crohns disease. Which nursing action is most important to recommend for inclusion in the patients plan of care?
a. Encourage oral fluids.
b. Encourage frequent ambulation.
c. Administer anti-gas agents as ordered.
d. Apply protective ointment to perianal skin.
____ 20. A patient scheduled for an ileostomy for Crohns disease asks the nurse to explain the procedure. What should the nurse respond?
a. You will have a loop of colon brought out onto your abdomen.
b. Your ileum will be anastomosed to your rectum, so your stools will be watery.
c. Your ileum will be removed, and the end of your jejunum will be made into a stoma.
d. Your colon will be removed, and the end of your small bowel will be brought out onto your abdomen.
____ 21. A patient with a new ileostomy asks if a bag needs to be worn on the abdomen. What is the most appropriate response by the nurse?
a. Your stool will be liquid, so you will always need a bag.
b. Your stool will be mushy, and you will need a bag most of the time.
c. You will be taught to irrigate your stoma to eliminate the need for a bag.
d. Your stool will be formed, and you may be able to regulate your bowel movements so that a bag will be optional.
____ 22. The nurse is caring for a patient recovering from ileostomy surgery. What should have the highest priority when caring for the patient after surgery?
a. Food intake
b. Participation in stoma care
c. Stoma condition every 8 hours
d. Bowel sounds every 4 hours for 24 hours
____ 23. The nurse is monitoring a patient and finds a bulging area in the patients groin. Which additional finding should cause the nurse the most concern?
a. The bulging disappears at times.
b. The white blood cell count is 10,000/mm3.
c. The patient develops pain at the site and vomiting.
d. The bulging occurs when the patient coughs or strains.
____ 24. The nurse is caring for a patient with an absorption disorder. What term should the nurse use to document fat in the patients stool?
a. Oleorrhea
b. Steatorrhea
c. Lactorrhea
d. Lipidorrhea
____ 25. A patient with a bowel obstruction asks for the term that describes telescoping of the bowel. Which should the nurse respond to this patient?
a. Ileus.
b. Volvulus.
c. Adhesions.
d. Intussusception.
____ 26. The nurse is caring for a patient admitted with a possible bowel obstruction. Which patient symptom should cause the nurse the most concern?
a. Flank pain
b. Fecal vomiting
c. Watery diarrhea
d. Occult blood in the stool
____ 27. While receiving report from the previous shift, the nurse is informed that a nasogastric tube was placed in a patient who has a bowel obstruction. For which reason should the nurse realize the tube was inserted?
a. To feed the patient
b. To relieve distention
c. To administer medications
d. To prevent another obstruction
____ 28. On admission, a patient with gastrointestinal bleeding had vital signs of a blood pressure of 140/80 mm Hg, pulse 72 beats/minute, respirations 14 breaths/minute, and temperature 98.8F (37.1C). What finding should be reported to the registered nurse (RN) or physician immediately?
a. Pulse 78 beats/minute
b. Crampy abdominal pain
c. Occult blood in the stool
d. Blood pressure 104/68 mm Hg
____ 29. The nurse is caring for a patient who has an ileostomy and feels crampy. The nurse notes that the stoma has become edematous and pale and suspects a blockage. What action should the nurse take?
a. Administer a laxative such as milk of magnesia.
b. Have the patient drink 2 to 3 L of water or other liquid.
c. Administer a 1000-mL warm tap water enema through the stoma.
d. Have the patient get into a tub full of warm water and drink warm liquids.
____ 30. The nurse is collecting data from a patient with a stoma. What should the nurse document for a health stoma?
a. Gray and dry
b. Black and dry
c. Bluish and wet
d. Pink and moist
____ 31. The nurse is contributing to the plan of care for patient with an ostomy. Why should the nurse recommend the use of a skin barrier product under the ostomy appliance?
a. To keep stool from irritating the skin
b. To ease removal of the pouch for changing
c. To prevent the bag from sticking too tightly to the skin
d. To prevent stool from coming in contact with the stoma
____ 32. The nurse is evaluating a patients ability to change an ostomy appliance. Which observation indicates that the patient can safely provide self-ostomy care?
a. Stoma measured prior to applying new appliance
b. Skin barrier applied tight to the base of the stoma
c. Skin barrier cut to the same size as previous barrier
d. Lotion applied to skin before application of skin barrier
____ 33. The spouse of a patient with an ascending ostomy asks if the patient will always have to wear a pouch. What response should the nurse make?
a. A bag will be needed all of the time.
b. A bag will be needed only during the night.
c. A bag will be needed only to protect the stoma.
d. No, a bag will not be needed after discharge from the hospital.
____ 34. A patient is experiencing melena. What does this observation indicate to the nurse?
a. The patient has a ruptured diverticulum
b. The patient has ingested a large volume of red meat
c. Blood has begun to seep into the stomach over the last 3 hours from esophageal varices
d. Blood has been in the gastrointestinal tract for more than 8 hours after being in contact with hydrochloric acid
____ 35. The nurse is reviewing the process of digestion with a patient diagnosed with malabsorption syndrome. How many mL of fluid should the nurse instruct that is absorbed through the intestinal mucosa into the portal bloodstream?
a. 1000
b. 2000
c. 4000
d. 8000
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 36. The nurse is reinforcing teaching provided to a patient about appropriate diet modifications to help prevent exacerbations of inflammatory bowel disease. Which patient statements indicate that teaching has been effective? (Select all that apply.)
a. I should avoid caffeine and spicy fiber foods.
b. I should avoid concentrated sweets and starches.
c. It is important to eat more whole grains and bran.
d. High-fiber foods should not be included in my diet.
e. I should increase my intake of fresh fruits and vegetables.
f. Milk and other dairy products should be limited in my diet.
____ 37. The nurse is participating in a community health fair program focusing on risk factors for cancer. Which should be included as increasing the risk for colon cancer? (Select all that apply.)
a. Low-fat diet
b. Low-fiber diet
c. Low-sodium diet
d. History of rectal polyps
e. History of ulcerative colitis
f. Family history of breast cancer
____ 38. The nurse reinforces teaching provided to a patient with constipation and straining who is experiencing abdominal distention and intestinal rumbling. What should be included in the teaching? (Select all that apply.)
a. Set a time for defecation every day.
b. Increase the intake of foods containing vitamin K.
c. Increase intake of fiber, especially bran, in the diet.
d. Sit on the toilet with feet planted firmly on the floor.
e. Drink water each morning and about 2 to 3 L throughout the day.
f. Use enemas and rectal suppositories if constipation persists after 2 days.
____ 39. The nurse is reinforcing teaching provided to a patient who is being discharged with a new colostomy. Which comments by the patient indicate understanding of the discharge teaching? (Select all that apply.)
a. I will empty the pouch when it is less than half full.
b. I can spray deodorant into the pouch after I clean it.
c. I will not be concerned if there is no stool for several days.
d. Im so glad I can eat all the foods I like now, including hot dogs.
e. I always check the seal and tape around the stoma after I shower.
f. I should change the pouch each morning and evening to prevent infection.
____ 40. The nurse provides teaching to a patient prescribed budesonide (Entocort EC) for Crohns disease inflammation. Which patient statements indicate that more teaching is necessary? (Select all that apply.)
a. I should avoid grapefruit juice.
b. I must avoid the sun while taking this drug.
c. I should swallow the pill whole, not crushed.
d. I will take the pill each evening before going to bed.
e. I can just stop taking the medication once I feel better.
f. I might experience mood swings or weight gain on this medication.
____ 41. The nurse is contributing to a patients plan of care. Which foods should the nurse recommend to be avoided or used with caution to reduce the possibility of ileostomy blockage? (Select all that apply.)
a. Celery
b. Apples
c. Potatoes
d. Dried fruits
e. Mushrooms
f. Broiled chicken
____ 42. A patient with fecal incontinence has an excoriated perianal region. Which interventions should be discussed with the RN? (Select all that apply.)
a. Stool culture
b. Antibiotic therapy
c. Protective barrier cream
d. Baby powder to peri area
e. A low-pressure rectal tube
f. Nasogastric (NG) tube to suction
____ 43. A patient comes into the client after experiencing diarrhea with five liquid stools in the past 24 hours. Which additional patient symptoms should cause the nurse concern? (Select all that apply.)
a. Fever
b. Blood in the stool
c. Severe abdominal cramping
d. Blood pressure 138/72 mm Hg
e. Oral intake of 3 L of fluid in 24 hours
f. Weight loss of 1 pound in the past week
____ 44. During a health history, the nurse learns that a patient uses laxatives every day to ensure a bowel movement. What should the nurse expect to be prescribed for this patient? (Select all that apply.)
a. Daily enema
b. Psyllium (Metamucil)
c. Daily rectal suppository
d. Docusate sodium (Colace)
e. Methylnaltrexone (Relistor)
____ 45. The nurse is assisting to prepare dietary teaching for a patient with diverticulosis. Which food items should the nurse suggest be added to this patients teaching plan? (Select all that apply.)
a. Peas
b. Salad
c. Cheese
d. Prunes
e. Raisins
____ 46. The nurse is teaching a patient newly diagnosed with ulcerative colitis about triggers for exacerbation of the disease. What should the nurse urge the patient to do to prevent a future exacerbation? (Select all that apply.)
a. Do not use tobacco
b. Reduce exposure to stress
c. Restrict fluids to 2 liters per day
d. Read food labels to avoid food additives
e. Avoid ingesting foods sprayed with pesticides
____ 47. A patient with Crohns disease is scheduled for an ileoanal pouch. What should the nurse include when teaching the patient about this surgery? (Select all that apply.)
a. Stool will pass through the anus.
b. A temporary ileostomy is needed.
c. The stool is hard and brown in color.
d. An ostomy pouch will need to be worn.
e. Several bowel movements occur per day.
____ 48. A patient with irritable bowel syndrome is being started on the FODMAP diet. What foods should the nurse instruct the patient to avoid when following this diet? (Select all that apply.)
a. Milk
b. Pears
c. Apples
d. Broccoli
e. Brussels sprouts

Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders
Answer Section

MULTIPLE CHOICE

1. ANS: B
Causes for constipation include rectal or anal conditions such as hemorrhoids. A. Absence of milk products in the diet is not a known cause for constipation. C. Stomach surgery is not a cause for constipation. D. History of breast cancer treatment does not cause constipation.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Analysis

2. ANS: B
Medications, such as narcotics, tranquilizers, and antacids with aluminum, decrease motility of the large intestine and may contribute to constipation. A. C. D. NSAIDs, antibiotics, and anticoagulants are not identified as causing constipation.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Analysis

3. ANS: A
Fecal impaction results when the fecal mass is so dry it cannot be passed. Small amounts of liquid stool ooze around the fecal mass and cause incontinence of liquid stools. B. If the incontinence is treated with an antidiarrheal medication, it will worsen the constipation. C. The patient is not experiencing liquid stools. D. Rebound tenderness is not a manifestation of fecal impaction.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application

4. ANS: B
Straining to have a bowel movement (Valsalvas maneuver) can result in cardiac, neurological, and respiratory complications. If the patient has a history of heart failure, hypertension, or recent myocardial infarction, straining can lead to cardiac rupture and death. A. C. D. These responses are not appropriate for the patient with a history of myocardial infarction who is straining with a bowel movement.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

5. ANS: B
The pouch should be emptied the same as emptying for stool. A. A pinhole will allow odor to escape so that should never be done. D. A new pouch is not necessary and would cost too much. C. Disrupting the skin barrier often could irritate the skin.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application

6. ANS: C
The most common cause of acute diarrhea is a bacterial or viral infection. A. B. Excessive food and fiber are not causes for diarrhea. D. Inflammatory bowel disease can cause chronic diarrhea.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

7. ANS: A
Weakness and dehydration from fluid loss may occur with diarrhea. B. A ruptured bowel is not an adverse effect of diarrhea. C. Obstipation is a term for chronic constipation. D. The patients risk for urinary tract infection is not high because of diarrhea.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

8. ANS: C
Replacing fluids and electrolytes is the first priority which is accomplished by increasing oral fluid intake or using solutions with glucose and electrolytes if ordered by the physician. A. Perineal skin care may or may not need to be done. B. There is no reason to auscultate the abdomen every day. D. There is no indication that the patient is experiencing abdominal pain.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

9. ANS: D
Ensure hand washing by patient, family, and health care staff to prevent the spread of infection. A. A mask and gown do not need to be worn. B. Avoid sharing eating utensils will not prevent the spread of infectious diarrhea. C. Keeping the perineal area clean and dry will promote comfort and prevent skin breakdown.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

10. ANS: D
Gluten is a protein found in wheat, barley, oats, and rye. In celiac disease, a high-calorie, high-protein, gluten-free diet is ordered to relieve symptoms and improve nutritional status. A. B. C. Gluten is not found in red meat, milk, milk products, or fresh fruits and vegetables.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

11. ANS: D
Signs and symptoms of appendicitis include fever, increased white blood cells, and generalized pain in the upper abdomen. Within hours of onset, the pain usually becomes localized to the right lower quadrant at McBurneys point. A. B. C. Appendicitis pain is not located in the suprapubic, mid-epigastric, or substernal regions.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

12. ANS: D
Local rebound tenderness (intensification of pain when pressure is released after palpation) in the right lower quadrant of the abdomen is a classic sign of appendicitis. A. B. C. Burping, tympanic bowel sounds, and hyperactive bowel sounds are not associated with appendicitis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

13. ANS: D
Perforation, abscess of the appendix, and peritonitis are major complications of appendicitis. A. B. C. Colitis, enteritis, and hepatitis are not complications of a ruptured appendix.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

14. ANS: C
With peritonitis, a life-threatening complication, abdominal rigidity is present. The physician should be notified promptly for treatment orders. A. The patient will be experiencing post-operative pain. B. Absence of bowel sounds is expected after anesthesia. D. Bleeding is expected after surgery.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

15. ANS: C
A clear liquid is one that can you can see through and has no pulp such as cranberry juice, apple juice, soda, or black coffee. A. Oatmeal would be permitted on a soft diet. B. Ice cream would be permitted on a full liquid diet. D. Graham crackers would be permitted on a regular diet.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Analysis

16. ANS: C
Chronic constipation usually precedes the development of diverticulosis by many years. When the patient is chronically constipated, pressure within the bowel is increased, leading to development of diverticula. A. D. A diet high in red meat is believed to contribute to the development of colon cancer. B. Chronic diarrhea does not cause diverticulosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

17. ANS: B
When food and bacteria are trapped in a diverticulum, inflammation and infection develop. This is called diverticulitis. A. C. D. These responses do not appropriate explain diverticulitis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

18. ANS: C
Diverticulosis is managed by preventing constipation. Diverticulitis can be prevented by increasing dietary fiber to prevent constipation and onset of diverticulosis. A. B. D. Avoiding milk products, hot and spicy foods, and cooking vegetables will not prevent the development of complications from diverticulosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

19. ANS: A
Per Maslows hierarchy, preventing dehydration from diarrhea is important, so fluids are encouraged.
B. C. D. Ambulation, anti-gas medications, and protective ointment to the perianal skin are not as important as ensuring the patients fluid and electrolyte status are maintained.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

20. ANS: A
An ileostomy is an end stoma formed by bringing the terminal ileum out to the abdominal wall following a total proctocolectomy. A. B. C. These responses do not appropriately describe an ileostomy.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

21. ANS: A
A conventional ileostomy is a small stoma in the right lower quadrant that requires a pouch at all times because of the continuous flow of liquid effluent. B. An ostomy device will always need to be worn by the patient. C. D. With an ileostomy, the stoma does not need to be irrigated and the stool will not be formed.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

22. ANS: C
The patient with a new ostomy has many nursing care needs. In addition to routine postoperative assessment, a stoma should be inspected at least every 8 hours to detect complications, such as color changes, that may require immediate surgery. A. Postoperatively food intake may be limited. B. It is too soon to expect the patient to participate in stoma care. D. Bowel sounds will most likely be absent or sluggish after surgery.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

23. ANS: C
An incarcerated hernia may become strangulated if the blood and intestinal flow are completely cut off. Symptoms are pain at the site of the strangulation, nausea and vomiting and colicky abdominal pain. A. The disappearance of the bulge means the hernia can be reduced. B. An elevated white blood cell count means an infection is present. D. Bulging with coughing or straining is an indication that a hernia is present.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

24. ANS: B
Steatorrhea is fat in the stool. A. C. D. These words are not used to describe fat in the stool.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

25. ANS: D
Intussusception occurs when peristalsis causes the intestine to telescope into itself, which can cause a mechanical obstruction. A. B. C. These terms do not describe telescoping of the bowel.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

26. ANS: B
As a bowel obstruction becomes more extreme, peristaltic waves reverse, propelling the intestinal contents toward the mouth, eventually leading to fecal vomiting. A. Flank pain is not associated with a bowel obstruction. C. Watery diarrhea would not be present with a bowel obstruction. D. Occult blood in the stool is not present with a bowel obstruction.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

27. ANS: B
In most cases, the bowel is decompressed using a nasogastric tube, which relieves symptoms and may resolve the obstruction. A. C. D. The nasogastric tube is not inserted to feed the patient, administer medications, or prevent another obstruction.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Analysis

28. ANS: D
Blood pressure 104/68 mm Hg is a significant drop from the patients prior pressure and may indicate that the patient is going into shock. Prompt treatment is needed. A. This is a normal pulse. B. Crampy abdominal pain does not indicate acute distress. C. Occult blood in the stool would be expected in the patient with gastrointestinal bleeding.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

29. ANS: D
For an ileostomy blockage, have the patient get into a tub of warm water, get into a knee-to-chest position, and sip on warm liquid such as coffee, tea, bouillon, broth, or hot chocolate. A. B. C. These interventions are not appropriate for the patient with an ileostomy blockage.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

30. ANS: D
The stoma should be pink to red, moist, and well attached to the surrounding skin. A. C. A bluish or gray stoma indicates inadequate blood supply. B. A black stoma indicates necrosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

31. ANS: A
Skin must be protected, as stool is irritating to the skin and will excoriate the skin if it is exposed to it. B. C. D. A skin barrier is not used to facilitate changing of the pouch, protect the bag from sticking to the skin, or to prevent stool from coming in contact with the stoma.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application

32. ANS: A
For the traditional skin barrier, the patient should measure the stoma with a stoma sizing guide initially with each appliance change, because the stoma will shrink for up to 6 months. B. The appliance should not be applied tightly to the base of the stoma. C. The stoma should be measured prior to each appliance application. D. The skin should be clean and dry prior to applying the skin barrier.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

33. ANS: A
A bag will be needed all of the time as the stool will be liquid to mushy. B. C. D. These responses are inappropriate for the patient with an ascending ostomy.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

34. ANS: B
When blood has been in the GI tract for more than 8 hours and has come in contact with hydrochloric acid, it causes melena, or black and tarry stools. A. B. C. These are not identified causes for the development of melena.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

35. ANS: D
In the normal process of digestion, the intestinal mucosa absorbs more than 8000 mL of liquid with nutrients and electrolytes into the portal bloodstream. A. B. C. These volumes are significantly lower than the estimated amount of liquid absorbed into the portal bloodstream.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

MULTIPLE RESPONSE

36. ANS: A, D, F
High-fiber foods, caffeine, spicy foods, and milk products are avoided with inflammatory bowel disease. B. C. E. These items can be safely consumed by the patient with inflammatory bowel disease.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

37. ANS: B, D, E
A major causative agent of colon cancer is lack of fiber in the diet, which prolongs fecal transit time and in turn prolongs exposure to possible carcinogens. Additional risk factors include a family history of colon cancer, ulcerative colitis, or polyps of the rectum or large intestine. A. C. F. These factors do not increase the risk for colon cancer.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

38. ANS: A, C, E
The patient should be encouraged to establish a time for defecation each day. The patient should increase the intake of fiber and drink water in the morning and throughout the day. D. Placing feet on a footstool to promote flexion of the hips aids defecation. F. Enemas and rectal suppositories are used only in extreme cases and are discontinued when an acute episode is resolved. B. Vitamin K does not help with constipation.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application

39. ANS: A, B, E
The patient should empty the pouch before it is less than half full, use a deodorant spray in the pouch, and check the stoma seal after showering. D. Ostomy patients receive a soft diet initially, progressing to a general diet as the surgeon prescribes. Stringy, high-fiber foods are avoided initially. C. Lack of stool could indicate a blockage and should be reported. F. Pouches are changed as needed, from every 3 days to every 14 days.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Analysis

40. ANS: B, D, E
This medication does not cause photosensitivity. The medication should be taken as prescribed in the morning and not stopped when the patient feels better. A. Grapefruit juice should be avoided. C. The medication should be swallowed whole. F. Mood swings or weight gain may be noted with the medication.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Analysis

41. ANS: A, B, D, E
Foods that can cause ileostomy blockage include celery, apples, dried fruits, and mushrooms. C. F. Potatoes and chicken are not identified as causing ostomy blockages.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

42. ANS: A, C, E
Research supports the use of the Flexi-Seal Management Systema soft silicone tube with a low-pressure balloon at the end inserted into the rectum. Stool cultures are appropriate to identify the presence of an infectious agent. Protective barrier cream is recommended to protect the skin from digestive enzymes. F. NG tube to suction is not necessary, although bowel rest with NPO status may be ordered. D. Baby powder will not promote healing or protect the skin. B. Antibiotics will not be ordered until stool specimen results indicate an infectious agent.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

43. ANS: A, B, C
Indications for medical intervention related to diarrhea include large volumes of stool; severe abdominal cramping; bloody stool; protracted duration of diarrhea; systemic symptoms such as fever; or history of a medical condition in which fasting, dehydration, or infection are hazardous. E. Oral intake of 3 L in 24 hours is sufficient to prevent dehydration. D. The listed blood pressure is stable. F. While weight loss is concerning, 1 pound in a week is not overly concerning.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

44. ANS: B, D
Chronic laxative use should be discontinued. Bulk-forming agents such as psyllium (Metamucil) or stool softeners such as docusate sodium (Colace) should be used instead of laxatives. Enemas and rectal suppositories are used only in extreme cases and are discontinued when an acute episode is resolved. Methylnaltrexone (Relistor) given subcutaneously treats opioid-induced constipation for patients receiving palliative care when other laxatives have not been effective. It does not treat other forms of constipation.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

45. ANS: A, B, D, E
Dietary considerations for a patient with diverticulosis (without evidence of inflammation) include foods that are soft but high in fiber, such as prunes, raisins, and peas. Unprocessed bran can be added to soups, cereals, and salads to give added bulk to the diet. Fiber should be in-creased in the diet slowly to prevent excess gas and cramping. C. Cheese can cause constipation and should be avoided.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

46. ANS: A, B, D, E
Environmental agents such as pesticides, tobacco, radiation, and food additives may precipitate an exacerbation. Diet or psychological stress may trigger or worsen an attack of symptoms. C, There is no need for the patient to restrict fluids.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

47. ANS: A, B, E
Because the anus and sphincter are saved, stool still passes through the anus. A temporary ileostomy is created to allow the pouch to heal. . Several bowel movements per day occur. C. The stool is of soft consistency. D. An ileoanal pouch does not require an ostomy pouch to be worn.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

48. ANS: A, B, C, E
FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols. Foods that should be avoided on this diet include milk, pears, apples, and Brussels sprouts. D. Broccoli does not need to be avoided on this diet.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

Leave a Reply