Concept 14: Elimination My Nursing Test Banks

Concept 14: Elimination

Test Bank

MULTIPLE CHOICE

1. A patient who was diagnosed with senile dementia has become incontinent of urine. The patients daughter asks the nurse why this is happening. The best response by the nurse is:

a.

The patient is angry about the dementia diagnosis.

b.

The patient is losing sphincter control due to the dementia.

c.

The patient forgets where the bathroom is located due to the dementia.

d.

The patient wants to leave the hospital.

ANS: B

Anger, wanting to leave the hospital, and forgetting where the bathroom is really have no bearing on the urinary incontinence. The patient is incontinent due to the mental ability to voluntarily control the sphincter. This is happening because of the dementia.

REF: 141 OBJ: NCLEX Client Needs Category: Psychosocial Integrity

2. You are caring for a patient who has suffered a spinal cord injury. You are concerned about the patients elimination status. As the nurse, your primary concern is to

a.

speak with the patients family about food choices.

b.

establish a bowel and bladder program for the patient.

c.

speak with the patient about past elimination habits.

d.

establish a bedtime ritual for the patient.

ANS: B

Establishing a bowel and bladder program for the patient is a priority to be sure that adequate elimination is happening for the patient with a spinal cord injury. Speaking with the family to determine food choices is okay, but it is not the primary concern. Speaking with the patient to know past elimination habits does not apply, because the spinal cord injury changes elimination habits. Establishing a bedtime ritual does not apply to elimination.

REF: 139 OBJ: NCLEX Client Needs Category: Physiological Integrity

3. The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body?

a.

Large intestine

b.

Stomach

c.

Small intestine

d.

Pancreas

ANS: C

Most digestion takes place in the small intestine. The main function of the large intestine is water absorption. The pancreas contains digestive enzymes; the stomach secrets hydrochloric acid to assist with food breakdown.

REF: 140

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3 to 4 minutes. The patient asks the nurse why this is happening. The best response from the nurse would be which of the following?

a.

Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel.

b.

Some people have a slower bowel than others, and this is nothing to be concerned about.

c.

The foods you eat contribute to peristalsis, so you should eat more fiber in your diet.

d.

Bowel peristalsis is slow because you are not walking. Get more exercise during the day.

ANS: A

Anesthesia and pain medication used in conjunction with the surgery are affecting the peristalsis of the bowel. Having a slower bowel, eating certain food, or lack of exercise will not have a direct effect on the bowel.

REF: 141 OBJ: NCLEX Client Needs Category: Physiological Integrity

5. A primary prevention tool used for colon cancer screening is

a.

abdominal x-rays.

b.

blood, urea, and nitrogen (BUN) testing.

c.

serum electrolytes.

d.

occult blood testing.

ANS: D

Occult blood testing will reveal unseen blood in the stool, and this may signal a potentially serious bowel problem like colon cancer. BUN is used to evaluate kidney function. Serum electrolytes and abdominal x-rays are not related to colon cancer screening.

REF: 144 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.)

a.

Increase fiber intake.

b.

Increase water consumption.

c.

Decrease physical exercise.

d.

Refrain from alcohol.

e.

Refrain from smoking.

ANS: A, B

Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcohol and smoking have no direct effect on bowel movements.

REF: 143

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

2. When conducting a health history assessment, the nurse would want to know what important information about the patients elimination status? (Select all that apply.)

a.

Recent changes in elimination patterns

b.

Changes in color, consistency, or odor of stool or urine

c.

Time of day patient defecates

d.

Discomfort or pain with elimination

e.

List of medications taken by patient

f.

Patients preferences for toileting

ANS: A, B, D, E

Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Time of day is not important, nor is the patients preferences for toileting. They are personal preferences and do not affect elimination.

REF: 142 OBJ: NCLEX Client Needs Category: Physiological Integrity

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