Chapter 33: Management of Clients with Intestinal Disorders Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 33: Management of Clients with Intestinal Disorders

MULTIPLE CHOICE

1. The nurse caring for a client with an intestinal malignancy assesses for bleeding, which would most likely be manifested by

a.

abdominal discomfort.

b.

hematemesis.

c.

hematochezia.

d.

hypotension.

ANS: C

Bleeding may be caused by trauma, ulceration, inflammation, or a growth that erodes through a blood vessel. The usual manifestation is blood in the stool (hematochezia) rather than in the vomitus (hematemesis). Hypotension would be a late sign of bleeding.

DIF: Comprehension/Understanding REF: p. 702 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

2. The nurse caring for a client with abdominal distention and vomiting that is fecal in nature should conduct further assessment aimed at discovering

a.

a distal, small intestinal obstruction.

b.

gastric ulceration.

c.

gastrointestinal (GI) bleeding.

d.

ulceration of the esophagus.

ANS: A

Vomiting that contains fecal material usually indicates a distal obstruction in the small intestine.

DIF: Application/Applying REF: p. 716 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

3. The nurse taking the history of an 80-year-old woman diagnosed with gastroenteritis would recognize that the most significant factor in determining potential for complications in this client is

a.

age.

b.

family history.

c.

gender.

d.

prior bouts of gastroenteritis.

ANS: A

Most cases of gastroenteritis are temporarily disabling and self-limiting, with resolution in 1 to 5 days. However, gastroenteritis can be fatal in debilitated, older, or very young people. Dehydration is a common cause of death in these cases, and the elderly tend to be slightly dehydrated as a baseline.

DIF: Comprehension/Understanding REF: p. 681 OBJ: Assessment

MSC: Health Promotion and Maintenance Aging Process-Age Related Changes

4. Until a diagnosis is made, the nurse caring for a client being evaluated for acute appendicitis should treat pain and discomfort with

a.

comfort touch and reassurance.

b.

frequently changing the clients position.

c.

narcotic pain medication.

d.

warm compresses applied to the belly.

ANS: A

Comfort touch and reassurance can help a client cope and manage pain with or without pain medication. Pain medication would be withheld until a diagnosis of appendicitis is confirmed. Warm compresses or heat should not be applied as they may cause the appendix to rupture.

DIF: Application/Applying REF: p. 684 OBJ: Intervention

MSC: Physiological Integrity Basic Care and Comfort-Non-Pharmacological Comfort Interventions

5. A nurse is caring for a postoperative client who has developed peritonitis. An assessment finding that would require immediate action would be

a.

a decrease in blood pressure of more than 15 mm Hg.

b.

an increase in urine output of more than 300 ml/day.

c.

pulse deficit of more than 20 beats/minute.

d.

weight gain of more than 5 pounds.

ANS: A

Postoperatively, the nurse should closely monitor the client for development of postoperative complications (e.g., adult respiratory distress syndrome [ARDS], sepsis, shock) by changes in vital signs, immediately reporting any manifestations of sepsis (e.g., decrease/increase in temperature, decrease in blood pressure). A urine output of only 300 ml in 1 day is below normal for an adult (30-50 ml/hr). Pulse deficit and weight gain would not indicate a common postoperative complication.

DIF: Analysis/Analyzing REF: p. 686 OBJ: Assessment

MSC: Safe, Effective Care Environment Establishing Priorities

6. A client with ulcerative colitis has severe diarrhea. Further assessments by the nurse are aimed at early recognition of

a.

dehydration.

b.

hemorrhoids.

c.

metabolic alkalosis.

d.

nephrolithiasis.

ANS: A

Severe diarrhea can cause a loss of 500 to 17,000 ml of water in 24 hours.

DIF: Application/Applying REF: p. 689 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Fluid and Electrolyte Imbalances

7. A client with inflammatory bowel disease (IBD) takes sulfasalazine (Azulfadine) for management of manifestations. To counteract a side effect of this drug, the nurse would encourage the client to increase intake of

a.

any citrus fruits.

b.

bananas and apples.

c.

fish and seafood.

d.

peas and beans.

ANS: D

Peas and beans are rich in folic acid. Folic acid absorption may be impaired in the client taking sulfasalazine. Fruits and seafoods are not good sources of folic acid.

DIF: Analysis/Analyzing REF: p. 690 OBJ: Intervention

MSC: Health Promotion and Maintenance Self Care

8. A client is admitted with dysentery caused by Clostridium difficile, or pseudomembranous colitis. To elicit the most helpful information about the cause of the dysentery, the nurse would ask the client

a.

Are you taking any antibiotics?

b.

Do you ever go barefoot outside your home?

c.

Does anyone else in your family have bowel problems?

d.

Have you traveled in any foreign countries lately?

ANS: A

Infection with C. difficile is a bacterial dysentery often seen in clients who have been receiving large doses of antibiotics or who have taken antibiotics over a long period.

DIF: Comprehension/Understanding REF: p. 680 OBJ: Assessment

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Adverse Effects

9. A client is admitted with appendicitis and is awaiting surgery. The client states, Now instead of pain in just one spot, the pain is kind of all over my abdomen. Which action by the nurse takes priority?

a.

Assess the clients abdomen.

b.

Get a set of vital signs.

c.

Call the physician.

d.

Prepare the client for another x-ray.

ANS: A

A complication of appendicitis is rupture. Any change in pain warrants a further assessment of the client. Pain that goes from more localized to generalized throughout the abdomen is characteristic of rupture. An abdominal exam may reveal a hard, board-like abdomen, which is further evidence of rupture. This information is vital to give the physician.

DIF: Application/Applying REF: p. 684 OBJ: Assessment

MSC: Safe, Effective Care Environment Establishing Priorities

10. In caring for a client with peritonitis from inflamed diverticuli, the nurse should assign priority to assessing

a.

bowel sounds.

b.

intake and output.

c.

neurologic status.

d.

vital signs.

ANS: A

Assessment of bowel signs is a priority because paralytic ileus can develop suddenly from the inflammation. Vital signs and intake and output are important as well, but not as high a priority.

DIF: Analysis/Analyzing REF: p. 685 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

11. A 13-year-old client with ulcerative colitis says, I am so glad I will grow out of this disease. Its so embarrassing at school. Which action by the nurse would best address this statement?

a.

Ask the client to explain what he/she means.

b.

Encourage the client to become active in school activities or sports.

c.

Review the pathophysiology of ulcerative colitis.

d.

Tell the client about other people who live successfully with the disease.

ANS: A

Ulcerative colitis, a progressive inflammatory process involving contiguous portions of the bowel, has remissions and exacerbations, and physical exertion and fatigue can bring on an attack. Clients do not outgrow ulcerative colitis; surgical intervention is the only cure. Exploring the statement further can direct the nurse to provide more helpful information and can elicit coping mechanisms.

DIF: Application/Applying REF: p. 689 OBJ: Assessment

MSC: Psychosocial Integrity Therapeutic Communication

12. In counseling a client with ulcerative colitis for 25 years about health maintenance plans, the nurse would include the advice that the client should

a.

avoid red meat.

b.

obtain genetic counseling.

c.

reduce physical exercise.

d.

schedule regular proctoscopic examinations.

ANS: D

Cancer of the colon is more common among clients with ulcerative colitis than in the general population. The other three options are not relevant to the health maintenance of a client with ulcerative colitis.

DIF: Application/Applying REF: p. 688 OBJ: Intervention

MSC: Health Promotion and Maintenance Health Screening

13. In caring for a client with Crohns disease and the nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements related to diarrhea, the nurse would plan to observe for

a.

bradycardia.

b.

increased urine output.

c.

increasing blood pressure.

d.

manifestations of anemia.

ANS: D

The client may have associated nutritional deficiencies, weight loss, anorexia, pain, anemia, debility, fatigue, and mental disturbances.

DIF: Application/Applying REF: p. 690 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

14. A client with Crohns disease is recovering from a fourth bowel resection and is being dismissed. The nurse determines that teaching goals have been met when the client indicates that s/he will watch for manifestations of

a.

chronic constipation.

b.

fatigue and weakness.

c.

Heberdens nodules.

d.

malabsorption syndrome.

ANS: D

Malabsorption syndrome occurs because the shortened bowel does not have adequate length to absorb intestinal fluids, causing watery stools. After four bowel resections, this is potentially a major complication. Fatigue and weakness do accompany Crohns disease, but malabsorption is a specific risk associated with this many bowel resections.

DIF: Evaluation/Evaluating REF: p. 694 OBJ: Evaluation

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

15. A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir (J pouch). What information should the nurse include in this clients teaching plan?

a.

The client will need an easily removable appliance.

b.

The client will need to plan for a daily irrigation.

c.

The stool will be expelled through the rectum eventually.

d.

The transverse loop ostomy will be temporary.

ANS: D

The ileal pouchanal anastomosis (also known as the J pouch) prevents the need for an ostomy and preserves the rectal sphincter muscle. The rectal mucosa is excised and the colon removed. An ileoanal reservoir is then created in the anal canal, and a temporary loop ostomy is formed. After healing has taken place, the ileostomy is reversed and stool drains into the reservoir.

DIF: Application/Applying REF: pp. 693-694 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

16. For a client who has returned to the nursing unit after creation of a continent ileostomy (Kock pouch), the action the nurse would include in the plan of care is

a.

attach the catheter to straight drainage initially for several days.

b.

irrigate the pouch daily with sterile solutions only.

c.

provide a permanent appliance and assist the client in application.

d.

restrict oral intake until ileal drainage is profuse.

ANS: A

During the surgical formation of the Kock pouch, an evacuation catheter is inserted. A skin barrier and special gauze dressing are then applied to hold the catheter in an upright position to avoid stress on the healing nipple valve. It is imperative to avoid distention of the ileostomy reservoir in the early postoperative period because of the pressure that distention would put on the suture line. Thus the Kock pouch is attached to straight drainage initially for several days, then emptied every 2 hours for about 2 weeks.

DIF: Application/Applying REF: p. 698 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

17. To help a client with a new ostomy integrate its appearance into the clients body image, the home health nurse would

a.

discourage the clients negative remarks about the stoma.

b.

discuss clothing options that will hide the appliance.

c.

limit family interaction in the clients stomal care.

d.

use humor and jokes regarding the ostomy.

ANS: B

The approach to integrate ostomies into body image should include using correct terminology for stoma and appliances, encouraging the venting of feelings about the ostomy, examining clothing options, and using helpful family responses. Discouraging client remarks is not using best therapeutic communication techniques. Family interaction may be helpful in client acceptance. Judicious use of humor may be helpful in the health care setting; however, without a thorough assessment of the client and a good relationship, humor and jokes may well make the client feel worse.

DIF: Application/Applying REF: p. 695 OBJ: Intervention

MSC: Psychosocial Integrity Coping Mechanisms

18. The nurse is instructing a client with a new colostomy on its care and notes that the stoma is large and dusky. The most appropriate nursing intervention at this time is to

a.

assess the clients reaction to the ostomy site.

b.

assist the client to irrigate the colostomy.

c.

notify the surgeon immediately.

d.

reassure the client that the stoma will decrease in size.

ANS: C

The nurse should assess the clients stoma closely. The stoma should be red and moist. If it becomes dark or dusky, the nurse must report this to the surgeon immediately as this probably represents ischemia.

DIF: Application/Applying REF: p. 695 OBJ: Intervention

MSC: Safe, Effective Care Environment Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

19. A client recovering from a recent colostomy is very reluctant to participate in self-care. To initiate the clients interaction, the nurse should

a.

allow care to be deferred until the client will participate.

b.

evaluate the level to which the client can tolerate participation.

c.

insist the client become involved in self-care.

d.

provide the client with a mirror to observe the stoma.

ANS: B

The nurse should carefully assess the clients physical condition and emotional and mental attitude toward the colostomy before attempting to teach ostomy self-care. Teaching is paced according to the clients level of acceptance of the colostomy and the clients ability to manage it.

DIF: Application/Applying REF: p. 695 OBJ: Assessment

MSC: Psychosocial Integrity Coping Mechanisms

20. When a client is admitted to the emergency department with a hernia, the classification of hernia that would represent a surgical emergency is

a.

incisional.

b.

inguinal.

c.

reducible.

d.

strangulated.

ANS: D

Incarcerated hernias usually become strangulated. This situation is a surgical emergency because unless the bowel is released, it soon becomes gangrenous from a lack of blood supply. An incisional hernia is one occurring at a surgical site, most often in clients with poor wound healing. A reducible hernia can be replaced into the abdominal cavity.

DIF: Knowledge/Remembering REF: p. 710 OBJ: N/A

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

21. For an 83-year-old client admitted with obstruction of the large bowel, the nurses most significant assessment during the nursing history in regard to development of an obstruction would be

a.

advanced age.

b.

poor appetite.

c.

previously treated colon cancer.

d.

well-controlled diabetes.

ANS: C

In the large bowel, cancer is the chief cause of obstruction.

DIF: Comprehension/Understanding REF: p. 714 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

22. In caring for a client who is vomiting fecal material, the nurse should place the highest priority on which action?

a.

Administering parenteral fluids that contain electrolytes

b.

Encouraging the client to take small sips of water

c.

Giving the client frequent oral hygiene

d.

Preparing the client for surgery

ANS: A

This client probably has a small bowel obstruction. In the client with small bowel obstruction, the nurse should maintain good fluid balance by carefully replacing fluid and electrolytes and should administer parenteral fluids, adding sodium chloride, bicarbonate, and potassium as ordered. The priority nursing diagnosis is Deficient Fluid Volume. The client should be maintained on bowel rest (NPO). Surgery is a last resort if decompression does not relieve the obstruction. Frequent oral hygiene is certainly indicated for this client, but is not as high a priority as maintaining fluid and electrolyte balance.

DIF: Analysis/Analyzing REF: p. 717 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

23. In advising a client on the care of an anal fissure caused by chronic constipation, the home health nurse would focus on

a.

avoiding long, hot baths.

b.

cleansing with peroxide after each bowel movement.

c.

keeping stools small by limiting fluid intake.

d.

the importance of a daily bowel movement.

ANS: D

It is important that the client with an anal fissure have a soft bowel movement daily, ease discomfort with warm sitz baths and anesthetic suppositories, and clean the anus with warm water.

DIF: Comprehension/Understanding REF: p. 722 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

24. A client with an ostomy is irrigating it with about 500 ml of warm tap water and is holding the irrigating container about 36 inches above the stoma. Which nursing diagnosis best fits this situation?

a.

Constipation

b.

Effective management of therapeutic regimen

c.

Enhanced individual coping

d.

Knowledge deficit

ANS: D

Using 500 to 1000 ml of warm tap water, the solution container should be suspended about 18 inches. This client needs further education.

DIF: Comprehension/Understanding REF: Client Education Guide, Evolve site

OBJ: Diagnosis MSC: Health Promotion and Maintenance Self Care

25. A nurse is caring for several clients. One client needs ostomy care. The nurse delegates ostomy care to the unlicensed assistive personnel for the client who

a.

has had the ostomy for several years, but whose arthritis makes self-care difficult.

b.

is afraid to touch the ostomy, causing the nurse to be frustrated and short-tempered.

c.

underwent ostomy surgery 3 days ago and has been stable with a red stoma.

d.

uses multiple brands and sizes of appliances and pouches.

ANS: A

An unlicensed assistive personnel can appropriately perform uncomplicated ostomy care on the stable, long-term ostomate. The RN should do this care on a client with a fresh ostomy in order to perform vital assessments and teaching.

DIF: Analysis/Analyzing REF: p. 696 OBJ: Planning

MSC: Safe, Effective Care Environment Management of Care-Delegation

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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