Chapter 46: Bowel Elimination Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank

MULTIPLE CHOICE

1. Which of the following would the nurse expect as a normal change in the bowel elimination as a person ages?

1.

Absorptive processes are increased in the intestinal mucosa.

2.

Esophageal emptying time is increased.

3.

Changes in nerve innervation and sensation cause diarrhea.

4.

Mastication processes are less efficient.

ANS: 4

An expected change in bowel elimination is decreased chewing and decreased salivation, resulting in less efficient mastication. There is decreased nutrient absorption of the small intestine in the older adult. Esophageal emptying slows, as a result of reduced motility, especially in the lower third of the esophagus. With decreased peristalsis and weakened musculature, the older adult is more prone to constipation. Duller nerve sensations may place the older adult at increased risk for fecal incontinence.

DIF: A REF: 1177 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

2. An 8-month-old infant is hospitalized with severe diarrhea. The nurse knows that the major problem associated with severe diarrhea is:

1.

Pain in the abdominal area

2.

Electrolyte and fluid loss

3.

Presence of excessive flatus

4.

Irritation of the perineal and rectal area

ANS: 2

Excess loss of colonic fluid because of diarrhea can result in serious fluid and electrolyte or acid-base imbalances. Infants and older adults are particularly susceptible to associated complications. Pain from abdominal cramping may occur with diarrhea, but it is not the major problem associated with severe diarrhea. Excessive flatus is not the major problem associated with severe diarrhea. Because repeated passage of diarrhea stools exposes the skin of the perineum and buttocks to irritating intestinal contents, meticulous skin care and containment of fecal drainage are needed to prevent skin breakdown. The greatest danger of severe diarrhea is a fluid and electrolyte or acid-base imbalance.

DIF: A REF: 1180 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

3. A 50-year-old male client is having a screening colonoscopy. The nurse instructs the client that:

1.

No special preparation is required

2.

Light sedation is normally used

3.

No metallic objects are allowed

4.

Swallowing of an opaque liquid is required

ANS: 2

Light sedation is required for a colonoscopy. Special preparation is required before a colonoscopy. Clear liquids are given the day before and then some form of bowel cleanser, such as GoLytely, is administered. Enemas until clear may also be ordered. There is no restriction of metallic objects for a colonoscopy, not does it require swallowing an opaque liquid.

DIF: A REF: 1178 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

4. A client is to have a stool test for occult blood. The nurse is instructing the nursing assistant in the correct procedure for the test. The nursing assistant is correctly informed that:

1.

Sterile technique is used for collection

2.

Stool should be collected over a 3-day period

3.

The specimen should be kept warm

4.

A 1-inch sample of formed stool is needed

ANS: 4

Tests performed by the laboratory for occult blood in the stool and stool cultures require only a small sample. The nurse uses clean technique to collect about 1 inch of formed stool or 15 to 30 mL of liquid stool. Unlike testing for occult blood, tests for measuring the output of fecal fat require a 3- to 5-day collection of stool, and tests that measure for ova and parasites require the stool to be warm.

DIF: A REF: 1188 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

5. A client who recently underwent surgery and now has a colostomy is correctly instructed by the nurse that for the next few weeks the clients diet will include foods such as:

1.

Vegetables

2.

Fresh fruit

3.

Whole grain breads

4.

Poached eggs and rice

ANS: 4

During the first weeks after surgery, many health care providers recommend low-fiber diets because the bowel requires time to adapt to the diversion. Low-fiber foods include bread, noodles, rice, cream cheese, eggs (not fried), strained fruit juices, lean meats, fish, and poultry. Poached eggs and rice would be appropriate for this client. After the ostomy heals, the client is allowed to eat whole grains, fruits, and vegetables. High-fiber foods such as fresh fruits and vegetables help ensure a more solid stool needed to achieve success at irrigation. Ostomy clients may benefit from avoiding foods that cause gas and odor, including broccoli, cauliflower, dried beans, and Brussels sprouts.

DIF: A REF: 1210 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

6. The client has been admitted to an acute care unit with a diagnosis of biliary disease. The nurse suspects that the feces will appear:

1.

Bloody

2.

Pus filled

3.

Black and tarry

4.

White or clay colored

ANS: 4

Stool that is white or clay colored indicates an absence of bile. Bloody feces is not an indication of biliary disease. Pus-filled feces indicate infection. Black or tarry feces may indicate upper gastrointestinal (GI) bleeding or iron ingestion.

DIF: A REF: 1188-1190 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

7. The client asks the nurse to recommend bulk-forming foods that may be included in the diet. Which of the following should be recommended by the nurse?

1.

Whole grains

2.

Fruit juice

3.

Rare meats

4.

Milk products

ANS: 1

Bulk-forming foods, such as grains, fruits, and vegetables, absorb fluids and increase stool mass. Fruit juice, rare meats, and milk products are not bulk-forming foods.

DIF: A REF: 1177 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

8. The client is taking medications to promote defecation. Which of the following instructions should be included by the nurse in the teaching plan for this client?

1.

Increased laxative use often causes hyperkalemia.

2.

Salt tablets should be taken to increase the solute concentration of the extracellular fluid.

3.

Emollient solutions may increase the amount of water secreted into the bowel.

4.

Bulk-forming additives may turn the urine pink.

ANS: 3

Emollient solutions are stool softeners that may increase the amount of water secreted into the bowel. Laxative overuse can cause serious diarrhea that can lead to dehydration and hypokalemia. Salt tablets should not be taken to increase the solute concentration of extracellular fluid. Bulk-forming additives do not turn the urine pink. Phenolphthalein or danthron stimulant cathartics (e.g., Doxidan, Correctol, Ex-Lax) may cause pink or red urine.

DIF: A REF: 1198 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

9. While undergoing a soapsuds enema, the client complains of abdominal cramping. The nurse should:

1.

Immediately stop the infusion

2.

Lower the height of the enema container

3.

Advance the enema tubing 2 to 3 inches

4.

Clamp the tubing

ANS: 2

The nurse should lower the container if the client complains of abdominal cramping. Cramping may prevent the client from retaining all of the fluid, which would alter the effectiveness of the enema. If the nurse stops the infusion, the client will not receive all of the fluid, and the enema will be less effective. The nurse may slow the infusion until the abdominal cramping passes. The enema tubing should not be advanced further. The tubing may be clamped temporarily if fluid escapes around the rectal tube. The instillation should be slowed in the instance of abdominal cramping.

DIF: B REF: 1202 OBJ: Application

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

10. A nurse who is caring for postoperative clients on a surgical unit knows that for 24 to 48 hours postoperatively, clients who have undergone general anesthesia may experience:

1.

Colitis

2.

Stomatitis

3.

Paralytic ileus

4.

Gastrocolic reflex

ANS: 3

Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. This condition, called paralytic ileus, usually lasts about 24 to 48 hours. Colitis is inflammation of the colon. Stomatitis is inflammation of the mouth. The gastrocolic reflex is the peristaltic wave in the colon induced by entrance of food into the stomach. Colitis, stomatitis, and gastrocolic reflex are not caused by anesthetic used during surgery.

DIF: A REF: 1178 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

11. For clients with hypocalcemia, the nurse should implement measures to prevent:

1.

Gastric upset

2.

Malabsorption

3.

Constipation

4.

Fluid secretion

ANS: 3

Disorders of calcium metabolism contribute to difficulty with the passage of stools. The nurse should implement measures to prevent constipation in clients with hypocalcemia. Gastric upset, malabsorption, and fluid secretion are not caused by hypocalcemia.

DIF: A REF: 1179 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

12. The client is to receive a Kayexalate enema. The nurse recognizes that this is used to:

1.

Prevent further constipation

2.

Remove excess potassium from the system

3.

Reduce bacteria in the colon before diagnostic testing

4.

Provide direct antidiarrheal medication to the intestine

ANS: 2

Kayexalate is a type of medicated enema used to treat clients with dangerously high serum potassium levels. This drug contains a resin that exchanges sodium ions for potassium ions in the large intestine. Kayexalate enemas are not used to treat or prevent constipation, and Kayexalate is not a diarrheal medication. Neomycin enemas, not Kayexalate enemas, may be used to reduce bacteria in the colon before diagnostic testing.

DIF: A REF: 1197 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

13. The appropriate amount of fluid to prepare for an enema to be given to an average-size school-age child is:

1.

150 to 250 mL

2.

250 to 350 mL

3.

300 to 500 mL

4.

500 to 750 mL

ANS: 3

The appropriate amount of fluid to prepare for an enema to be given to an average-size school-age child is 300 to 500 mL. An infant should receive 150 to 250 mL, a toddler should receive 250 to 350 mL, and an adolescent should receive 500 to 750 mL.

DIF: A REF: 1200 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

14. A client has undergone intestinal surgery and now has an incontinent ostomy. The use of which of the following products by the client indicates that the discharge learning goals have been achieved?

1.

A powder for a yeast infection

2.

Peroxide to toughen the peristomal skin

3.

A commercial deodorant around the stoma

4.

Alcohol to cleanse the stoma

ANS: 1

If a yeast infection occurs, thorough cleansing should be performed, followed by patting the area dry and applying a prescribed topical agent, such as triamcinolone acetonide (Kenalog) spray or nystatin (Mycostatin), to the affected region. The peristomal skin should be cleansed gently with warm tap water using gauze pads or a clean washcloth. An ostomy deodorant may be placed into the pouch, not around the stoma. Alcohol should not be used to clean the stoma. The area may be cleaned with warm tap water.

DIF: A REF: 1217 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

15. Which of the following is an appropriate nursing intervention for a client with a nasogastric tube in place?

1.

Tape the tube up and around the ear on the side of insertion.

2.

Secure the tubing to the bed by the clients head.

3.

Mark the tube where it exits the nose.

4.

Change the tubing daily.

ANS: 3

Once placement is confirmed, a mark should be placed, either making a red mark or using tape, on the tube to indicate where the tube exits the nose. The mark or tube length is to be used as a guide to indicate whether displacement may have occurred. The tube should be taped to the nose, not to the ear. The tubing should be secured to the clients gown, not the bed. The tubing should not be changed daily, but it should be irrigated daily.

DIF: A REF: 1208 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

16. The nurse instructs the client that before the fecal occult blood test (FOBT) she may eat:

1.

Whole wheat bread

2.

A lean, T-bone steak

3.

Veal

4.

Salmon

ANS: 1

Whole wheat bread may be eaten before a fecal occult blood test. A lean, T-bone steak may cause false-positive results if eaten before a fecal occult blood test. Veal may cause false-positive results if eaten before a fecal occult blood test. Salmon may cause false-positive results if eaten before a fecal occult blood test.

DIF: A REF: 1188 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

17. The nurse is discussing arteriosclerosis and the effects it has on the body with an older adult client. Although the most commonly recognized effect is on the cardiovascular system, the nurse should include which of the following statements regarding its effect on the gastrointestinal system to complete the discussion?

1.

Circulatory problems make getting to the bathroom easily problematic.

2.

The benefit you get from your food is also decreased by this condition.

3.

The aging process that causes the vascular problems also causes elimination problems.

4.

The problem it creates with blood flow also affects blood flow to the bowels and so affects elimination.

ANS: 4

Systemic changes in the function of digestion and absorption of nutrients result from changes in older clients cardiovascular and neurological systems, rather than their gastrointestinal system. For example, arteriosclerosis causes decreased mesenteric blood flow, thus decreasing absorption from the small intestine.

DIF: C REF: 1177 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

18. Which of the following statements made by an older adult reflects the best understanding of the role of fiber regarding bowel patterns?

1.

The more fiber I eat, the fewer problems I have with my bowels.

2.

Whole grain cereal and toast for breakfast keeps my bowels moving regularly.

3.

My wife makes whole grain muffins; they are really good and good for me too.

4.

I use to have trouble with constipation until I started taking a fiber supplement.

ANS: 2

The bowel walls are stretched, creating peristalsis and initiating the defecation reflex. By stimulating peristalsis, bulk foods pass quickly through the intestines, keeping the stool soft. Ingestion of a high-fiber diet improves the likelihood of a normal elimination pattern if other factors are normal. The other options are not as specific about the role of fiber, or they fail to provide an example of a high-fiber food.

DIF: C REF: 1177 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

19. Which of the following statements made by an older adult reflects the best understanding of the role of fiber regarding good bowel health?

1.

Fiber is very effective at cleaning out the bowels.

2.

A high-fiber diet results in softer bowel movements.

3.

Passing hard, dry stool is more uncomfortable and harder on the bowels.

4.

The more fiber there is in my diet, the less risk I have of developing polyps.

ANS: 4

When there is no fiber to transport waste matter through the colon, it increases the risk for polyps. Although the other options are not incorrect, they do not address the most important barrier to good bowel health.

DIF: C REF: 1177 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

20. The nurse is discussing food allergies with a group of mothers whose children are allergy prone. Which of the following statements made by the nurse best describes lactose intolerance?

1.

If milk causes diarrhea, cramps, or gas, it might be an intolerance of lactose.

2.

You dont have to be allergic to dairy for it to cause you problems.

3.

Allergies to milk can be very dangerous, even life threatening.

4.

Many children outgrow their intolerance of dairy lactose.

ANS: 1

Food intolerance is not an allergy, but a particular food that causes the body distress within a few hours of ingestion. The result is diarrhea, cramps, or flatulence. For example, people who drink cows milk who have these symptoms are not allergic to milk but lack the enzyme needed to digest the milk sugar lactose; they are lactose intolerant.

DIF: C REF: 1177 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

21. The nurse is discussing food allergies with a group of mothers whose children are allergy prone. Which of the following statements made by a mother best describes lactose intolerance?

1.

My child is allergic to milk; it makes her very gassy.

2.

Dairy products require a special enzyme to be digested properly.

3.

Being lactose intolerant means my child cant tolerate dairy products.

4.

My child gets diarrhea from dairy products because she cant digest lactose.

ANS: 4

Food intolerance is not an allergy, but a particular food that causes the body distress within a few hours of ingestion. The result is diarrhea, cramps, or flatulence. For example, people who drink cows milk who have these symptoms are not allergic to milk but lack the enzyme needed to digest the milk sugar lactose; they are lactose intolerant. To be lactose intolerant (exhibiting the signs after ingesting dairy products) does not constitute a dairy allergy. The remaining options are not as specific as the answer.

DIF: C REF: 1177 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

22. An adult client reports to the nurse that she has been experiencing constipation recently and is interested in any suggestions regarding dietary changes she might make. Which of the following suggestions provided by the nurse is most likely to minimize the clients complaint?

1.

Have you tried foods like prunes and bran?

2.

You might find the new flavored bulk laxatives helpful.

3.

What have you tried in the past that hasnt been helpful?

4.

Increase your fluid intake; have some juice with breakfast.

ANS: 4

Unless there is a medical contraindication, an adult needs to drink six to eight glasses (1500 to 2000 mL) of noncaffeinated fluid daily. An increase in fluid intake with the use of fruit juices softens stool and increases peristalsis. Poor fluid intake increases the risk for constipation because of reabsorption of fluid in the colon, resulting in hard, dry stools. Although some of the options are food related, they are not as direct; a laxative is not a dietary change.

DIF: C REF: 1178 OBJ: Analysis

TOP: Nursing Process: Physiological Integrity/Basic Care and Comfort/Elimination

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

23. A client who is 2 days postoperative reports feeling constipated to the nurse. The client has good bowel sounds in all four quadrants and has tolerated liquids well. Her pain is being controlled with an opioid analgesic. Which of the following interventions should the nurse try initially?

1.

Let me get you some apple juice.

2.

Ambulating may get your bowels moving.

3.

Ill see about getting a different pain medication.

4.

Your health care provider might prescribe an enema if I call.

ANS: 1

An increase in fluid intake with the use of fruit juices softens stool and increases peristalsis. The remaining interventions are not inappropriate, but they are not the initial intervention for such a complaint.

DIF: B REF: 1178 OBJ: Application

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

24. Which of the following statements by a client reporting constipation reflects the most informed understanding of interventions that will aid in assuming proper bowel mobility?

1.

Could it be that I need to get more exercise, even here in the hospital?

2.

Is it true that drinking coffee often helps stimulate the bowels to work?

3.

I guess a little high-fiber cereal might help. Can you get me some from the cafeteria?

4.

May I have a cup of decaffeinated tea in addition to my breakfast juice? That usually helps.

ANS: 4

Unless there is a medical contraindication, an adult needs to drink six to eight glasses (1500 to 2000 mL) of noncaffeinated fluid daily. An increase in fluid intake with the use of fruit juices softens stool and increases peristalsis. Poor fluid intake increases the risk for constipation because of reabsorption of fluid in the colon, resulting in hard, dry stools. Although the other options are not incorrect, the client does not seem to have past experience with these suggestions.

DIF: C REF: 1177-1178 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

25. A client is caring for her husband who recently experienced a cerebral vascular accident. She tells the home care nurse that she has been very anxious lately about all the added responsibilities. She adds that she has not been sleeping well and has had several bouts of diarrhea. Which of the following statements by the nurse focuses on the most likely cause of the gastrointestinal problem?

1.

Have you experienced increased gas and cramping in addition to the diarrhea?

2.

You are under a lot of stress; that can affect your bowels and result in diarrhea.

3.

I suggest you get some over-the-counter medication and keep it on hand to manage those bouts.

4.

Have you been eating a well-balanced diet since you brought your husband home?

ANS: 2

During emotional stress the digestive process is accelerated, and peristalsis is increased. Side effects of increased peristalsis are diarrhea and gaseous distention. The remaining options are focused on the most likely cause of the problem, or they are focused on treatment, not cause.

DIF: C REF: 1178 OBJ: Analysis

TOP: Nursing Process: Analysis

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

26. A client is caring for her daughter, who recently suffered multiple fractures in an automobile accident. The client tells the home care nurse that she has been really down since all this happened. She adds that she has been constipated and not really interested in eating. Which of the following statements by the nurse focuses on the most likely cause of the gastrointestinal problem?

1.

Actually, how long have you been constipated?

2.

Are you eating fiber-rich foods like fruit and whole grains?

3.

You may be depressed; emotional depression can cause constipation.

4.

I suggest you get some over-the-counter mild laxative and see if that helps.

ANS: 3

If a person becomes depressed, the autonomic nervous system slows impulses, and peristalsis decreases, resulting in constipation. Although the other options are not incorrect, they are not the most likely cause for this particular client.

DIF: C REF: 1178 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

27. A 70-year-old client is discussing his recent difficulty with having regular bowel movements while on a cross-country bus tour with a senior citizens group. Which of the following assessment questions is directed toward the most likely cause of the problem?

1.

Did the bus stop frequently so you could get up and walk around?

2.

Did you eat enough fiber while you were on the trip?

3.

Do you find using public restrooms unsettling?

4.

Do you have any chronic bowel-related problems?

ANS: 3

Attempting to eliminate in a public restroom sometimes results in a temporary inability to defecate. This embarrassment may prompt clients to ignore the urge to defecate, which begins a vicious cycle of constipation and discomfort. Although the remaining options may affect bowel elimination, the situation of the scenario strongly suggests an emotional cause.

DIF: C REF: 1178 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

28. The nurse is caring for a 19-year-old male client with a fractured left femur whose leg was pinned 36 hours ago and is now in traction. Which of the following stressors is mostly likely the cause of this clients difficulty related to constipation?

1.

Pain related to the fracture and its repair

2.

Anxiety regarding the serious nature of the injury

3.

The need to defecate in an unfamiliar, awkward position

4.

Poor fluid intake after the accident and ensuing surgery

ANS: 3

For the client immobilized in bed, defecation is often difficult. In a supine position it is impossible to contract the muscles used during defecation. If the clients condition permits, raise the head of the bed; this assists the client to a more normal sitting position on a bedpan, enhancing the ability to defecate. Although the other options may have some effect, the primary cause is most likely the emotional stress of not being able to assume the usual position for defecation.

DIF: C REF: 1178 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

29. A client who was recently diagnosed with anemia and rheumatoid arthritis reports to the nurse that she has noticed that her stool is black, and she is concerned because there is a history of colon cancer in her family. Which of the following assessment questions is most likely to provide information regarding this clients bowel problem?

1.

What medications are you currently on?

2.

When did you have your last colonoscopy?

3.

Does the arthritis severely impair your mobility?

4.

Would you like to have the stool tested for occult blood?

ANS: 1

Ingestion of iron, commonly prescribed for certain types of anemia, causes discoloration of the stool (black), nausea, vomiting, constipation (diarrhea is less commonly reported), and abdominal cramps. The remaining options, although focusing on aspects of function that could result in constipation, are not focused on the most likely cause in this scenario.

DIF: C REF: 1190 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

30. Which of the following statements made by a nurse discussing the effect of an antibiotic on the gastrointestinal system reflects the best understanding of the possible occurrence of diarrhea?

1.

The GI tract naturally rids itself of bacterial toxins by increasing peristalsis, and that causes diarrhea.

2.

The antibiotic is responsible for killing off the GI tracts normal bacterial, and diarrhea is the result.

3.

For some, antibiotics irritate the mucous lining of the intestines, causing decreased absorption and diarrhea.

4.

When you are taking an antibiotic, your body is fighting off an infection, and peristalsis is faster and so diarrhea occurs.

ANS: 2

Antibiotics inadvertently produce diarrhea by disrupting the normal bacterial flora in the GI tract. The remaining options are not necessarily true.

DIF: A REF: 1179 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

31. A client is reporting that the oral medication she was prescribed for her hypothyroidism does not seem to be helping. The client goes on to report that she has been experiencing tension-related headaches and constipation. She has been self-medicating with nonsteroidal antiinflammatory drugs (NSAIDs) and bulk laxatives. Which of the following assessment questions is most likely to provide information regarding this clients concern regarding her thyroid problem?

1.

How long have you taken Synthroid?

2.

What other medications are you currently on?

3.

How long have you been taking a bulk laxative?

4.

Have you developed any other gastrointestinal symptoms?

ANS: 3

Laxatives often influence the efficacy of other medications by altering the transit time (i.e., the time the medication remains in the GI tract and is available for absorption). The remaining options would have little bearing on the effectiveness of the hypothyroid medication unless the medication has not been taken long enough to reach therapeutic levels.

DIF: C REF: 1178 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

32. The nurse is assessing a cognitively impaired older adult client and observes a leaking of liquid stool from the rectum. The nurses initial intervention for this client is to:

1.

Determine if the client has been eating sufficiently, especially fiber-rich foods

2.

Determine how long it has been since the client had a normal-size, formed stool

3.

Perform a digital examination of the rectum to determine the presence of stool

4.

Call the health care provider to get a prescription for an antidiarrheal medication

ANS: 1

When a continuous oozing of diarrhea stool occurs, suspect impaction. The liquid portion of feces located higher in the colon seeps around the impacted mass. An obvious sign of impaction is the inability to pass a stool for several days, despite the repeated urge to defecate. The digital examination should be performed after it has been determined that the client has been without a normal bowel movement for several days. Although the remaining options are not inappropriate, they would not be the initial intervention.

DIF: B REF: 1179 OBJ: Application

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

33. The greatest risk for injury for a client who has fecal incontinence is:

1.

Perineal and rectal skin breakdown

2.

The contamination of existing wounds

3.

Falls resulting from attempts to reach the bathroom

4.

Cross-contamination into the upper gastrointestinal tract

ANS: 1

Fecal incontinence is a potentially dangerous condition in terms of contamination and risk for skin ulceration. The greatest risk to the otherwise healthy individual is skin breakdown. Although the other options may be risk factors, they are not as great as that of skin breakdown.

DIF: C REF: 1181 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

34. The nurse is providing ancillary personnel with instructions regarding the proper methods to implement when caring for a client with a Clostridium difficile infection. Which of the following practices will have the greatest impact on containment of the bacteria and thus prevention of cross-contamination?

1.

Frequent in-services on transmission modes of C. difficile

2.

Practice of proper hand hygiene by all staff

3.

Appropriate handling of contaminated linen

4.

Stool cultures on all suspected carriers

ANS: 2

Poor hand hygiene and erratic disinfection practices result in the transmission of C. difficile. Stool cultures are useful in the diagnosis, not the prevention, of C. difficile. Although the other options are appropriate, they do not have the most impact on preventing the spread of these bacteria.

DIF: C REF: 1180 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

35. Which of the following clients is at greatest risk for serious complications when using the Valsalva maneuver to expel feces?

1.

25-year-old pregnant client

2.

66-year-old male with hypertrophied prostate disease

3.

44-year-old male client with glaucoma

4.

53-year-old female with stomach cancer

ANS: 3

Clients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk, such as cardiac irregularities and elevated blood pressure, with this maneuver and need to avoid straining to pass the stool. Although the Valsalva maneuver may contribute to hemorrhoids, this is not as serious as increasing the intraocular pressure of a client with glaucoma. The Valsalva maneuver is not contraindicated in a client with hypertrophied prostate disease or in a client with stomach cancer.

DIF: A REF: 1179 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

36. The mother of an 18-month-old male client shares with the nurse that she is trying to get her child to tell her when he needs to have a bowel movement. Which of the following statements is the most appropriate response from the nurse?

1.

Im sure that you will be glad to have your son out of diapers.

2.

I once heard of a child who was totally potty-trained by the time he was a year old.

3.

Development of neuromuscular control of the bowels doesnt normally occur until a child is between 2 and 3 year of age.

4.

You will have to really be persistent about taking him to the bathroom frequently in order to be successful.

ANS: 3

Developmental changes affecting elimination occur throughout life. The infant is unable to control defecation because of a lack of neuromuscular development. This development usually does not take place until 2 to 3 years of age.

DIF: A REF: 1177 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

37. The 35-year-old pregnant client is concerned about constipation. When weighing the advantages and disadvantages of having a local anesthetic over a general anesthetic for a caesarian section, the nurse shares with the client that the local will cause less risk for constipation following surgery. The best reason that there is less constipation following this surgery is because:

1.

The client will not have to be allowed nothing by mouth (NPO) before surgery

2.

The client will be able to ambulate immediately following surgery

3.

The client will be able to eat following surgery

4.

Local or regional anesthetic often has little or no effect on bowel activity

ANS: 4

The client who receives a local or regional anesthetic is less at risk for elimination alterations because this often affects bowel activity minimally or not at all whereas general anesthetic agents used during surgery cause temporary cessation of peristalsis, which can result in constipation. The client will still need to remain NPO before a scheduled caesarian section in case she would need to receive a general anesthetic. The client will not be able to ambulate immediately after surgery because of loss of feeling in the lower extremities. Clients should be able to eat following nonbowel-related surgery whether or not they have undergone a general anesthetic or a local anesthetic.

DIF: A REF: 1178 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

38. A 44-year-old male client was placed on a daily low-dose aspirin regimen by his health care provider following a recent diagnosis of hypertension and periodic atrial fibrillation. The client is currently hospitalized with renal stones. As the nurse is admitting the client, he shares that he has been very tired. The nurse gathers additional data regarding his bowel habits. The client shares that he has recently had black, tarry stools. The nurse is most concerned that the client may have:

1.

Colon cancer

2.

A GI bleed from the aspirin therapy

3.

Ongoing atrial fibrillation

4.

Electrolyte imbalance

ANS: 2

Although the client could have any one of the items mentioned, it is most likely that the aspirin is causing a GI bleed. The loss of blood can cause the client to be fatigued. Aspirin is a prostaglandin inhibitor, which interferes with the formation and production of protective mucus and causes GI bleeding.

DIF: C REF: 1179 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

39. The nurse is counseling a 65-year-old female client on her use of mineral oil as a laxative. One of the most important things that the nurse can share with the client is how mineral oil can cause the decreased absorption of which of the following vitamins?

1.

Vitamin C

2.

Niacin

3.

Vitamin D

4.

Riboflavin

ANS: 3

Mineral oil, a common laxative, decreases fat-soluble vitamin absorption. Vitamin D is the only fat soluble vitamin listedthe others are all water-soluble.

DIF: A REF: 1178 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

40. An active 25-year-old female client shared with the nurse that ever since she had gone on a high-protein low-carbohydrate diet she had suffered from constipation. The client states that the diet is working for her in terms of weight loss and would like to stay on it. The best response from the nurse is that the client should try:

1.

Consuming more low-carbohydrate fiber-rich foods like broccoli, raspberries, blackberries, and asparagus

2.

Taking a laxative when feeling constipated

3.

Try a different diet with less tendency to cause constipation

4.

Exercise more

ANS: 1

A low-fiber diet high in animal fats (e.g., meats, dairy products, eggs) can slow peristalsis, leading to constipation. By consuming fiber-rich low-carbohydrate foods, the client can still maintain weight loss while avoiding constipation. The client could develop a dependence on laxatives by using them on a regular basis. The client has expressed a desire to remain on the diet she is currently on, and it seems to be working to help her lose weight. Because client is already active, additional activity is not likely to have a profound effect on relieving the constipation.

DIF: A REF: 1177 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

41. The nurse knows that the client receiving enteral feedings is at risk for diarrhea. One of the measures that the nurse can take to minimize the risk for diarrhea in this client is:

1.

Making sure to chill the canned feeding before administering

2.

Using strict sanitation when administering the formula

3.

Not deviating from the prescribed rate of delivery for the formula

4.

Not diluting or changing the strength of the prescribed formula

ANS: 2

Interventions to prevent diarrhea include the following: administer canned formulas at room temperature, follow strict sanitation when preparing the formula, increase the rate slowly, administer the volume at a rate tolerable to your client, or if using a hypertonic solution, give the initial feeding at half strength and gradually increase the volume to allow the client to adjust to a hypertonic solution. Consult a dietitian when diarrhea occurs.

DIF: A REF: 1180 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

42. Upon auscultation of the clients abdomen, the nurse hears hyperactive bowel sounds (greater than 35 per minute). The nurse knows that this can indicate which of the following?

1.

Paralytic ileus

2.

Fecal impaction

3.

Small intestine obstruction

4.

Abdominal tumor

ANS: 3

Absent (no auscultated bowel sounds) or hypoactive sounds (less than five sounds per minute) occur with paralytic ileus, such as after abdominal surgery. High-pitched and hyperactive bowel sounds (35 or more sounds per minute) occur with small intestine obstruction and inflammatory disorders.

DIF: A REF: 1187 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

43. The health care provider has ordered a stool specimen for ova and parasites from the 43-year-old male client. The nurse knows that when collecting the specimen the stool must be:

1.

Kept on ice

2.

Kept warm

3.

Collected using sterile technique

4.

Free from urine

ANS: 2

It is important to avoid delays in sending specimens to the laboratory. Some tests such as measurement for ova and parasites require the stool to be warm. The specimen need not be collected using sterile technique, because the laboratory will not be testing the sample for bacteria, but it should be collected with good sanitation practices. Likewise, a small amount of urine should not alter the test results.

DIF: A REF: 1188 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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