(59) A nurse is caring for a client 1 day after an open hernia repair surgery. Which assessment finding will the nurse report to the surgeon immediately?
D. Rigid, board-like abdomen
Rationale: A rigid, boardlike abdomen requires immediate medical attention because it may indicate peritonitis or an intestinal obstruction. The abdominal incision will normally result in some pain. A blood pressure measurement of 130/82 mm Hg is a near-normal reading. Bronchovesicular breath sounds are considered normal and should not be a concern in this postoperative client.
(59) A nurse is assigned to care for a client who had a partial colectomy and ascending colostomy yesterday. What assessment findings are expected for the client? Select all that apply.
A. The colostomy stoma is pinkish red and moist.
B. The nasogastric tube is draining bright red blood.
C. The client has pain that is controlled by analgesics.
D. The colostomy is draining solid brown stool.
E. The perineal incision is covered with a surgical dressing.
A, C
Rationale: A healthy stoma should be reddish pink and moist and protrude about 3⁄4 inch (2 cm) from the abdominal wall. Pain will be expected after this procedure but can be managed with analgesics. The normal color of gastric drainage is light yellow to green (because of the presence of bile). Bloody drainage may occur after gastric surgery and should be brought to the attention of the surgeon. The stool from a colostomy in the ascending colon is liquid and should not be formed. The perineal incision should contain drains (such as Jackson-Pratt) to help prevent drainage from collecting within the wound.
(59) A 91-year-old woman is admitted from an independent living facility with a diagnosis of complete intestinal obstruction due to a severe fecal impaction. She has been vomiting for 2 days and is extremely dehydrated. Her serum electrolytes are abnormal, and she is very weak. Her daughter and granddaughter are in the emergency department and tell you that they are very concerned about her health. They ask you what is wrong with her and what her prognosis is.
What is your best response to the family members at this time?
The patient likely has impacted stool in her bowel and will require some tests to determine the cause of the backup. She will be given IV fluids, and a tube will be placed down her nose into her stomach to relieve some gastric pressure. Her pain will be managed. Based on the outcome of the tests, the physician will determine if the impaction can be managed by medications or if surgery will be required.
(59) A 91-year-old woman is admitted from an independent living facility with a diagnosis of complete intestinal obstruction due to a severe fecal impaction. She has been vomiting for 2 days and is extremely dehydrated. Her serum electrolytes are abnormal, and she is very weak. Her daughter and granddaughter are in the emergency department and tell you that they are very concerned about her health. They ask you what is wrong with her and what her prognosis is.
What evidence-based collaborative interventions are appropriate for this patient immediately?
Maintaining hemodynamic stability is the priority of care. IV fluid replacement and maintenance are indicated for all patients with intestinal obstruction because the patient is placed on NPO status and fluids and electrolytes are lost (particularly potassium) through vomiting and nasogastric suction. On the basis of serum electrolytes and BUN levels, aggressive fluid replacement of 2 to 4 L of normal saline or lactated Ringer’s solution with potassium added may be prescribed. Pain management must also be addressed. Before administering any medications for pain, the patient’s vital signs will need to be assessed, particularly blood pressure. Dehydration may lead to hypovolemia and, ultimately, hypotension. If the patient is experiencing hypotension, pain medications must be administered with caution or in decreased doses to prevent a further decrease blood pressure.
(59) A 91-year-old woman is admitted from an independent living facility with a diagnosis of complete intestinal obstruction due to a severe fecal impaction. She has been vomiting for 2 days and is extremely dehydrated. Her serum electrolytes are abnormal, and she is very weak. Her daughter and granddaughter are in the emergency department and tell you that they are very concerned about her health. They ask you what is wrong with her and what her prognosis is.
What information do you need to better care for the patient?
A complete history and physical should be performed on the patient and should include the length of time she has been having the symptoms, a medication history, a review of co-morbid conditions, and a recent health history.
(59) A 91-year-old woman is admitted from an independent living facility with a diagnosis of complete intestinal obstruction due to a severe fecal impaction. She has been vomiting for 2 days and is extremely dehydrated. Her serum electrolytes are abnormal, and she is very weak. Her daughter and granddaughter are in the emergency department and tell you that they are very concerned about her health. They ask you what is wrong with her and what her prognosis is.
What electrolyte imbalances would you expect? What clinical manifestations of dehydration do you expect this patient to have? How might her presentation be somewhat different from that of a younger adult and why?
Any of the patient’s electrolyte values, namely potassium and sodium, may be decreased because of vomiting and dehydration. The patient may experience symptoms of dehydration such as decreased skin turgor, decreased urine output and/or the production of concentrated urine, hypotension, an increased heart rate due to compensation for hypotension and/or dehydration, and dizziness. The older adult may be more sensitive to electrolyte and fluid imbalances and their correction. Older adults may also be more prone to changes in vital signs and urine output due to decreased cardiac output related to poor heart function.
(59) A 91-year-old woman is admitted from an independent living facility with a diagnosis of complete intestinal obstruction due to a severe fecal impaction. She has been vomiting for 2 days and is extremely dehydrated. Her serum electrolytes are abnormal, and she is very weak. Her daughter and granddaughter are in the emergency department and tell you that they are very concerned about her health. They ask you what is wrong with her and what her prognosis is.
What safety concerns do you have for this patient? What interventions are needed to ensure her safety?
The NG tube should be monitored to ensure proper functioning; the patient should be assessed for nausea, vomiting, increased abdominal distention, and correct tube placement. When managing fluid and electrolyte replacement, fluid overload is a concern (especially in older adults with a history of heart or kidney failure, who are susceptible); lung sounds, weight, and intake and output should be monitored daily.
(59) A 21-year-old with a stab wound to the abdomen has come to the emergency department (ED). Once stabilized, the client is admitted to a medical-surgical unit. What does the admitting nurse do first for this client?
A. Takes vital signs
Assessment of vital signs should be done first to determine the adequacy of the airway and circulation. Vital signs initially reveal the most about the client's condition.
The client should not be medicated for pain until his or her alertness level is determined.
Skin temperature and color are not specifically indicative of the client's overall condition.
If the client is in shock, urine output will be scant and will not be an accurate assessment variable.
(59) A nurse case manager is discussing community resources with a client who has colorectal cancer (CRC) and is scheduled for a colostomy. Which referral is of greatest value to this client initially?
D. Certified Wound, Ostomy, Continence Nurse (CWOCN)
A Certified Wound, Ostomy, Continence Nurse (CWOCN) (or an enterostomal therapist) will be of greatest value to the client because the client is scheduled to receive a colostomy.
Incorrect: The client is newly diagnosed, so it is not yet known whether home health nursing will be needed.
Incorrect: A referral to hospice may be helpful for the terminally ill client. Because the client is newly diagnosed, hospice is not needed at this time.
Incorrect: Referral to a chaplain may be helpful later in the process of adjusting to the disease.
(59) A home health nurse is teaching a client about the care of a new colostomy. Which client statement demonstrates correct understanding of the instructions?
B. "I need to check for leakage underneath my colostomy."
Incorrect: A purplish stoma is indicative of ischemia and necrosis.
Incorrect: Redness or scratched skin around the stoma should be reported to prevent it from beginning to break down.
Correct: The pouch system should be checked frequently for evidence of leakage to prevent excoriation.
Incorrect: An overly tight fit may lead to necrosis of the stoma.
(59) A client with irritable bowel syndrome (IBS) is constipated. The nurse instructs the client about a management plan. Which client statement shows an accurate understanding of the nurse's teaching?
A. "I need to go for a walk every evening."
Incorrect: Caffeinated beverages can cause bloating or diarrhea and should be avoided in clients with IBS.
Correct: Increased ambulation is part of the management plan for IBS, along with increased fluids and fiber and avoiding caffeinated beverages.
Incorrect: Fiber is encouraged in clients with IBS because it produces a bulky soft stool and aids in establishing regular bowel habits.
Incorrect: At least 8 to 10 cups of fluid should be consumed daily to promote normal bowel function.
(59) A 67-year-old male client reports pain in the inguinal area that occurs when he coughs. A bulge that can be pushed back into the abdomen is found in his inguinal area. What type of hernia does he have?
D. Reducible
Incorrect: Femoral hernias tend to occur more frequently in obese and pregnant women.
Correct: The hernia is reducible because its contents can be pushed back into the abdominal cavity.
Incorrect: A hernia is considered to be strangulated when the blood supply to the herniated segment of the bowel is cut off.
Incorrect: It cannot be a ventral hernia because it would have to occur at the site of a previous surgical incision.
(59) A 24-year-old male is scheduled for a minimally invasive inguinal hernia repair (MIIHR). Which client statement indicates a need for further teaching about this procedure?
D. "I will need to stay in the hospital overnight."
Incorrect: Male clients who have difficulty urinating after the procedure should be encouraged to push fluids and to assume a natural position when voiding.
Correct: Usually, the client is discharged 3 to 5 hours after MIIHR surgery.
Incorrect: Clients undergoing MIIHR surgery must be NPO after midnight before the surgery.
(59) A client with a family history of colorectal cancer (CRC) regularly sees a health care provider for early detection of any signs of cancer. Which laboratory result may be an indication of CRC in this client?
C. Elevated carcinoembryonic antigen
Incorrect: Liver involvement may or may not occur in CRC.
Correct: Carcinoembryonic antigen may be elevated in many clients diagnosed with CRC.
Incorrect: Hemoglobin will likely be decreased with CRC, not increased.
Incorrect: An occult blood test is not a reliable test to affirm or rule out CRC.
(59) A nurse is caring for a client who is to be discharged after a bowel resection and the creation of a colostomy. Which client statement demonstrates that additional instruction from the nurse is needed?
C. "I can drive my car in about 2 weeks."
Correct: The client who has had a bowel resection and colostomy should avoid driving for 4 to 6 weeks.
Incorrect: The client who has had a bowel resection and colostomy should avoid drinking sodas and other carbonated drinks because of the gas they produce.
Incorrect: The client who has had a bowel resection and colostomy may not be able to see the effect of certain foods on bowel patterns for several weeks.
Incorrect: The client who has had a bowel resection and colostomy should avoid straining at stool.
(59) A client is being evaluated in the emergency department (ED) for a possible small bowel obstruction. Which symptoms does the nurse expect to assess?
A. Upper abdominal distention, metabolic alkalosis, and great amount of vomiting
Incorrect: Intermittent cramping, metabolic acidosis, and minimal vomiting are all symptoms of a largebowel obstruction.
Incorrect: Lower abdominal cramping is characteristic of a largebowel obstruction.
Incorrect: Intermittent cramping and metabolic acidosis are characteristic of a largebowel obstruction.
Correct: A smallbowel obstruction is characterized by upper or epigastric abdominal distention, metabolic alkalosis, and a great amount of vomiting.
(59) A client with a bowel obstruction is requested a nasogastric (NG) tube. After the nurse inserts the tube, which nursing intervention is the highest priority for this client?
D. Connecting the tube to low intermittent suction
Incorrect: Continuous high suction is rarely used because it can injure the gastric mucosa of the client's stomach.
Incorrect: Bowel sounds should not be auscultated with suction on and running.
Correct: The nasogastric tube should be attached to intermittent low suction unless otherwise requested by a health care provider. Continuous suction is rarely used because it can injure the gastric mucosa of the client's stomach.
Incorrect: The tube should be flushed every 4 hours, minimally.
(59) A client with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. What does the nurse do first?
C. Prepares the client for emergency surgery
Incorrect: Pain medication may mask the client's symptoms but will not address the root cause.
Incorrect: A change in the nasogastric suction rate will not resolve the cause of the client's pain and could be particularly ineffective if a nonvented tube is in use.
Incorrect: A high Fowler's position will have no effect on an intestinal perforation or peritonitis, which this client is likely experiencing.
Correct: The change in pain type could be indicative of perforation or peritonitis and will require immediate surgical intervention.
(59) A nurse is teaching a client who has undergone a hemorrhoidectomy about a follow-up plan of care. Which client statement demonstrates correct understanding of the nurse's instructions?
A. "I will need to eat a diet high in fiber."
Incorrect: Stimulant laxatives are discouraged because they are habit forming.
Correct: A diet high in fiber serves as a natural stool softener and will prevent irritation to hemorrhoids caused by painful bowel movements.
Incorrect: Increased amounts of fluids are needed to prevent constipation.
Incorrect: Moist heat (sitz baths) will be more effective with postoperative discomfort than cold applications. Cold therapy is sometimes recommended and useful before surgery for inflamed hemorrhoids.
(59) A client with malabsorption syndrome asks the nurse, "What did I do to cause this disorder to develop?" How does the nurse respond?
D. "Nothing you did could have caused it; it is the result of flattening of the mucosa of your large intestine."
Incorrect: Malabsorption syndrome is not associated with an excessive intake of alcohol.
Incorrect: Malabsorption syndrome is not inherited, although a genetic immune defect is present in the related disease celiac sprue.
Incorrect: Malabsorption syndrome is not caused by a virus.
Correct: This is the only statement that is physiologically accurate.
(59) A client with malabsorption syndrome asks the nurse, "What did I do to cause this disorder to develop?" How does the nurse respond? A."An excessive intake of alcohol is associated with it, so your substance abuse could have contributed to its development." B."It is inherited, so it could run in your family." C."It might be caused by a virus, so you could have gotten it almost anywhere." D."Nothing you did could have caused it; it is the result of flattening of the mucosa of your large intestine."19. A client suspected of having irritable bowel syndrome (IBS) is scheduled for a hydrogen breath test. What does the nurse tell the client about this test?
A. "If you have IBS, hydrogen levels will be increased in your breath samples."
Incorrect: The client will ingest small amounts of sugar during the test, not an antacid.
Correct: Excess hydrogen levels are produced in clients with IBS. This is due to bacterial overgrowth in the small intestine that accompanies the disease. The hydrogen travels to the lungs to be excreted.
Incorrect: The test takes longer than 45 minutes. (1 to 2 hours.)
Incorrect: The client needs to be NPO (except for water) for 12 hours before the test.
(59) A nurse is teaching a group of clients with irritable bowel syndrome (IBS) about complementary and alternative therapies. What does the nurse suggest as possible treatment modalities? Select all that apply.
A. Acupuncture
B. Decreasing physical activities
C. Herbs (moxibustion)
D. Meditation
E. Peppermint oil capsules
F. Yoga
All but B.
(59) A nurse is teaching a client with a newly created colostomy about foods to limit or avoid because of flatulence or odors. Which foods are included? Select all that apply.
A. Broccoli
B. Buttermilk
C. Mushrooms
D. Onions
E. Peas
F. Yogurt
A, C, D, E
Incorrect: Buttermilk will help prevent odors.
Incorrect: Yogurt can help prevent flatus.
(59) Which client does the medical-surgical unit charge nurse assign to an LPN/LVN?
A. 47-year-old who needs to receive "whole gut" lavage before a colon resection
Correct: Because administration of medications is within the LPN/LVN scope of practice, this preoperative client can be assigned to the LPN/LVN.
Incorrect: A recent postoperative client will need assessments that should be done by an RN.
Incorrect: This critically ill client needs assessments and interventions that should be done by an RN.
(59) An RN on the medical-surgical unit receives shift report about four clients. Which client does the nurse assess first?
A. 36-year-old recently admitted after a motor vehicle accident with areas of ecchymoses on the abdomen in a "lap-belt" pattern
(59) After an automobile accident, a client is admitted to the emergency department (ED) with possible abdominal trauma. Which health care provider request does the nurse implement first?
A. Starts an IV line and infuses normal saline at 200 mL/hr
After the initial airway, breathing, and circulation assessment is completed, the most immediate concerns are the high risks for hemorrhage and shock. To rapidly treat for these possible complications, IV access and infusion of fluids are necessary as the priority intervention.
(59) Situation: The client is a 66-year-old man with colorectal cancer. He is started on 5-fluorouracil (5-FU) and experiences fatigue, diarrhea, and mouth ulcers. A relatively new chemotherapeutic agent, oxaliplatin (Eloxatin), is added to his treatment regimen. He takes this medication for several weeks and develops peripheral neuropathies. The health care provider discontinues the oxaliplatin and starts him on cetuximab (Erbitux). The client asks how this "new" medication works. How does the nurse respond?
A. "This medication works by binding to a growth factor receptor and decreases cell growth."
(59) Situation: The client is a 66-year-old man with colorectal cancer. He has been started on 5-fluorouracil (5-FU) and is experiencing fatigue, diarrhea, and mouth ulcers. A relatively new chemotherapeutic agent, oxaliplatin (Eloxatin), has been added to his treatment regimen. He reports peripheral sensory neuropathy. What other medications does the nurse expect to administer to clients with advanced colorectal cancer for relief of symptoms?
C. Analgesics and antiemetics
None of the other drugs are "routinely used".
(59) Situation: A 28-year-old comes to the clinic with a history of recurrent episodes of diarrhea or constipation and reports of abdominal pain and bloating. The client is diagnosed with irritable bowel syndrome (IBS). What OTC medications does a nurse suspect as a possible cause of the client's problem?
C. Nonsteroidal anti-inflammatory drugs (NSAIDs)
Nothing else.
(59) Situation: A 28-year-old comes to the clinic with a history of recurrent episodes of diarrhea or constipation and abdominal pain with bloating. The client is diagnosed with irritable bowel syndrome (IBS). What does the nurse advise the client to take during the periods of constipation?
D. Bulk-forming laxatives
No other laxitives are used and stool-softening agents are not effective in the treatment of constipation-predominant IBS.
(59) Situation: A 28-year-old comes to the clinic with a history of recurrent episodes of diarrhea or constipation and abdominal pain with bloating. The client is diagnosed with irritable bowel syndrome (IBS). The client is discharged home with a variety of medications for the symptoms of IBS. Upon returning to the clinic, the client states, "Most of my symptoms have improved-except for the diarrhea." What does the health care provider prescribe for this client?
A. Muscarinic receptor agonist
Incorrect: Antidiarrheal agents are not the most effective choices for this client.
Correct: A muscarinic (M3)-receptor antagonist can also inhibit intestinal motility.
Incorrect: Antidiarrheal agents are not the most effective choices for this client.
Incorrect: Serotonin antagonists will not be the most effective choices for the client's diarrhea.
Incorrect: A tricyclic antidepressant is not going to be effective for this client's diarrhea.
(59) Most CRCs are?
Adenocarcinomas, a cancer of an epithelium that originates in glandular tissue
(59)What can people with a genetic risk for FAP (familial adeomatous polyposis) and HNPCC (Hereditary nonpolyposis colorectal cancer) do about it?
high-dose aspirin
diet modification
CRC screening (colonoscopy)
dietary calcium suppliments
(59) CRC most common signs:
rectal bleeding
anemia
a change in stool
(59) Lab test that can determine if Tx for CRC is working?
It was found that serum from individuals with colorectal carcinoma,[6] gastric carcinoma, pancreatic carcinoma, lung carcinoma and breast carcinoma, as well as individuals with medullary thyroid carcinoma, had higher levels of CEA (Carcinoembryonic antigen) than healthy individuals (above 2.5 ng/ml).
(59) Cancer staging
Stage I:
Invades up to muscle layer
Cancers are localized to one part of the body.
Stage II:
Invades up to other organs or perforates peritoneum
Cancers are locally advanced.
Stage III:
Any level of invasion and up to 4 regional lymph nodes
Cancers are also locally advanced. Whether a cancer is designated as Stage II or Stage III can depend on the specific type of cancer; for example, in Hodgkin's Disease, Stage II indicates affected lymph nodes on only one side of the diaphragm, whereas Stage III indicates affected lymph nodes above and below the diaphragm. The specific criteria for Stages II and III therefore differ according to diagnosis.
Stage IV:
Any level of invasion; many lymph nodes with distant metatases
Cancers have often metastasized, or spread to other organs or throughout the body.
Author
TomWruble
ID
213234
Card Set
NUR212CH59
Description
Care of Patients with Noninflammatory Intestinal Disorders
