Exam #4 Chapter 30
Total Questions : 21
Showing 21 questions, Sign in for moreThe nurse is caring for a patient with complaints of constant diarrhea for 3 days. The patient is exhibiting signs and symptoms of dehydration. The best fluid source for this patient to
drink small amounts of is
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After an initial assessment, a nurse documents that a patient, admitted for abdominal pain, has hyperactive bowel sounds. As a result, the nurse could expect the patient's bowel movements to be
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A doctor orders a test to find "hidden blood" from patient's stool sample. A nurse identifies that this type of test is used to detect the presence of
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The day after surgery, a patient asks a nurse, "Why do the nurses keep listening to my abdomen? That's not where I had surgery." Which of the following responses best answers the patient's question?
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A 68-year-old male has been admitted to the hospital for nutritional deficiencies.
Approximately 6 months ago, he had part of his duodenum surgically removed following a bowel obstruction. The nurse understands that the patient's nutritional deficiencies are occurring because
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During an admission physical assessment, a nurse questions a patient about their bowel
elimination pattern. The nurse may say. "Can you tell me your bowel regimen? Do you have a regular, bowel movement every day? What is the approximate time that you have a bowel movement?" The nurse's goal is
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A nurse is caring for 4 patients - each patient has a colostomy bag. Which patient should be seen first and made a priority?
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What could be a potential nursing diagnosis for the patient with a new colostomy?
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Your patient is supposed to get a tap water enema. What medical diagnosis would NOT qualify him for this procedure?
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Your patient complains of excessive flatus. When reviewing the patient's dietary intake, which food, if eaten regularly, would you identify as possibly responsible?
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A nurse explains to a patient that when a bowel diversion is brought to the outside of the body through the abdominal wall, the new opening is called an ostomy, and the mouth of the ostomy is called a______
Explanation
When a bowel diversion is created surgically to bring a portion of the intestine or bowel to the outside of the body through the abdominal wall, it forms an opening known as an ostomy. This procedure is performed to allow feces or intestinal contents to be eliminated through this new opening, bypassing the usual route of passing through the rectum and anus.
The actual opening or mouth of the ostomy, through which waste material exits the body, is called a "stoma." The stoma is created by suturing the end of the bowel to the skin of the abdominal wall, and it appears as a small, pinkish or reddish, moist protrusion on the skin surface.
There are different types of ostomies, depending on the location in the gastrointestinal tract where the diversion is made. The most common types include:
Colostomy: The stoma is created from the colon (large intestine).
Ileostomy: The stoma is created from the ileum (the last part of the small intestine).
Urostomy: The stoma is created from the urinary system, diverting urine from the bladder.
The stoma serves as a new pathway for waste elimination and requires special care and management, which is typically taught to the patient by healthcare professionals, including nurses, to ensure proper stoma care and adaptation to living with an ostomy.
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A nurse stops administering an enema because the patient develops bradycardia and hypotension. The nurse understands the response as a result of stimulating a specific nerve. Patient has had a
Explanation
A vagal response, also known as a vasovagal response or a vasovagal reaction, is a specific type of reflex response that can occur when the vagus nerve is stimulated. The vagus nerve, also called the tenth cranial nerve, plays a crucial role in regulating various bodily functions, including heart rate, blood pressure, digestion, and respiratory rate.
When the vagus nerve is stimulated, it can lead to a sudden decrease in heart rate (bradycardia) and blood pressure (hypotension). This response is a protective mechanism of the body that can occur in response to certain triggers, such as:
Sudden pain or discomfort Stress or anxiety
Straining during bowel movements or urination
Sudden changes in body position, like sitting or standing up quickly (orthostatic changes) Certain medical procedures, including enemas, bladder catheterization, or blood draws
In the context of the question, the patient's bradycardia and hypotension occurred when the nurse was administering an enema. The introduction of fluid into the rectum during the enema procedure can potentially stimulate the vagus nerve, leading to a vagal response.
Recognizing and responding promptly to a vagal response is essential for patient safety. When a vagal response occurs, the nurse should stop the procedure, help the patient assume a comfortable position (such as lying down with legs elevated), and provide reassurance to reduce anxiety. If
necessary, the healthcare team may administer additional interventions to stabilize heart rate and blood pressure.
It is important for healthcare providers to be aware of potential vagal responses and take appropriate precautions during procedures to minimize the risk of adverse reactions in susceptible patients.
A nurse can expect that which of the following patients are most likely to suffer from fecal incontinence? Select all that apply.
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While inspecting a patient's stool, a nurse notices that the stool has pus in it. The nurse identifies this type of stool as having
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A patient with Crohn's disease underwent a procedure to remove a portion of the large
intestine. The distal portion of the colon was removed, allowing it time to rest and heal. A nurse identifies that this type of bowel diversion is known as an
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A male patient has told a nurse that he occasionally fights constipation. Teaching the patient how to prevent constipation and promote normal elimination, the nurse instructs him to
Explanation
To prevent constipation and promote normal elimination, the nurse recommends adequate fluid intake and a balanced diet with appropriate fiber intake.
- Take a stool softener or laxative every day until a normal elimination pattern has been
reestablished. This option is not the best recommendation for preventing constipation. While stool softeners or laxatives can be used occasionally for short-term relief, relying on them
every day can lead to dependency and may not address the underlying cause of constipation. Long-term use of laxatives can also lead to potential side effects and complications.
- Eat small amounts at meals so less waste will need to be expelled. While portion control can be beneficial for some digestive issues, eating small amounts at meals is not the primary approach to prevent constipation. A balanced diet with adequate fiber and fluid intake is more effective for promoting regular bowel movements.
- Eat a minimum of 50 g fiber every day and quickly increase the amount until normal
defecation becomes routine. While fiber is essential for bowel regularity, suddenly increasing fiber intake can cause bloating, gas, and abdominal discomfort. Gradually increasing fiber
intake is a better approach to allow the digestive system to adjust. Starting with 25-30 grams of fiber per day and gradually increasing it over several days or weeks can be more
manageable for the patient.
Drinking at least 2000 ml fluid every day, but limit the amount of caffeine to 300 mg is the correct recommendation. Adequate fluid intake is essential for maintaining normal bowel movements and preventing constipation. Water helps soften stools and facilitates their passage through the
intestines. The recommended amount of fluid intake for most adults is around 2000-2500 ml per day. However, it's important to limit caffeine intake because excessive caffeine can have a diuretic effect, potentially leading to dehydration.
In summary, the best instruction to prevent constipation and promote normal elimination is to drink at least 2000 ml of fluid every day while limiting caffeine intake to 300 mg. Additionally, the patient should aim for a balanced diet with appropriate fiber intake, but the increase in fiber should be gradual to avoid discomfort. If the patient continues to experience constipation despite these
measures, it is important to consult a healthcare provider for further evaluation and individualized recommendations.
An adult patient has orders for an enema. A nurse will
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A patient's admission assessment includes pertinent information about bowel elimination. Which subjective information collected by the nurse will be documented?
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A nurse is speaking to a patient about his recent bowel movement. He says, "Sometimes my bowel movements are greenish in color. Is that normal?" The nurse replies:
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A nurse educator explains to staff nurses that diarrhea can quickly become life-threatening in elderly patients because
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A nurse notices that the patient's stool is light, clay-colored. The nurse suspects the patient
No explanation
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