Bowel Elimination PDF

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Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 46: Bowel Elimination 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 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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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 client's diet will include foods such as: 1. Vegetables 2. Fresh fruit 3. Whole grain breads 4. Poached eggs and rice ANS: 4 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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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

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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

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

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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 client’s head. 3. Mark the tube where it exits the nose. 4. Change the tubing daily. ANS: 3

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Test Bank

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 client’s 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 falsepositive 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

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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 don’t 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.”

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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 cow’s 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 can’t tolerate dairy products.” 4. “My child gets diarrhea from dairy products because she can’t 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 cow’s 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 s...