C H A P T E R
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Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
Nursing Management:
186 Chapter 43 Nursing Management: Lower Gastrointestinal Problems
9. Priority Decision: A patient returns to the surgical unit with a nasogastric (NG) tube to low intermittent suction, IV fluids, and a Jackson-Pratt drain at the surgical site following an exploratory laparotomy and repair of a bowel perforation. Four hours after admission, the patient experiences nausea and vomiting. What is a priority nursing intervention for the patient?
a. Assess the abdomen for distention and bowel sounds.
b. Inspect the surgical site and drainage in the Jackson-Pratt.
c. Check the amount and character of gastric drainage and the patency of the NG tube.
d. Administer prescribed prochlorperazine (Compazine) to control the nausea and vomiting.
10. Priority Decision: A postoperative patient has a nursing diagnosis of pain related to effects of medication and decreased GI motility as evidenced by abdominal pain and distention and inability to pass flatus. Which nursing intervention is most appropriate for this patient?
a. Ambulate the patient more frequently.
b. Assess the abdomen for bowel sounds.
c. Place the patient in high Fowler’s position.
d. Withhold opioids because they decrease bowel motility.
11. A 22-year-old patient calls the outpatient clinic complaining of nausea and vomiting and right lower abdominal pain.
What should the nurse advise the patient to do?
a. Use a heating pad to relax the muscles at the site of the pain.
b. Drink at least 2 quarts of juice to replace the fluid lost in vomiting.
c. Take a laxative to empty the bowel before examination at the clinic.
d. Have the symptoms evaluated by a health care provider right away.
12. Priority Decision: When caring for a patient with irritable bowel syndrome (IBS), what is most important for the nurse to do?
a. Recognize that IBS is a psychogenic illness that cannot be definitively diagnosed.
b. Develop a trusting relationship with the patient to provide support and symptomatic care.
c. Teach the patient that a diet high in fiber will relieve the symptoms of both diarrhea and constipation.
d. Inform the patient that new medications for IBS are available and effective for treatment of IBS manifested by either diarrhea or constipation.
13. Priority Decision: A patient with a gunshot wound to the abdomen complains of increasing abdominal pain several hours after surgery to repair the bowel. What action should the nurse take first?
a. Take the patient’s vital signs.
b. Notify the health care provider.
c. Position the patient with the knees flexed.
d. Determine the patient’s IV intake since the end of surgery.
14. The patient has persistent and continuous pain at McBurney’s point. The nursing assessment reveals rebound tenderness and muscle guarding with the patient preferring to lie still with the right leg flexed. What should the nursing interventions for this patient include?
a. Laxatives to move the constipated bowel
b. NPO status in preparation for possible appendectomy
c. Parenteral fluids and antibiotic therapy for 6 hours before surgery d. NG tube inserted to decompress the stomach and prevent aspiration
15. The patient has peritonitis, which is a major complication of appendicitis. What treatment will the nurse plan to include?
a. Peritoneal lavage c. IV fluid replacement
b. Peritoneal dialysis d. Increased oral fluid intake
16. A 20-year old patient with a history of Crohn’s disease comes to the clinic with persistent diarrhea. What are characteristics of Crohn’s disease (select all that apply)?
a. Weight loss d. Toxic megacolon
b. Rectal bleeding e. Has segmented distribution
c. Abdominal pain f. Involves the entire thickness of the bowel wall
Chapter 43 Nursing Management: Lower Gastrointestinal Problems 187 17. What laboratory findings are expected in ulcerative colitis as a result of diarrhea and vomiting?
a. Increased albumin c. Decreased Na+, K+, Mg+, Cl–, and HCO3–
b. Elevated white blood cells (WBCs) d. Decreased hemoglobin (Hgb) and hematocrit (Hct) 18. What extraintestinal manifestations are seen in both ulcerative colitis and Crohn’s disease?
a. Celiac disease and gallstones c. Conjunctivitis and colonic dilation b. Peptic ulcer disease and uveitis d. Erythema nodosum and osteoporosis
19. For the patient hospitalized with inflammatory bowel disease (IBD), which treatments would be used to rest the bowel (select all that apply)?
a. NPO d. Sedatives
b. IV fluids e. Nasogastric suction
c. Bed rest f. Parenteral nutrition
20. The medications prescribed for the patient with inflammatory bowel disease include cobalamin and iron injections.
What is the rationale for using these drugs?
a. Alleviate stress c. Correct malnutrition
b. Combat infection d. Improve quality of life
21. The patient is receiving the following medications. Which one is prescribed to relieve symptoms rather than treat a disease?
a. Corticosteroids c. Antidiarrheal agents
b. 6-Mercaptopurine d. Sulfasalazine (Azulfidine)
22. A patient with ulcerative colitis undergoes the first phase of a total proctocolectomy with ileal pouch and anal anastomosis. On postoperative assessment of the patient, what should the nurse expect to find?
a. A rectal tube set to low continuous suction
b. A loop ileostomy with a plastic rod to hold it in place
c. A colostomy stoma with an NG tube in place to provide pouch irrigations d. A permanent ileostomy stoma in the right lower quadrant of the abdomen
23. Priority Decision: A patient with ulcerative colitis has a total proctocolectomy with formation of a terminal ileum stoma. What is the most important nursing intervention for this patient postoperatively?
a. Measure the ileostomy output to determine the status of the patient’s fluid balance.
b. Change the ileostomy appliance every 3 to 4 hours to prevent leakage of drainage onto the skin.
c. Emphasize that the ostomy is temporary and the ileum will be reconnected when the large bowel heals.
d. Teach the patient about the high-fiber, low-carbohydrate diet required to maintain normal ileostomy drainage.
24. A patient with inflammatory bowel disease has a nursing diagnosis of imbalanced nutrition: less than body requirements related to decreased nutritional intake and decreased intestinal absorption. Which assessment data support this nursing diagnosis?
a. Pallor and hair loss c. Anorectal excoriation and pain
b. Frequent diarrhea stools d. Hypotension and urine output below 30 mL/hr 25. A physician just told a patient that she has a volvulus. When the patient asks the nurse what this is, what is the best
description for the nurse to give her?
a. Bowel folding on itself c. Emboli of arterial supply to the bowel
b. Twisting of bowel on itself d. Protrusion of bowel in weak or abnormal opening 26. The patient comes to the emergency department with intermittent crampy abdominal pain, nausea, projectile
vomiting, and dehydration. The nurse suspects a GI obstruction. Based on the manifestations, what area of the bowel should the nurse suspect is obstructed?
a. Large intestine c. Upper small intestine
b. Esophageal sphincter d. Lower small intestine
188 Chapter 43 Nursing Management: Lower Gastrointestinal Problems
27. An important nursing intervention for a patient with a small intestinal obstruction who has an NG tube is to a. offer ice chips to suck PRN.
b. provide mouth care every 1 to 2 hours.
c. irrigate the tube with normal saline every 8 hours.
d. keep the patient supine with the head of the bed elevated 30 degrees.
28. During a routine screening colonoscopy on a 56-year-old patient, a rectosigmoidal polyp was identified and removed. The patient asks the nurse if his risk for colon cancer is increased because of the polyp. What is the best response by the nurse?
a. “It is very rare for polyps to become malignant but you should continue to have routine colonoscopies.”
b. “Individuals with polyps have a 100% lifetime risk of developing colorectal cancer and at an earlier age than those without polyps.”
c. “All polyps are abnormal and should be removed but the risk for cancer depends on the type and if malignant changes are present.”
d. “All polyps are premalignant and a source of most colon cancer. You will need to have a colonoscopy every 6 months to check for new polyps.”
29. When obtaining a nursing history from the patient with colorectal cancer, the nurse should specifically ask the patient about
a. dietary intake.
b. sports involvement.
c. environmental exposure to carcinogens.
d. long-term use of nonsteroidal antiinflammatory drugs (NSAIDs).
30. When a patient returns to the clinical unit after an abdominal-perineal resection (APR), what should the nurse expect?
a. An abdominal dressing c. A temporary colostomy and drains b. An abdominal wound and drains d. A perineal wound, drains, and a stoma
31. The patient with a new ileostomy needs discharge teaching. What should the nurse plan to include in this teaching?
a. The pouch can be worn for up to 2 weeks before changing it.
b. Decrease the amount of fluid intake to decrease the amount of drainage.
c. The pouch can be removed when bowel movements have been regulated.
d. If leakage occurs, promptly remove the pouch, clean the skin, and apply a new pouch.
32. On examining a patient 8 hours after having surgery to create a colostomy, what should the nurse expect to find?
a. Hyperactive, high-pitched bowel sounds b. A brick-red, puffy stoma that oozes blood c. A purplish stoma, shiny and moist with mucus
d. A small amount of liquid fecal drainage from the stoma
33. Delegation Decision: The RN coordinating the care for a patient who is 2 days postoperative following an anterior-posterior resection with colostomy may delegate which interventions to the licensed practical nurse (LPN) (select all that apply)?
a. Irrigate the colostomy.
b. Teach ostomy and skin care.
c. Assess and document stoma appearance.
d. Monitor and record the volume, color, and odor of the drainage.
e. Empty the ostomy bag and measure and record the amount of drainage.
34. A male patient who has undergone an anterior-posterior repair is worried about his sexuality. What is an appropriate nursing intervention for this patient?
a. Have the patient’s sexual partner reassure the patient that he is still desirable.
b. Reassure the patient that sexual function will return when healing is complete.
c. Remind the patient that affection can be expressed in ways other than through sexual intercourse.
d. Explain that physical and emotional factors can affect sexual function but not necessarily the patient’s sexuality.
Chapter 43 Nursing Management: Lower Gastrointestinal Problems 189 35. In report, the nurse learns that the patient has a transverse colostomy. What should the nurse expect when providing
care for this patient?
a. Semiliquid stools with increased fluid requirements b. Liquid stools in a pouch and increased fluid requirements
c. Formed stools with a pouch, needing irrigation, but no fluid needs d. Semiformed stools in a pouch with the need to monitor fluid balance
36. The nurse plans teaching for the patient with a colostomy but the patient refuses to look at the nurse or the stoma, stating, “I just can’t see myself with this thing.” What is the best nursing intervention for this patient?
a. Encourage the patient to share concerns and ask questions.
b. Refer the patient to a chaplain to help cope with this situation.
c. Explain that there is nothing the patient can do about it and must take care of it.
d. Tell the patient that learning about it will prevent stool leaking and the sounds of flatus.
37. What information should be included when the nurse teaches a patient about colostomy irrigation?
a. Infuse 1500 to 2000 mL of warm tap water as irrigation fluid.
b. Allow 30 to 45 minutes for the solution and feces to be expelled.
c. Insert a firm plastic catheter 3 to 4 inches into the stoma opening.
d. Hang the irrigation bag on a hook about 36 inches above the stoma.
38. What should the nurse teach the patient with diverticulosis to do?
a. Use anticholinergic drugs routinely to prevent bowel spasm.
b. Have an annual colonoscopy to detect malignant changes in the lesions.
c. Maintain a high-fiber diet and use bulk laxatives to increase fecal volume.
d. Exclude whole grain breads and cereals from the diet to prevent irritating the bowel.
39. An 82-year-old man is admitted with an acute attack of diverticulitis. What should the nurse include in his care?
a. Monitor for signs of peritonitis.
b. Treat with daily medicated enemas.
c. Prepare for surgery to resect the involved colon.
d. Provide a heating pad to apply to the left lower quadrant.
40. The patient calls the clinic and describes a bump at the site of a previous incision that disappears when he lies down.
The nurse suspects that this is which type of hernia (select all that apply)?
a. Ventral d. Reducible
b. Inguinal e. Incarcerated
c. Femoral f. Strangulated
41. The patient asks the nurse why she needs to have surgery for a femoral, strangulated hernia. What is the best explanation the nurse can give the patient?
a. The surgery will relieve her constipation.
b. The abnormal hernia must be replaced into the abdomen.
c. The surgery is needed to allow intestinal flow and prevent necrosis.
d. The hernia is because the umbilical opening did not close after birth as it should have.
42. What is a nursing intervention that is indicated for a male patient following an inguinal herniorrhaphy?
a. Applying heat to the inguinal area c. Applying a truss to support the operative site b. Elevating the scrotum with a scrotal support d. Encouraging the patient to cough and deep breathe 43. How is the most common form of malabsorption syndrome treated?
a. Administration of antibiotics b. Avoidance of milk and milk products c. Supplementation with pancreatic enzymes
d. Avoidance of gluten found in wheat, barley, oats, and rye
190 Chapter 43 Nursing Management: Lower Gastrointestinal Problems
CASE STUDY
Cancer of the Rectum Patient Profile
C.D., a 63-year-old married insurance salesman, has undergone an abdominal-perineal resection for stage III cancer of the rectum. He is 1 day postoperative on the general surgical unit.
Subjective Data
• Complains of pain in his abdominal and perineal incisions that is not well controlled even with his patient-controlled analgesia (PCA) machine
• Jokes about his stoma winking at him when the dressings are removed the first time and a temporary colostomy bag is applied
• Refers to his stoma as “Jake”
• Tells his wife that “Jake” will be watching her Objective Data
• Bright-red stoma on left lower quadrant of abdomen; colostomy bag has small amount of pink mucus drainage
• Midline abdominal incision; no signs of infection; sutures intact
• Perineal incision partially closed; two Penrose drains with bulky dressings with a large amount of serosanguineous drainage
• All vital signs normal
• PCA orders of 1 mg morphine sulfate every 10 minutes, with 17 attempts in the past hour
44. A patient is diagnosed with celiac disease following a workup for iron-deficiency anemia and decreased bone density. The nurse identifies that additional teaching about disease management is needed when the patient makes which statement?
a. “I should ask my close relatives to be screened for celiac disease.”
b. “If I do not follow the gluten-free diet, I might develop a lymphoma.”
c. “I don’t need to restrict gluten intake because I don’t have diarrhea or bowel symptoms.”
d. “It is going to be difficult to follow a gluten-free diet because it is found in so many foods.”
45. Which patient is most likely to be diagnosed with short bowel syndrome?
a. History of ulcerative colitis c. Diagnosed with irritable bowel syndrome
b. Had extensive resection of the ileum d. Had colectomy performed for cancer of the bowel 46. The patient asks the nurse to explain what the physician meant when he said the patient had an anorectal abscess.
Which description should the nurse use to explain this to the patient?
a. Ulcer in anal wall c. Sacrococcygeal hairy tract
b. Collection of perianal pus d. Tunnel leading from the anus or rectum
47. A 60-year-old African American patient is afraid she might have anal cancer. What assessment finding puts her at high risk for anal cancer?
a. Alcohol use c. Human papillomavirus (HPV)
b. Only one sexual partner d. Use of a condom with sexual intercourse 48. Following a hemorrhoidectomy, what should the nurse advise the patient to do?
a. Use daily laxatives to facilitate bowel emptying.
b. Use ice packs to the perineum to prevent swelling.
c. Avoid having a bowel movement for several days until healing occurs.
d. Take warm sitz baths several times a day to promote comfort and cleaning.
Chapter 43 Nursing Management: Lower Gastrointestinal Problems 191
Discussion Questions
Using a separate sheet of paper, answer the following questions:
1. What symptoms may have alerted C.D. to seek medical care for his cancer of the rectum?
2. What care is indicated for C.D.’s perineal wound?
3. What are the primary goals of care for C.D.’s colostomy?
4. What would be the nurse’s evaluation of C.D.’s adjustment to his colostomy?
5. What factors may be influencing the pain that C.D. is experiencing?
6. Will C.D. need adjuvant chemotherapy or biologic and targeted therapy? If so, which medications would be used?
7. Priority Decision: What are the priority teaching needs for C.D. before his discharge?
8. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?