Question 1

The nurse is providing care for a client postoperative for the placement of a colostomy for colon cancer. When examining the stoma, which finding causes the nurse to immediately contact the health care provider (HCP)?

Accepted Answer

A healthy stoma should appear moist and pink or red, indicating good blood supply. A dusky color and dryness suggest compromised blood flow or necrosis, requiring immediate attention from a healthcare provider.

Question 2

The nurse is monitoring a patient recovering from an emergency appendectomy. Which finding does the nurse report immediately to the HCP?

Accepted Answer

Abdomen rigidity on palpation could indicate peritonitis or internal bleeding, which are serious complications requiring immediate medical attention. Pain at the operative site and a small amount of bloody drainage are expected post-operative findings. Absence of bowel sounds can be normal shortly after abdominal surgery due to temporary ileus.

Question 3

The nurse is providing care for a patient diagnosed with celiac disease. The patient initially presented with a skin rash with severe pruritus and blistering. Which additional manifestation is the nurse unlikely to associate with the patient's condition?

Accepted Answer

Celiac disease typically leads to malabsorption of nutrients, which can cause weight loss rather than weight gain. Other symptoms like gas, bloating, diarrhea, and changes in stool appearance are common due to the body's inability to properly digest gluten.

Question 4

The nurse is monitoring a patient and finds a bulging area in the patient's groin. Which additional finding causes the nurse the most concern?

Accepted Answer

The development of pain at the site and vomiting indicates that the hernia may be incarcerated or strangulated, leading to compromised blood supply to the herniated tissue. This is a surgical emergency and requires immediate attention.

Question 5

A patient with ulcerative colitis is scheduled for a colectomy with formation of an ileoanal pouch. The patient is reviewing information presented by the HCP regarding possible surgical complications. Which statement by the patient causes the nurse to report a misunderstanding to the HCP?

Accepted Answer

The formation of an ileoanal pouch for a patient with ulcerative colitis is not considered a cure for the condition, but rather a treatment to manage symptoms and improve quality of life. Ulcerative colitis is an inflammatory bowel disease, and while surgery can remove the diseased part of the colon, it does not cure the underlying immune system-related causes of the disease.

Question 6

The nurse notes that a patient with a history of a myocardial infarction is straining during defecation. Which response by the nurse is best?

Accepted Answer

Straining during defecation can increase intrathoracic pressure, which in turn can affect cardiac function by increasing the risk of another myocardial infarction in patients with a history of heart problems.

Question 7

A patient receives a diagnosis of Crohn disease and states, "I don't understand anything about this disease." Which information provided by the nurse is most helpful at this time?

Accepted Answer

The answer of A patient receives a diagnosis of Crohn...

Question 8

The nurse is providing discharge teaching to a patient with diarrhea. Which patient statement indicates that teaching has been effective?

Accepted Answer

Increasing fluid intake is crucial for someone with diarrhea to prevent dehydration, as diarrhea can lead to significant fluid and electrolyte loss.

Question 9

The nurse is reinforcing teaching to a patient with diverticulosis about how to avoid complications. Which patient statement indicates that teaching has been effective?

Accepted Answer

Increasing fluids and fiber in the diet is recommended for patients with diverticulosis to help prevent constipation and reduce the risk of diverticula becoming inflamed or infected, which can lead to complications.

Question 10

The nurse is providing care for a patient who reports feeling constipated, yet passes frequent small liquid stools. The nurse suspects an impaction. Which statement by the patient causes the nurse concern?

Accepted Answer

Taking medication to stop diarrhea when experiencing a fecal impaction can worsen the condition by preventing the passage of the impaction, leading to increased discomfort and potential complications.

Question 11

The nurse is providing care for a patient admitted with a complete, nonmechanical small bowel obstruction. Which manifestation indicates to the nurse that the patient's condition is improving?

Accepted Answer

The answer of The nurse is providing care for a...

Question 12

The spouse of a patient with an ascending ostomy asks if the patient will always have to wear an ostomy bag. Which is the correct response by the nurse?

Accepted Answer

An ascending ostomy involves the surgical creation of an opening (stoma) from an area of the body to the outside, typically as part of the treatment for certain gastrointestinal diseases or conditions. Because the ascending colon is involved, where liquid stool is produced, patients with an ascending ostomy generally need to wear an ostomy bag continuously to collect fecal matter. This is necessary to manage output and protect the skin around the stoma.

Question 13

The nurse is caring for a patient admitted with a possible bowel obstruction. Which patient symptom should cause the nurse the most concern?

Accepted Answer

Fecal vomiting indicates a severe and advanced bowel obstruction, where contents from the bowel are regurgitated due to the inability to pass through the digestive tract. This is a medical emergency requiring immediate attention.

Question 14

The nurse is contributing to the plan of care for a patient with gluten enteropathy (celiac disease). Which food(s) does the nurse recommend be eliminated from the diet of the patient?

Accepted Answer

Gluten enteropathy, or celiac disease, is a condition where the ingestion of gluten leads to damage in the small intestine. Gluten is found in wheat, rye, oats, and barley, so eliminating these foods from the diet is essential for managing the condition.

Question 15

The nurse is gathering data on a patient with severe diarrhea for 3 days. The patient reports being out of the country for 2 weeks. Laboratory results indicate the presence of red blood cells (RBCs) and mucus in a stool sample. For which conditions does the nurse expect further testing?

Accepted Answer

Cholera, typhoid, typhus, and amebiasis are all conditions that can cause severe diarrhea and are associated with the presence of RBCs and mucus in the stool.

Question 16

The nurse is collecting data from a patient who is reporting abdominal pain. Which symptom suggests that the patient is experiencing appendicitis?

Accepted Answer

Appendicitis typically presents as pain in the right lower abdominal quadrant, which is a classic symptom indicating inflammation of the appendix.

Question 17

On admission, a patient with gastrointestinal bleeding had the following vital signs: blood pressure (BP) 140/80 mm Hg, pulse 72 beats/min, respirations 14 breaths/min, and temperature 98.8°F (37.1°C) orally. Which finding does the licensed practical nurse/licensed vocational nurse (LPN/LVN) report immediately to the registered nurse (RN) or HCP?

Accepted Answer

A drop in blood pressure (from 140/80 mm Hg to 104/68 mm Hg) in a patient with gastrointestinal bleeding is a significant finding that indicates potential worsening of the condition, possibly due to ongoing blood loss. This should be reported immediately to ensure prompt intervention.

Question 18

The nurse is providing care for a client with advanced Crohn disease who has developed multiple complications of the disease and no longer responds to treatment. The HCP is recommending surgery. Which detail about the patient's surgery does the nurse comprehend?

Accepted Answer

Crohn's disease affects the entire gastrointestinal tract, making a Kock pouch, which is an internal reservoir for stool, unsuitable due to the risk of disease recurrence.

Question 19

A patient is informed, after a colonoscopy, of diverticulosis. The patient asks the nurse about the causes and management of the condition. Which information shared by the nurse is inaccurate?

Accepted Answer

The advice to avoid nuts, seeds, and hulls to prevent complications of diverticulosis, such as diverticulitis, is outdated. Current evidence does not support the need to avoid these foods in individuals with diverticulosis.

Question 20

The nurse is providing care for a patient diagnosed with obstipation. Which condition is the nurse aware as being unrelated to the patient's diagnosis?

Accepted Answer

Obstipation is a severe form of constipation characterized by an inability to pass stool or gas. It is directly related to factors affecting bowel movements, such as ignoring the urge to defecate (A), insensitivity of colon and rectal tissues to feces (B), and requiring stronger stimulation for peristalsis (D). Obesity and cardiovascular disorders (C) are not directly related to the mechanical or functional aspects of bowel movement, making this option unrelated to the diagnosis of obstipation.

Quiz 34: Nursing Care of Patients With Lower Gastrointestinal Disorders

The nurse is providing care for a client postoperative for the placement of a colostomy for colon cancer. When examining the stoma, which finding causes the nurse to immediately contact the health care provider (HCP) ?