Question 1

In response to a nurse's question about bowel function, a client shares that sometimes the feces are greenish black in color.Which answer by the nurse is correct?

Accepted Answer

D

Question 2

The nurse is admitting a client and performs a focused assessment.Which techniques will result in the nurse acquiring objective data related to bowel function?

Accepted Answer

Using the diaphragm of a stethoscope to hear bowel sounds is an objective technique because it involves directly observing or measuring physical signs related to bowel function.

Question 3

During an admission physical assessment, a nurse questions a client about bowel elimination habits.Which client care goal is the nurse attempting to identify?

Accepted Answer

The nurse aims to maintain the client's normal elimination habit by inquiring about their bowel elimination habits, ensuring comfort and preventing potential complications related to changes in these habits while under care.

Question 4

The nurse is assessing a client immediately after the placement of a colostomy.Which assessment finding does the nurse expect to see?

Accepted Answer

A healthy stoma should appear red, shiny, moist, and beefy in appearance, indicating good blood supply and normal function immediately after colostomy placement.

Question 5

A nurse explains to a client that it is wise to avoid taking a laxative every day because of the problems it can cause.The client demonstrates understanding by saying laxative abuse can result in which condition? Select all that apply.

Accepted Answer

Laxative abuse can lead to fluid and electrolyte imbalances, a need for increasing dosages due to tolerance, loss of natural bowel contractility, and increased risk for fecal impaction. However, it is not directly linked to the development of irritable bowel syndrome.

Question 6

The nurse is obtaining a health history from an older adult client.The client tells the nurse that a bowel movement occurs about every 2 to 3 days.Which question should the nurse ask to determine if this is normal functioning for the client?

Accepted Answer

The consistency of the stool is an important indicator of normal bowel function. Regular bowel movements can vary from person to person, and a bowel movement every 2 to 3 days can be normal if the stool is soft and passes easily.

Question 7

While inspecting a client's stool, a nurse notices a small amount of black, tarry blood with a distinctive old-blood odor that appears to have been partially digested.Which term does the nurses use to describe the client's stool?

Accepted Answer

Melena refers to black, tarry stools that have a distinctive smell, indicating blood that has been digested. This is typically a sign of upper gastrointestinal bleeding.

Question 8

The nurse is caring for multiple clients with a variety of bowel conditions.Which client does the nurse consider at greatest risk for surgery to place a colostomy?

Accepted Answer

A client with a portion of bowel without circulation (ischemic bowel) is at greatest risk for surgery to place a colostomy because the lack of blood flow can lead to tissue death, requiring surgical intervention to remove the affected portion of the bowel and possibly necessitate a colostomy.

Question 9

A female client has been admitted with ulcerative colitis.Which appearance of the client's stools will the nurse expect with the exacerbation of this condition?

Accepted Answer

Ulcerative colitis is characterized by inflammation and ulceration of the colon and rectum, leading to stools that often contain pus, mucus, and blood due to the damage and irritation of the intestinal lining.

Question 10

The nurse assists a client to the bathroom, and notices that the client's stool is clay colored.The client tells the nurse that this has occurred off and on for the last month or two.Which condition does the nurse suspect?

Accepted Answer

Clay-colored stool can indicate a lack of bile, which may be caused by gallstones or liver problems, blocking the bile ducts and affecting the digestion and absorption of fats.

Question 11

A client has undergone diagnostic tests of the gastrointestinal (GI)system.The client, who has chronic constipation, tells the nurse the physician is concerned about peristalsis, and asks why it is important.Which information will the nurse include?

Accepted Answer

Peristalsis involves rhythmic contractions of circular and longitudinal muscles in the gastrointestinal tract, which help in moving food through the digestive system. This process is crucial for the proper digestion and movement of food from the esophagus to the rectum.

Question 12

The nurse is preparing to administer an ordered enema to a client.Which intervention by the nurse is correct for this procedure?

Accepted Answer

DB) The tip of the enema tube should be inserted 3 to 4 inches into the rectum to ensure that the enema solution is delivered properly into the colon. This depth allows for the solution to bypass the anal sphincter effectively without causing injury.D) Having the client lie on the left side, known as the Sims' position, is the correct position for administering an enema. This position helps facilitate the flow of the enema solution into the sigmoid colon and rectum by taking advantage of the natural curve of the sigmoid colon. However, the question mistakenly states the right side, which is less effective than the left side for this purpose. The correct practice is the left side, but given the options, D emphasizes the importance of positioning, albeit with an inaccuracy in direction.

Question 13

The nurse is discussing ways to help prevent constipation.Which information is most important for the nurse to share?

Accepted Answer

Ignoring the defecation reflex can lead to constipation, as it is important to respond to the body's natural signals to maintain regular bowel movements.

Question 14

A client with a known history of diverticulosis who is experiencing severe cramping and diarrhea is admitted to the hospital during the night with a diagnosis of diverticulitis.The client's pain increases, and the abdomen is distended and hard.The client has spiked a fever of 102.4°F.The nurse concludes the client may be developing a life-threatening complication and notifies the physician.Which possible complication concerns the nurse?

Accepted Answer

The nurse is concerned about peritonitis, a life-threatening complication, indicated by symptoms such as severe abdominal pain, distension, hardness, fever, and a history of diverticulitis.

Question 15

The nurse is preparing to collect a stool specimen ordered by the physician.Which client and reason defines the need for the specimen?

Accepted Answer

A client who has traveled outside the country and has lost weight since returning may need a stool specimen to check for parasites or infections that could have been contracted while traveling, which could cause weight loss and gastrointestinal symptoms.

Question 16

The nurse is caring for a client who has fecal incontinence.The symptoms include intermittent periods when small amounts of liquid stool are passed, followed by periods of severe constipation requiring the use of enemas to resolve.Which intervention should the nurse perform first?

Accepted Answer

The first step in managing a client with symptoms of fecal incontinence, especially when there are intermittent periods of liquid stool passage followed by severe constipation, is to examine the client for fecal impaction. This condition can cause such symptoms and needs to be addressed before other interventions.

Question 17

After an initial assessment, a nurse documents that a client, admitted for abdominal pain, has hyperactive bowel sounds.Which type of bowel movement will the nurse expect this client to have?

Accepted Answer

Hyperactive bowel sounds typically indicate increased intestinal activity, which often results in liquid or semi-liquid stools due to the rapid transit of intestinal contents.

Question 18

While providing care for an older adult client, the nurse learns that the client has had only small, watery stools for several days.Which is the nurse's priority in providing care for this client?

Accepted Answer

Assessing for an impaction is the priority because small, watery stools can be a sign of a fecal impaction, where liquid stool leaks around the impaction. This assessment is crucial to provide appropriate care.

Question 19

The nurse is assigned to provide client care to multiple clients.Which client does the nurse recognize as being at greatest risk for a fecal impaction?

Accepted Answer

Older adults with poor fluid intake and a history of laxative abuse are at a higher risk for fecal impaction due to dehydration and the bowel's decreased response to the natural urge to defecate, exacerbated by laxative overuse.

Question 20

An older adult client is admitted to the hospital for a bowel obstruction, and part of the client's duodenum was surgically removed.Which condition does the nurse recognize as a potential problem for the client?

Accepted Answer

The duodenum is the first part of the small intestine and plays a crucial role in nutrient absorption. Removing part of the duodenum can lead to decreased nutrient absorption.

Quiz 30: Bowel Elimination and Care