Question 1

Which of the following assessment skills would the RN perform first when examining a client for faecal elimination problems?

Accepted Answer

B

Question 2

Which of the following nursing diagnoses would be most appropriate for a client on bed rest?

Accepted Answer

Clients on bed rest are at increased risk for constipation due to decreased mobility and changes in diet and hydration. Disturbed Body Image may be an appropriate diagnosis for some clients on bed rest, but it is not specific to this population. Diarrhoea and Bowel Incontinence are less likely to be issues for clients on bed rest.

Question 3

Which part of the nursing process is the nurse using when obtaining a nursing history of a client's faecal elimination?

Accepted Answer

Obtaining a nursing history falls under the assessment phase of the nursing process which involves collecting subjective and objective data about the client's health status.

Question 4

Which of the following goals would be appropriate for a client dealing with a faecal elimination problem like diarrhoea?

Accepted Answer

The answer of Which of the following goals would be...

Question 5

The normal colour of faeces is due to the presence of ________ and ________.

Accepted Answer

The answer of The normal colour of faeces is due...

Question 6

Which of the following characteristics assessed by the nurse is considered normal for an adult's faeces?

Accepted Answer

Normal adult faeces should be tubular in shape. Faeces should not be yellow or black, as this may be a sign of underlying health issues. The odour of faeces may vary, but it should not be excessively pungent or foul.

Question 7

Faecal impaction can occur as a result of ________.

Accepted Answer

The answer of Faecal impaction can occur as a result...

Question 8

The nurse is called to the client's room to assess the client's first bowel movement since surgery. Upon investigation, the nurse finds hard, dry, but formed stool. This is characteristic of which of the following?

Accepted Answer

Hard, dry, but formed stool is characteristic of constipation, which is a common post-operative complication. Faecal impaction usually presents with complete bowel obstruction, whereas bowel incontinence and diarrhoea are characterized by loose stool, with or without loss of control.

Question 9

A client is asking for assistance from the community nurse, as her bowel habits seem to be irregular. Her risk factors include a lack of exercise and poor diet. Nursing interventions include all of the following except:

Accepted Answer

Referring the client to the doctor for laxatives is not the best choice as it should be considered as a last resort after other interventions have been tried. The community nurse can first educate the client on the benefits of exercise and a high fibre diet, teach her how to keep a food diary to identify any triggers, and instruct her on the effects of any medications that may be contributing to her irregular bowel habits. If these interventions do not yield positive results, then referral to a doctor for laxatives may be considered.

Question 10

Which of the following suggestions by the nurse would be appropriate to maintain a normal faecal elimination pattern?

Accepted Answer

Including more whole grains in the diet can increase fiber intake and help promote normal bowel movements. Spicy foods and sugar may actually disrupt bowel function. Drinking enough water is also important for bowel function, but the recommended amount is typically higher than 2-4 glasses. Using enemas as desired is not a healthy or recommended way to maintain bowel regularity.

Question 11

A nurse observes that the stool of a client is black and tarry. The nurse would undertake all of the following except:

Accepted Answer

Steroid drugs do not typically cause black, tarry stools. Black, tarry stools (melena) are often indicative of gastrointestinal bleeding, which can be tested for with a stool test for blood. Consuming liquorice and diets high in red meat and leafy vegetables can also affect stool color, but steroids are not associated with this symptom.

Question 12

A client asks the RN why it is more difficult to use a bedpan for defecating than sitting on the toilet. Which of the following is the best response?

Accepted Answer

The sitting position increases the downward pressure on the rectum, which aligns the rectum in a way that makes it easier to pass stool. This is due to the effect of gravity and the natural position of the body when sitting, which facilitates bowel movements.

Question 13

Which of the following assessment data would indicate compromised gastrointestinal function?

Accepted Answer

Clay colour stool can be an indication of obstructive jaundice or other conditions affecting bile excretion, which may compromise gastrointestinal function. The other options do not necessarily indicate compromised gastrointestinal function.

Question 14

Which of the following is included in client teaching prior to administration of a cleansing enema?

Accepted Answer

The left lateral position is recommended for administering a cleansing enema as it allows the solution to flow more easily into the colon.

Question 15

Which of the following clients is at greatest risk for developing constipation?

Accepted Answer

An adult who is on bed rest is at greatest risk for developing constipation because the lack of mobility can slow down the digestive system and decrease bowel movements.

Question 16

The nurse would instruct a client with frequent bouts of diarrhoea to:

Accepted Answer

Using soft, unperfumed toilet tissue can help prevent further irritation of the anus and perianal area during frequent bouts of diarrhoea. Changing the daily routine or decreasing fluid consumption may not necessarily alleviate the symptoms, and increasing fibre in the diet may worsen diarrhoea.

Question 17

Which of the following actions by the client would signal to the nurse that client teaching was effective for preventing constipation?

Accepted Answer

Walking around several times a day promotes bowel motility and can help prevent constipation. A client who continues to ask for pain medication may indicate that constipation is already present and possibly not prevented. Refusing to eat bran flakes and decreasing fluid consumption can both contribute to constipation.

Question 18

A disease of the colon that can cause inflammation, ulcer formation and diarrhoea is ________.

Accepted Answer

The answer of A disease of the colon that can...

Question 19

The Assistant in Nursing (AIN) informs the Registered Nurse (RN) that one of the clients is passing lots of gas which is very noxious. The AIN asks why the smell is so bad. What should be the RN's response?

Accepted Answer

The most likely cause of the noxious gas is the action of microorganisms within the GI tract. As food is digested, it moves through the GI tract where it is broken down by bacteria, producing gas as a byproduct. The composition of this gas can vary depending on the type of bacteria present in the gut, as well as the type of food being digested. Certain foods, such as those high in sulfur, can lead to particularly foul-smelling gas. Emotions and the swallowing of air can also contribute to gas formation, but the odour is most likely due to the presence of microorganisms in the gut.

Question 20

The nurse is taking care of a client who states that he ignores the urge to defecate when he is at work. Which of the following responses by the nurse would explain why this practice should be changed?

Accepted Answer

Ignoring the urge to defecate can lead to loss of the urge, which can lead to constipation and other bowel problems. It is important to respond to the normal physiological urge to defecate.

Quiz 51: Faecal Elimination