Nokea
A client tells the nurse, 'I am not having normal bowel movements.' When differentiating between what are normal and abnormal bowel habits, what indicators are the most important?
- A. The consistency of stool and comfort when passing stool
- B. That the client has a bowel movement daily
- C. That the stool is formed and soft
- D. The client is able to fully evacuate with each bowel movement
Correct Answer: A
Rationale: In differentiating normal from abnormal, the consistency of stools and the comfort with which a person passes them are more reliable indicators than is the frequency of bowel elimination. People differ greatly in their bowel habits and normal bowel patterns range from three bowel movements per day to three bowel movements per week. It is important for the stool to be soft to pass without pain. The client may not be able to fully evacuate with a bowel movement, it may take time.
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A client realizes that regular use of laxatives has led to bowel pattern improvement. However, the nurse cautions this client against the prolonged use of laxatives for which reason?
- A. The client may develop inflammatory bowel disease.
- B. The client may develop arthritis or arthralgia.
- C. The client's natural bowel function may become sluggish.
- D. The client's appetite may be depleted.
Correct Answer: C
Rationale: It is essential for the nurse to caution the client against the prolonged use of laxatives because it decreases muscle tone in the large intestine. Prolonged use of laxatives may cause the client's natural bowel function to become sluggish. Laxatives do not increase the risk of developing inflammatory bowel disease, arthritis, or arthralgia, nor do they cause a loss in appetite.
The nurse is reviewing the laboratory test results of a client with Crohn disease. Which of the following would the nurse most likely find?
- A. Decreased white blood cell count
- B. Increased albumin levels
- C. Stool cultures negative for microorganisms or parasite
- D. Decreased erythrocyte sedimentation rate
Correct Answer: C
Rationale: Stool cultures fail to reveal an etiologic microorganism or parasite, but occult blood and white blood cells (WBCs) often are found in the stool. Results of blood studies indicate anemia from chronic blood loss and nutritional deficiencies. The WBC count and erythrocyte sedimentation rate may be elevated, confirming an inflammatory disorder. Serum protein and albumin levels may be low because of malnutrition.
The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to?
- A. Referred pain
- B. Rebound pain
- C. Rovsing sign
- D. Cremasteric reflex
Correct Answer: C
Rationale: When an examiner deeply palpates the left lower abdominal quadrant and the client feels pain in the right lower quadrant, this is referred to as a positive Rovsing sign and suggests acute appendicitis. Referred pain indicates pain in another area but is not necessarily manipulated by the examiner. Rebound pain is indicated when the pain of palpation is worse when the pressure is off the site. The cremasteric reflex is a superficial reflex that is present in male clients.
The nurse is caring for a client who has had diarrhea for 3 days. What major problem(s) associated with severe or prolonged diarrhea should the nurse monitor for when caring for this client? Select all that apply.
- A. Oral candidiasis
- B. Dehydration
- C. Electrolyte imbalances
- D. Vitamin deficiencies
- E. Rectal fissures
Correct Answer: B,C,D
Rationale: Three major problems associated with severe or prolonged diarrhea include dehydration, electrolyte imbalances, and vitamin deficiencies.
The nurse is interviewing a client with internal hemorrhoids. What would the nurse expect the client to report?
- A. Rectal bleeding
- B. Pain
- C. Itching
- D. Soreness
Correct Answer: A
Rationale: Internal hemorrhoids cause bleeding but are less likely to cause pain, unless they protrude through the anus. External hemorrhoids may cause few symptoms, or they can produce pain, itching, and soreness of the anal area.