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A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next?
- A. Administer intravenous opioid medications.
- B. Position the client with knees to chest.
- C. Insert a nasogastric tube for decompression.
- D. Auscultate the client's bowel sounds.
Correct Answer: D
Rationale: A change from intermittent to constant abdominal pain in a client with a bowel obstruction may signal peritonitis or perforation. The nurse should auscultate for bowel sounds and check for rebound tenderness, then notify the provider.
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A nurse cares for a client who states, 'My husband is repulsed by my colostomy and refuses to be intimate with me.' How should the nurse respond?
- A. Let's discuss ways to help you and your husband address these concerns together.
- B. You could try to wear longer lingerie that will better hide the ostomy appliance.
- C. You should empty the pouch first so it will be less noticeable for your husband.
- D. If you are not careful, you can hurt the ostomy if you engage in sexual activity.
Correct Answer: A
Rationale: The nurse should collaborate with the client and her husband, possibly involving an ostomy nurse, to address intimacy concerns. The other options either minimize the issue or provide inaccurate information.
A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this client's assessment? (Select all that apply.)
- A. Which food types cause an exacerbation of symptoms?
- B. Which food types cause an amelioration of symptoms?
- C. Have you lost a significant amount of weight lately?
- D. Are your stools soft, watery, and black in color?
- E. Do you experience nausea associated with defecation?
Correct Answer: A,B,E
Rationale: The nurse should assess factors that exacerbate or ameliorate IBS symptoms, such as food, stress, and nausea related to defecation. Weight loss and black stools are not typical of IBS.
A nurse cares for a client with colon cancer who has a new colostomy. The client states, 'I think it would be helpful to talk with someone who has had a similar experience.' How should the nurse respond?
- A. I have a good friend with a colostomy who would be willing to talk with you.
- B. I will make a referral to the United Ostomy Associations of America.
- C. I will arrange for a visit from an enterostomal therapist.
- D. I can talk with people who have colostomies, but many don't want to share their experiences.
Correct Answer: B
Rationale: The nurse should refer the client to a community-based resource like the United Ostomy Associations of America, where they can connect with others who have similar experiences.
A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, 'My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it.' How should the nurse respond?
- A. Your doctor should not have given you that information prior to the colonoscopy.
- B. The colonoscopy is required due to the high percentage of false negatives with the blood test.
- C. A negative fecal occult blood test does not rule out the possibility of colon cancer.
- D. I will contact your doctor so that you can discuss your concerns about the procedure.
Correct Answer: C
Rationale: A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. A colonoscopy is necessary to visualize the entire colon and take a tissue sample for biopsy.
A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, 'The stool in my pouch is still liquid.' How should the nurse respond?
- A. The stool will always be liquid with this type of colostomy.
- B. Eating additional fiber will bulk up your stool and decrease diarrhea.
- C. The stool will become firmer over the next couple of weeks.
- D. This is abnormal. I will contact your health care provider.
Correct Answer: A
Rationale: Stool from an ascending colostomy remains liquid because there is little large bowel to reabsorb liquid. This is expected and not abnormal, and neither fiber nor time will change this.