Nokea
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.
You may also like to solve these questions
A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider?
- A. White blood cell (WBC) count of 1500/mm3
- B. Fatigue
- C. Nausea and diarrhea
- D. Mucositis and oral ulcers
Correct Answer: A
Rationale: A WBC count of 1500/mm3 is significantly below the normal range (5000-10,000/mm3), indicating a high risk for infection. The provider should be notified immediately, as chemotherapy may need to be delayed.
A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes visible peristaltic waves. Which action should the nurse take next?
- A. Ask if the client is experiencing pain in the right shoulder.
- B. Perform a rectal examination and assess for polyps.
- C. Contact the provider and recommend computed tomography.
- D. Administer a laxative to increase bowel movement activity.
Correct Answer: C
Rationale: The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of a partial obstruction caused by the tumor. The nurse should contact the provider and recommend a computed tomography scan for further diagnostic testing.
After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which meal indicates the client correctly understands the dietary teaching?
- A. Ham sandwich on white bread, cup of applesauce, glass of diet cola
- B. Baked chicken with brown rice, steamed broccoli, glass of apple juice
- C. Grilled cheese sandwich, small banana, cup of tea with lemon
- D. Baked tilapia, fresh green beans, cup of coffee with low-fat milk
Correct Answer: B
Rationale: Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Baked chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.
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.
After teaching a client who has a femoral hernia, the nurse assesses the client's understanding. Which statement indicates the client needs additional teaching related to the proper use of a truss?
- A. I will put on the truss before I go to bed each night.
- B. I will place some padding under the truss to avoid skin irritation.
- C. The truss will help my hernia because I can't have surgery.
- D. If I have abdominal pain, I'll let my health care provider know right away.
Correct Answer: A
Rationale: The client should be instructed to apply the truss before arising, not before going to bed at night. The other statements show an accurate understanding of using a truss.