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A patient admitted with acute diverticulitis has experienced a sudden increase in temperature and complains of a sudden onset of exquisite abdominal tenderness. The nurses rapid assessment reveals that the patients abdomen is uncharacteristically rigid on palpation. What is the nurses best response?
- A. Administer a Fleet enema as ordered and remain with the patient.
- B. Contact the primary care provider promptly and report these signs of perforation.
- C. Position the patient supine and insert an NG tube.
- D. Page the primary care provider and report that the patient may be obstructed.
Correct Answer: B
Rationale: The patients change in status is suggestive of perforation, which is a surgical emergency. Obstruction does not have this presentation involving fever and abdominal rigidity. An enema would be strongly contraindicated. An order is needed for NG insertion and repositioning is not a priority.
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A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer?
- A. Development of new hemorrhoids
- B. Abdominal bloating and flank pain
- C. Unexplained weight gain
- D. Change in bowel habits
Correct Answer: D
Rationale: The most common presenting symptom associated with colorectal cancer is a change in bowel habits. The passage of blood is the second most common symptom. Symptoms may also include unexplained anemia, anorexia, weight loss, and fatigue. Hemorrhoids and bloating are atypical.
A 35-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize?
- A. Insertion of a nasogastric tube
- B. Insertion of a central venous catheter
- C. Administration of a mineral oil enema
- D. Administration of a glycerin suppository and an oral laxative
Correct Answer: A
Rationale: Decompression of the bowel through a nasogastric tube is necessary for all patients with small bowel obstruction. Peripheral IV access is normally sufficient. Enemas, suppositories, and laxatives are not indicated if an obstruction is present.
A nurse is working with a patient who has chronic constipation. What should be included in patient teaching to promote normal bowel function?
- A. Use glycerin suppositories on a regular basis.
- B. Limit physical activity to promote bowel peristalsis.
- C. Consume high-residue, high-fiber foods.
- D. Resist the urge to defecate until the urge becomes intense.
Correct Answer: C
Rationale: Goals for the patient include restoring or maintaining a regular pattern of elimination by responding to the urge to defecate, ensuring adequate intake of fluids and high-fiber foods, learning about methods to avoid constipation, relieving anxiety about bowel elimination patterns, and avoiding complications. Ongoing use of soaps or pharmacologic aids should not be promoted, due to the risk of dependence. Increased mobility helps to maintain a regular pattern of elimination. The urge to defecate should be heeded.
A nurse is caring for a patient with constipation whose primary care provider has recommended senna (Senokot) for the management of this condition. The nurse should provide which of the following education points?
- A. Limit your fluid intake temporarily so you dont get diarrhea.
- B. Avoid taking the drug on a long-term basis.
- C. Make sure to take a multivitamin with each dose.
- D. Take this on an empty stomach to ensure maximum effect.
Correct Answer: B
Rationale: Laxatives should not be taken on an ongoing basis in order to reduce the risk of dependence. Fluid should be increased, not limited, and there is no need to take each dose with a multivitamin. Senna does not need to be taken on an empty stomach.
A nurse is providing care for a patient who has a diagnosis of irritable bowel syndrome (IBS). When planning this patients care, the nurse should collaborate with the patient and prioritize what goal?
- A. Patient will accurately identify foods that trigger symptoms.
- B. Patient will demonstrate appropriate care of his ileostomy.
- C. Patient will demonstrate appropriate use of standard infection control precautions.
- D. Patient will adhere to recommended guidelines for mobility and activity.
Correct Answer: A
Rationale: A major focus of nursing care for the patient with IBS is to identify factors that exacerbate symptoms. Surgery is not used to treat this health problem and infection control is not a concern that is specific to this diagnosis. Establishing causation likely is more important to the patient than managing physical activity.