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An older adult has a diagnosis of Alzheimers disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the patients stools. What is the nurses most appropriate intervention?
- A. Keep a food diary to determine the foods that exacerbate the patients symptoms.
- B. Provide the patient with a bland, low-residue diet.
- C. Toilet the patient on a frequent, scheduled basis.
- D. Liaise with the primary care provider to obtain an order for loperamide.
Correct Answer: C
Rationale: Because the patients fecal incontinence is most likely attributable to cognitive decline, frequent toileting is an appropriate intervention. Loperamide is unnecessary in the absence of diarrhea. Specific foods are not likely to be a cause of, or solution to, this patients health problem.
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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 patients screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this patients health problem?
- A. Adherence to a high-fiber diet will help the polyps resolve.
- B. The patient should be assured that these are a normal, age-related physiologic change.
- C. The patients polyps constitute a risk factor for cancer.
- D. The presence of polyps is associated with an increased risk of bowel obstruction.
Correct Answer: C
Rationale: Although most polyps do not develop into invasive neoplasms, they must be identified and followed closely. They are very common, but are not classified as a normal, age-related physiologic change. Diet will not help them resolve and they do not typically lead to obstructions.
A nurse is providing care for a patient whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis?
- A. Encourage the patient to conduct online research into colostomies.
- B. Engage the patient in the care of the ostomy to the extent that the patient is willing.
- C. Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem.
- D. Emphasize the fact that the colostomy is temporary measure and is not permanent.
Correct Answer: B
Rationale: For some patients, becoming involved in the care of the ostomy helps to normalize it and enhance familiarity. Emphasizing the benefits of the intervention is unlikely to improve the patients body image, since the benefits are likely already known. Online research is not likely to enhance the patients body image and some ostomies are permanent.
A nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of the following would be appropriate nursing diagnoses for this patient?
- A. Acute Pain Related to Increased Peristalsis and GI Inflammation
- B. Activity Intolerance Related to Generalized Weakness
- C. Bowel Incontinence Related to Increased Intestinal Peristalsis
- D. Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea
- E. Impaired Urinary Elimination Related to GI Pressure on the Bladder
Correct Answer: A,B,D
Rationale: Patients with diverticulitis are likely to experience pain and decreased activity levels, and are at risk of fluid volume deficit. The patient is unlikely to experience fecal incontinence and urinary function is not directly influenced.
A nurse is assessing a patients stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding?
- A. Irrigate the ostomy to clear a possible obstruction.
- B. Contact the primary care provider to report this finding.
- C. Document that the stoma appears healthy and well perfused.
- D. Document a nursing diagnosis of Impaired Skin Integrity.
Correct Answer: C
Rationale: A healthy, viable stoma should be shiny and pink to bright red. This finding does not indicate that the stoma is blocked or that skin integrity is compromised.