The home health nurse is caring for a patient who has frequent abdominal pain and diarrhea. The nurse uses the Rome Criteria to direct data collection for irritable bowel syndrome. What is included in the Rome Criteria?
- A. Discomfort at least 3 days a month
- B. Blood in stool
- C. Pain relieved by defecation
- D. Excessive flatulence
- E. Nausea and vomiting associated with onset
- F. Onset associated with change in stool consistency or frequency
Correct Answer: A,C,F
Rationale: The Rome Criteria include that the patient experience discomfort at least 3 days a month within the last 3 months, pain relieved by defecation, onset associated with change in stool frequency, and onset in association with a change in stool appearance. Although increased flatus is associated with diverticulitis, it is not part of the Rome Criteria.
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Flexible sigmoidoscopy should be performed every years.
- A. 5
Correct Answer: 5
Rationale: Flexible sigmoidoscopy should be performed every 5 years. Endoscopy of the lower GI tract allows visualization and, if indicated, access to obtain biopsy specimens of tumors, polyps, or ulcerations of the anus, rectum, and sigmoid colon. The lower GI tract is difficult to visualize radiographically, but sigmoidoscopy allows direct visualization.
In caring for a patient with gastric bleeding who has a nasogastric (NG) tube in place, the nurse expects to see which intervention for the nasogastric tube included in the plan of care?
- A. clamp for 10 minutes every hour.
- B. keep the patent with irrigation.
- C. frequently reposition to the opposite nostril.
- D. change every 72 hours.
Correct Answer: B
Rationale: Irrigating the NG tube as needed will keep the tube patent and ensure effective decompression.
Due to frequent bouts of constipation, the nurse examines the bedfast nursing home resident for ulceration of the anus, called anal
- A. fissure
Correct Answer: fissure
Rationale: Ulceration and laceration of the anal skin can occur because of overstretching with the passing of constipated stool.
Bowel sound assessment on a patient with an early bowel obstruction who has distention, nausea, and visible peristaltic waves will demonstrate which type of bowel sound?
- A. loud and clearly audible.
- B. high pitched.
- C. hyperactive.
- D. absent.
Correct Answer: B
Rationale: Because there are visible peristaltic waves, there will be bowel sounds that will be faint and high pitched.
The nurse takes into consideration that long-term use of antibiotics can cause an antibiotic-associated pseudomembranous colitis from the organism
- A. Clostridium difficile
Correct Answer: Clostridium difficile
Rationale: C. difficile causes a type of colitis from long-term antibiotic use to which older adults are extremely susceptible.
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