Nokea
The nurse is caring for a patient who has blunt abdominal trauma after an automobile accident and severe pain. A peritoneal lavage returns brown drainage with fecal material. Which of the following actions should the nurse plan to take next?
- A. Auscultate the bowel sounds.
- B. Prepare the patient for surgery.
- C. Check the patient's oral temperature.
- D. Obtain information about the accident.
Correct Answer: B
Rationale: Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.
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The nurse is obtaining a history for a female patient who is being evaluated for acute lower abdominal pain and vomiting. Which of the following questions is most useful in determining the cause of the patient's symptoms?
- A. Is it possible that you are pregnant?
- B. Can you tell me more about the pain?
- C. What type of foods do you usually eat?
- D. What is your usual elimination pattern?
Correct Answer: B
Rationale: A complete description of the pain provides clues about the cause of the problem. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain.
The nurse is admitting a patient with an exacerbation of inflammatory bowel disease (IBD). Which of the following nursing actions should the nurse include in the plan of care?
- A. Restrict oral fluid intake.
- B. Monitor stools for blood.
- C. Increase dietary fibre intake.
- D. Ambulate four times daily.
Correct Answer: B
Rationale: Since anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Because dietary fibre may increase gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.
The nurse is preparing a 50-year-old patient for an annual physical examination. Which of the following diagnostic tests should the nurse teach to the patient?
- A. Endoscopy
- B. Fecal occult blood test
- C. Computerized tomography screening
- D. Carcinoembryonic antigen (CEA) testing
Correct Answer: B
Rationale: At age 50, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC, including a fecal occult blood test (FOBT). Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical examination at age 50.
The nurse is caring for a patient with an exacerbation of ulcerative colitis who is having 15-20 stools daily and has external hemorrhoids. Which of the following patient behaviours indicate that teaching regarding maintenance of skin integrity has been effective?
- A. The patient uses incontinence briefs to contain loose stools.
- B. The patient asks for antidiarrheal medication after each stool.
- C. The patient uses witch hazel compresses to decrease anal discomfort.
- D. The patient cleans the perianal area with soap and water after each stool.
Correct Answer: C
Rationale: Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15-20 times a day. The perianal area should be washed with plain water after each stool.
The nurse is caring for a patient who has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 4.5 kg over 2 months. Which of the following topics should the nurse plan to include in the teaching plan?
- A. Medication use
- B. Fluid restriction
- C. Enteral nutrition
- D. Activity restrictions
Correct Answer: A
Rationale: Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.