Nokea
The nurse is teaching a client with constipation to increase dietary fiber intake to 25 g/day. Which recommendation would the nurse include?
- A. Avoiding bran cereals and beans in the diet
- B. Adding fiber-rich foods to the diet gradually
- C. Limiting fluid intake to 5 to 6 glasses per day
- D. Minimizing activity levels for at least 2 months
Correct Answer: B
Rationale: The nurse instructs the client to add fiber-rich foods to the diet gradually to avoid bloating, gas, and diarrhea. It is essential for a client to include bran cereals and beans in the diet because they ease defecation. The nurse also instructs the client to increase fluids to 6 to 8 glasses per day to prevent hard, dry stools. The client should also develop a regular exercise program to increase peristalsis and promote bowel elimination.
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A client has developed an anorectal abscess. Which client is likely at risk for the development of this type of abscess?
- A. A client with Crohn disease
- B. A client with hemorrhoids
- C. A client with colon cancer
- D. A client with diverticulosis
Correct Answer: A
Rationale: An anorectal abscess is common in clients with Crohn disease. The other disorders do not predispose the client to risk for anorectal abscess.
A nurse is preparing a presentation for a local community group of older adults about colon cancer. What would the nurse include as the primary characteristic associated with this disorder?
- A. Abdominal distention
- B. Frank blood in the stool
- C. A change in bowel habits
- D. Abdominal pain
Correct Answer: C
Rationale: Although abdominal distention and blood in the stool (frank or occult) may be present, the chief characteristic of cancer of the colon is a change in bowel habits, such as alternating constipation and diarrhea. Abdominal pain is a late sign.
The nurse is reviewing the laboratory test results of a client with Crohn disease. Which of the following would the nurse most likely find?
- A. Decreased white blood cell count
- B. Increased albumin levels
- C. Stool cultures negative for microorganisms or parasite
- D. Decreased erythrocyte sedimentation rate
Correct Answer: C
Rationale: Stool cultures fail to reveal an etiologic microorganism or parasite, but occult blood and white blood cells (WBCs) often are found in the stool. Results of blood studies indicate anemia from chronic blood loss and nutritional deficiencies. The WBC count and erythrocyte sedimentation rate may be elevated, confirming an inflammatory disorder. Serum protein and albumin levels may be low because of malnutrition.
The instructor is teaching a group of students about intestinal obstruction. The instructor determines that the teaching was effective when the students identify which of the following as a cause of a functional obstruction?
- A. Volvolus
- B. Intussusception
- C. Tumor
- D. Abdominal surgery
Correct Answer: D
Rationale: In functional obstruction, the intestine can become adynamic from an absence of normal nerve stimulation to intestinal muscle fibers. For example, abdominal surgery can lead to paralytic ileus. Mechanical obstructions result from a narrowing of the bowel lumen with or without a space-occupying mass. A mass may include a tumor, adhesions (fibrous bands that constrict tissue), incarcerated or strangulated hernias, volvulus (kinking of a portion of intestine), intussusception (telescoping of one part of the intestine into an adjacent part), or impacted feces or barium.
The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to?
- A. Referred pain
- B. Rebound pain
- C. Rovsing sign
- D. Cremasteric reflex
Correct Answer: C
Rationale: When an examiner deeply palpates the left lower abdominal quadrant and the client feels pain in the right lower quadrant, this is referred to as a positive Rovsing sign and suggests acute appendicitis. Referred pain indicates pain in another area but is not necessarily manipulated by the examiner. Rebound pain is indicated when the pain of palpation is worse when the pressure is off the site. The cremasteric reflex is a superficial reflex that is present in male clients.