Digestive & Gastrointestinal System Disorders | NCLEX Quiz 83

1. The nurse is caring for a male client postoperatively following creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care?

Sexual dysfunction

Body image. disturbed

Fear related to poor prognosis

Nutrition: more than body requirements. imbalanced

Body image. disturbed relates to loss of bowel control. the presence of a stoma. the release of fecal material onto the abdomen. the passage of flatus. odor. and the need for an appliance (external pouch). No data in the question support options A and C. Nutrition: less than body requirements. imbalanced is the more likely nursing diagnosis.

Explanation

Body image. disturbed relates to loss of bowel control. the presence of a stoma. the release of fecal material onto the abdomen. the passage of flatus. odor. and the need for an appliance (external pouch). No data in the question support options A and C. Nutrition: less than body requirements. imbalanced is the more likely nursing diagnosis.

2. The nurse is performing a colostomy irrigation on a male client. During the irrigation. the client begins to complain of abdominal cramps. What is the appropriate nursing action?

Notify the physician

Stop the irrigation temporarily

Increase the height of the irrigation

Medicate for pain and resume the irrigation

If cramping occurs during a colostomy irrigation. the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. The physician does not need to be notified. Increasing the height of the irrigation will cause further discomfort. Medicating the client for pain is not the appropriate action in this situation.

Explanation

If cramping occurs during a colostomy irrigation. the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. The physician does not need to be notified. Increasing the height of the irrigation will cause further discomfort. Medicating the client for pain is not the appropriate action in this situation.

3. The nurse is preparing a discharge teaching plan for the male client who had umbilical hernia repair. What should the nurse include in the plan?

Irrigating the drain

Avoiding coughing

Maintaining bed rest

Restricting pain medication

Coughing is avoided following umbilical hernia repair to prevent disruption of tissue integrity. which can occur because of the location of this surgical procedure. Bed rest is not required following this surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A drain is not used in this surgical procedure. although the client may be instructed in simple dressing changes.

Explanation

Coughing is avoided following umbilical hernia repair to prevent disruption of tissue integrity. which can occur because of the location of this surgical procedure. Bed rest is not required following this surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A drain is not used in this surgical procedure. although the client may be instructed in simple dressing changes.

4. The nurse is instructing the male client who has an inguinal hernia repair how to reduce postoperative swelling following the procedure. What should the nurse tell the client?

Limit oral fluid

Elevate the scrotum

Apply heat to the abdomen

Remain in a low-fiber diet

Following inguinal hernia repair. the client should be instructed to elevate the scrotum and apply ice packs while in bed to decrease pain and swelling. The nurse also should instruct the client to apply a scrotal support when out of bed. Heat will increase swelling. Limiting oral fluids and a low-fiber diet can cause constipation.

Explanation

Following inguinal hernia repair. the client should be instructed to elevate the scrotum and apply ice packs while in bed to decrease pain and swelling. The nurse also should instruct the client to apply a scrotal support when out of bed. Heat will increase swelling. Limiting oral fluids and a low-fiber diet can cause constipation.

5. The nurse is teaching a female client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns. what measure should the nurse instruct the client to do?

Increase fluid intake

Place heat on the abdomen

Perform the irrigation in the evening

Reduce the amount of irrigation solution

To enhance effectiveness of the irrigation and fecal returns. the client is instructed to increase fluid intake and to take other measures to prevent constipation. Options B. C and D will not enhance the effectiveness of this procedure.

Explanation

To enhance effectiveness of the irrigation and fecal returns. the client is instructed to increase fluid intake and to take other measures to prevent constipation. Options B. C and D will not enhance the effectiveness of this procedure.

6. The nurse is caring for a female client following a Billroth II procedure. Which postoperative order should the nurse question and verify?

Leg exercises

Early ambulation

Irrigating the nasogastric tube

Coughing and deep-breathing exercises

In a Billroth II procedure. the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery. unless specifically ordered by the physician. In this situation. the nurse should clarify the order. Options A. B. and D are appropriate postoperative interventions.

Explanation

In a Billroth II procedure. the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery. unless specifically ordered by the physician. In this situation. the nurse should clarify the order. Options A. B. and D are appropriate postoperative interventions.

7. The nurse is providing discharge instructions to a male client following gastrectomy and instructs the client to take which measure to assist in preventing dumping syndrome?

Ambulate following a meal

Eat high carbohydrate foods

Limit the fluid taken with meal

Sit in a high-Fowler’s position during meals

Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating. especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo. tachycardia. syncope. sweating. pallor. palpitations. and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods. including fluids such as fruit nectars; to assume a low-Fowler’s position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.

Explanation

Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating. especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo. tachycardia. syncope. sweating. pallor. palpitations. and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods. including fluids such as fruit nectars; to assume a low-Fowler’s position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.

8. The nurse is monitoring a female client for the early signs and symptoms of dumping syndrome. Which of the following indicate this occurrence?

Sweating and pallor

Bradycardia and indigestion

Double vision and chest pain

Abdominal cramping and pain

Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo. tachycardia. syncope. sweating. pallor. palpitations. and the desire to lie down.

Explanation

Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo. tachycardia. syncope. sweating. pallor. palpitations. and the desire to lie down.

9. The nurse is caring for a hospitalized female client with a diagnosis of ulcerative colitis. Which finding. if noted on assessment of the client. would the nurse report to the physician?

Hypotension

Bloody diarrhea

Rebound tenderness

A hemoglobin level of 12 mg/dL

Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss. the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the physician.

Explanation

Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss. the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the physician.

10. The nurse is reviewing the record of a female client with Crohn's disease. Which stool characteristics should the nurse expect to note documented in the client's record?

Diarrhea

Chronic constipation

Constipation alternating with diarrhea

Stools constantly oozing from the rectum

Crohn’s disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time. the diarrhea episodes increase in frequency. duration. and severity. Options B. C. and D are not characteristics of Crohn’s disease.

Explanation

Crohn’s disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time. the diarrhea episodes increase in frequency. duration. and severity. Options B. C. and D are not characteristics of Crohn’s disease.