ATI Care of Patients with Noninflammatory Intestinal Disorders, Questions and Answers with Explanations, 100% Correct, Download to Score A

Test Bank

MULTIPLE CHOICE

1. A client has irritable bowel syndrome. Which menu selections by this client indicate good understanding of dietary teaching?

a.            Tuna salad on white bread, cup of applesauce, glass of diet cola

b.            Broiled chicken with brown rice, steamed green beans, glass of apple juice

c.             Grilled cheese sandwich, small ripe banana, cup of hot tea with lemon

d.            Grilled steak, green beans, dinner roll with butter, cup of coffee with cream

ANS: B

Clients with irritable bowel syndrome are advised to eat a high-fiber diet (30 to 40 grams a day), with 8 to 10 cups of liquid daily. This selection has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Evaluation)

2. The nurse is performing a physical examination on a client. Which assessment finding leads the nurse to check the client’s abdomen for the presence of an acquired umbilical hernia?

a.            Body mass index (BMI) of 41.9

b.            Cholecystectomy last year

c.             History of irritable bowel syndrome

d.            Daily dose of lansoprazole (Prevacid) 30 mg orally

ANS: A

This type of hernia is associated with obesity. The other assessment findings do not place the client at increased risk for an acquired umbilical hernia.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse notes a bulge in a client’s groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings?

a.            Reducible inguinal hernia

b.            Indirect umbilical hernia

c.             Strangulated ventral hernia

d.            Incarcerated femoral hernia

ANS: A

In a reducible hernia, the contents of the hernial sac can be replaced into the abdominal cavity by gentle pressure or by lying flat. The contents of irreducible, strangulated, or incarcerated hernias may not be replaced into the abdomen when the client lies down.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

4. The nurse is caring for a client with an umbilical hernia who reports increased abdominal pain, nausea, and vomiting. The nurse notes high-pitched bowel sounds. Which conclusion does the nurse draw from these assessment findings?

a.            Bowel obstruction; client should be placed on NPO status.

b.            Perforation of the bowel; client needs emergency surgery.

c.             Adhesions in the hernia; client needs elective surgery.

d.            Hernia is dangerously enlarged; client needs a nasogastric (NG) tube.

ANS: A

The client with a hernia presenting with abdominal pain, fever, tachycardia, nausea and vomiting, and hypoactive bowel sounds should be suspected of having developed strangulation. Strangulation poses a risk of intestinal obstruction. The client should be placed on NPO status, and the health care provider should be notified. The symptoms are not suggestive of enlargement of the hernia, adhesion formation, or bowel perforation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

5. The nurse is teaching a client how to use a truss for a femoral hernia. Which statement by the client indicates the need for further teaching?

a.            “I will put on the truss before I go to bed each night.”

b.            “I will put some powder under the truss to avoid skin irritation.”

c.             “The truss will help my hernia because I can’t have surgery.”

d.            “If I have abdominal pain, I will let my health care provider know right away.”

ANS: A

The client is instructed to apply the truss before arising, not before going to bed at night. The other statements show accurate knowledge in using a truss.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Evaluation)

6. The nurse is providing preoperative teaching for a client who will undergo herniorrhaphy surgery. Which instruction does the nurse give to the client?

a.            “Eat a low-residue diet for the first week after surgery.”

b.            “Change the dressing every day until the staples are removed.”

c.             “Take acetaminophen (Tylenol) 1000 mg every 4 hours for pain.”

d.            “Cough and deep breathe every 2 hours for the first week after surgery.”

ANS: B

The dressing should be changed every day until the staples are removed, so the client can check the incision for signs of infection. Constipation is common following hernia surgery, so clients should include adequate amounts of fiber in the diet. The maximum daily dosage of Tylenol is 4000 mg. Taking 1000 mg of Tylenol every 4 hours means that intake is 6000 mg/day, which could cause toxicity and liver damage. The client should change positions and take deep breaths to facilitate lung expansion but should avoid coughing, which can place stress on the incision line.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

7. The nurse is performing a physical assessment for a client who underwent a hemorrhoidectomy the previous day. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which is the nurse’s priority action?

a.            Assess the client’s vital signs.

b.            Determine the last time the client voided.

c.             Insert a rectal tube to facilitate passage of flatus.

d.            Document the findings in the client’s chart.

ANS: B

Assessment findings indicate that the client may have an overfull bladder. In the immediate postoperative period, the client may experience difficulty voiding owing to urinary retention. A rectal tube should not be inserted for a client who had a hemorrhoidectomy the previous day. The client’s vital signs may be checked after the nurse determines the client’s last void. The nurse should document all findings and actions in the client’s medical record.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

8. The nurse is screening clients at a community health fair. Which client is at highest risk for development of colorectal cancer?

a.            Young adult who drinks eight cups of coffee every day

b.            Middle-aged client with a history of irritable bowel syndrome

c.             Older client with a BMI of 19.2 who works 65 hours per week

d.            Older client who travels extensively and eats fast food frequently

ANS: D

Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Irritable bowel syndrome, a heavy workload, and coffee intake do not increase the risk for colon cancer. A BMI of 19.2 is within normal limits.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1246

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

9. The nurse is performing a physical assessment of a client with a new diagnosis of colorectal cancer. The nurse notes the presence of visible peristaltic waves and, on auscultation, hears high-pitched bowel sounds. Which conclusion does the nurse draw from these findings?

a.            The tumor has metastasized to the liver and biliary tract.

b.            The tumor has caused an intussusception of the intestine.

c.             The growing tumor has caused a partial bowel obstruction.

d.            The client has developed toxic megacolon from the growing tumor.

ANS: C

The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. Assessment findings do not indicate metastasis to the liver, intussusception of the intestine, or toxic megacolon.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

10. The nurse is caring for a client who is scheduled to have fecal occult blood testing. Which instructions does the nurse give to the client?

a.            “You must fast for 12 hours before the test.”

b.            “You will be given a cleansing enema the morning of the test.”

c.             “You must avoid eating meat for 48 hours before the test.”

d.            “You will be sedated and will require someone to accompany you home.”

ANS: C

The client is instructed to avoid meat, aspirin, vitamin C, and anti-inflammatory drugs for 48 hours before the test. The other directions are not accurate for this test.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1247

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Teaching/Learning

11. A client who has had fecal occult blood testing tells the nurse that the test was negative for colon cancer and wishes to cancel a colonoscopy scheduled for the next day. Which is the nurse’s best response?

a.            “I will call and cancel the test for tomorrow.”

b.            “You need two negative fecal occult blood tests.”

c.             “This does not rule out the possibility of colon cancer.”

d.            “You should wait at least a week to have the colonoscopy.”

ANS: C

A negative result does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed, so the entire colon can be visualized and a tissue sample taken for biopsy. The client need not wait a week before the colonoscopy. Two negative fecal occult blood tests do not rule out the presence of colorectal cancer (CRC).

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1247

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Teaching/Learning

12. The nurse is caring for a client who has been newly diagnosed with colon cancer. The client has become withdrawn from family members. Which strategy does the nurse use to assist the client at this time?

a.            Ask the health care provider for a psychiatric consult for the client.

b.            Explain the improved prognosis for colon cancer with new treatment.

c.             Encourage the client to verbalize feelings about the diagnosis.

d.            Allow the client to remain withdrawn as long as he or she wishes.

ANS: C

The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client’s feelings with a generalization about cancer prognosis and treatment. The nurse should not ignore the client’s withdrawal behavior.