Exam (elaborations)
Chapter 40 Bowel Elimination
- Course
- Fundamentals of Nursing
- Institution
- Oxford College Of Emory University
Chapter 40 Bowel Elimination
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DAWITChapter 40: Bowel Elimination
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 3RD Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient who periodically has small streaks of fresh red blood in the
stool. The patient denies abdominal pain or loss of appetite. The nurse identifies what to be
the most likely cause of this patient‘s bleeding?
a. Hemorrhoids
b. Bleeding gastric ulcer
c. Colon polyps
d. Perforated colon
ANS: A
Bleeding hemorrhoids can lead to small streaks of fresh red blood in the stool. Bleeding
gastric ulcer would lead to black, tarry stools as the blood is digested. Colon polyps do not
cause bleeding.
DIF: Understanding OBJ: 40.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Elimination
2. The nurse is caring for a patient who has diarrhea and identifies which priority nursing
diagnosis for this patient?
a. Lack of knowledge related to prescribed diet modifications
b. Impaired nutritional intakN
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ite
c. Diarrhea related to excessive loss of fluid through stool
d. Anxiety related to incontinence with loose stools and need for clothing change
ANS: C
Dehydration is the priority nursing problem for this patient, so diarrhea is the most important
Nursing diagnosis. Impaired nutritional intake, lack of knowledge, and anxiety can be
addressed once fluid balance is restored.
DIF: Applying OBJ: 40.4 TOP: Diagnosis
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Elimination
3. The nurse is caring for a patient who is prescribed diphenoxylate-atropine (Lomotil). Which
assessment finding by the nurse indicates a need to contact the prescriber and question the
order?
a. The patient has skin breakdown from loose stools.
b. The patient is constipated with last BM 3 days ago.
c. The patient is on a low-fiber, gluten-free diet.
d. The patient has painful bleeding hemorrhoids.
ANS: B
, DAWIT
Diphenoxylate-atropine is an antidiarrheal medication. It should not be given to patients who
are constipated until the patient is checked for impaction. The other assessment findings are
not contraindications.
DIF: Understanding OBJ: 40.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral
Therapies NOT: Concepts: Elimination
4. The nurse is caring for an immobile patient who has abdominal pain and frequent small, liquid
stools. The patient vomited his breakfast and is still nauseated. Which action by the nurse is
the highest priority?
a. Provide oral care after each episode of emesis.
b. Apply a skin barrier to the patient‘s perineal area.
c. Check the patient for a fecal impaction.
d. Administer antiemetic medication with a sip of water.
ANS: C
The patient who has abdominal pain and frequent small liquid stools should be checked for
fecal impaction, especially since the patient is vomiting. Immobility is a risk factor for the
development of fecal impaction. The other actions can be performed once fecal impaction is
ruled out.
DIF: Applying OBJ: 40.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort
NOT: Concepts: Elimination
5. The nurse is caring for a patient who is recovering from bowel surgery. Which assessment
finding best indicates that theNbUoRelI
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taT ng.tC
oOreM
sume function and the patient will be able
to resume oral intake soon?
a. The patient has bowel sounds x 4 quadrants and is passing gas.
b. The patient has no nausea, and abdominal pain is minimal.
c. The patient feels hungry for chicken soup and hot tea.
d. The patient‘s nasogastric tube was discontinued the previous day.
ANS: A
The presence of bowel sounds and passage of flatus indicate that the patient‘s bowels are
starting to resume function and the patient will be able to resume oral intake soon. Hunger,
discontinuation of the NG tube, or absence of nausea are not definite indicators of readiness to
resume oral feedings.
DIF: Applying OBJ: 40.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Nutrition
6. The nurse is caring for a patient who has an ileostomy. Which Nursing diagnosis has the
highest priority for the patient?
a. Impaired skin integrity r/t localized skin irritation from liquid stool
b. Social isolation r/t potential leakage of stool from ostomy appliance
c. Lack of knowledge r/t care and maintenance of ostomy appliance
d. Disturbed body image r/t presence of stoma and altered elimination
ANS: A
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