Chapter 18: Elimination

1. To encourage a normal daily bowel movement, the nurse can aid the older adult by:

a.
decreasing fluid intake.
b.
providing a warm beverage at breakfast.
c.
medicating with a mild laxative at bedtime.
d.
providing a warm shower each morning.

ANS: B

Warm beverages at breakfast frequently stimulate the urge to defecate.

DIF: Cognitive Level: Comprehension REF: 286 OBJ: 6

TOP: Promoting Normal Elimination KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurse assesses constipation in the patient who passes:

a.
firm stool without difficulty every 3 days.
b.
hard stool without difficulty every 2 days.
c.
soft brown stool with difficulty every 2 days.
d.
hard dry stool with difficulty every 3 days.

ANS: D

Constipation is defined as a hard, dry stool that is difficult to pass.

DIF: Cognitive Level: Analysis REF: 287 OBJ: 1

TOP: Constipation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. The nurse recognizes a need for instruction about prevention of constipation when the patient says:

a.
“I eat bran flakes or oatmeal every day to add bulk to my diet.”
b.
“Since I started eating three servings of fruit a day, I haven’t been constipated.”
c.
“I’m never constipated. I take a gentle laxative every night.”
d.
”My daily walks have kept my bowels working regularly.”

ANS: C

Long-term laxative use may cause the body to become so dependent on laxatives that the patient is unable to have a normal elimination pattern without medication.

DIF: Cognitive Level: Application REF: 287 OBJ: 1

TOP: Constipation Prevention KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. The nurse explains that a diet low in dietary fiber results in a small stool that:

a.
moves rapidly through the intestines.
b.
becomes excessively dry.
c.
overstimulates the defecation reflex.
d.
contributes to frequent bowel movements.

ANS: B

Small stools move slowly because of the understimulation of peristalsis. The stool becomes dry and leads to infrequent defecation and constipation.

DIF: Cognitive Level: Application REF: 287 OBJ: 1

TOP: Dietary Fiber KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. The nurse would be especially observant for the indication of constipation in the patient who is taking:

a.
antibiotics for an upper respiratory infection.
b.
hormones for postmenopausal symptoms.
c.
iron supplements for anemia.
d.
nonsteroidal inhalants for chronic obstructive pulmonary disease (COPD).

ANS: C

Iron supplements increase the risk of constipation.

DIF: Cognitive Level: Analysis REF: 287 OBJ: 4

TOP: Medications Causing Constipation KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. The nurse explains that the urge to defecate (defecation reflex) can be destroyed by:

a.
frequent episodes of diarrhea.
b.
long-term use of vitamin A and vitamin B complex.
c.
repeatedly ignoring the urge.
d.
excessive fiber and bulk in the diet.

ANS: C

Ignoring the urge to defecate repeatedly suppresses the urge and may destroy it completely.

DIF: Cognitive Level: Comprehension REF: 288 OBJ: 4

TOP: Defecation Reflex KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. The nurse recognizes a need to make a focused bowel assessment when the 80-year-old resident complains of:

a.
the inability to have a bowel movement every day.
b.
feeling pressure and fullness in the rectum but is unable to defecate.
c.
having had one loose stool after breakfast.
d.
ingestion and flatulence.

ANS: B

Feelings of pressure and fullness without being able to defecate may indicate a fecal impaction or rectal cancer. One loose stool does not represent diarrhea. Indigestion and flatulence are common in the older adult.

DIF: Cognitive Level: Application REF: 288, Patient Teaching

OBJ: 4 TOP: Assessing Bowel Problems

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

8. The nurse uses special caution when performing a rectal digital examination on a patient with:

a.
chronic obstructive pulmonary disease (COPD).
b.
diabetes.
c.
Parkinson disease.
d.
congestive heart failure.

ANS: D

Persons with a cardiac history may experience vagal stimulation and have a sudden drop in heart rate, resulting in syncope.

DIF: Cognitive Level: Application REF: 288 OBJ: 6

TOP: Vagal Response KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. To assist an 85-year-old older adult with weak abdominal muscles to defecate, the nurse would:

a.
encourage the use of a bedpan before getting up in the morning.
b.
place a footstool under the feet of the patient when seated on the toilet.
c.
insert a finger in the patient’s rectum to stimulate the urge to defecate.
d.
instruct the patient to do isometric exercises to strengthen the abdominal muscles.

ANS: B

Placement of a stool under the patient’s feet increases intra-abdominal pressure and encourages bearing down (Valsalva maneuver) to accomplish defecation.

DIF: Cognitive Level: Application REF: 289 OBJ: 6

TOP: Weak Abdominal Muscles KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

10. The nurse tells the older adult that a food with the double action of providing fiber and being a natural laxative is:

a.
oatmeal.
b.
pineapple.
c.
prunes.
d.
raw apple.

ANS: C

Although all the options add fiber and bulk to the diet, only prunes provide a laxative effect.

DIF: Cognitive Level: Application REF: 289 OBJ: 6

TOP: Nonconstipating Foods KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. When the patient tells the home health nurse that he has begun to take psyllium (Metamucil), the nurse cautions him that to avoid fecal impaction with this drug, he should:

a.
eat several servings of fresh fruit and vegetables a day.
b.
avoid citrus fruit juices.
c.
reduce intake of carbonated drinks.
d.
increase his fluid intake to 3000 mL a day.

ANS: D

Increased fluid intake is essential to dissolve the fiber in this drug completely; otherwise, fecal impaction can occur.

DIF: Cognitive Level: Application REF: 289 OBJ: 6

TOP: Psyllium KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

12. The nurse recognizes the patient who is exhibiting signs of diarrhea and will need enhanced skin care precautions as the patient who has:

a.
one unformed stool after a bolus of tube feeding.
b.
an unformed stool followed by a formed stool 3 hours later.
c.
cramping and nausea followed by an unformed stool.
d.
no abdominal discomfort but has had three unformed stools in 8 hours.

ANS: D

Frequent passage of unformed stool with or without other symptoms should call for a heightened level of skin care.

DIF: Cognitive Level: Application REF: 292 OBJ: 2

TOP: Diarrhea KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

13. The nurse plans to help reduce episodes of bowel incontinence by a proactive program of:

a.
encouraging intake of foods that cause mild constipation.
b.
using appropriate disposable garments, pads, and bed covering.
c.
establishing a toileting schedule.
d.
coaching the patient in Kegel exercises.

ANS: C

Establishing a toileting schedule that follows the preincontinent state can train the patient’s bowel and caregivers so that incontinence is reduced.

DIF: Cognitive Level: Application REF: 293 OBJ: 6

TOP: Bowel Incontinence KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

14. The patient complains of feeling the need to urinate and fullness and tenderness in the bladder area. The patient is restless and diaphoretic. The initial nursing intervention would be to:

a.
help the patient into a warm tub bath to stimulate voiding.
b.
catheterize the patient.
c.
palpate the bladder fundus.
d.
place heated towels over the bladder area.

ANS: C

Palpation to assess distention would be the initial intervention before trying to remedy the urinary retention.

DIF: Cognitive Level: Application REF: 294 OBJ: 3

TOP: Urinary Distention KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

15. The nurse recognizes the cardinal sign of stress incontinence when the patient says:

a.
“Lifting my grandchild makes me wet my pants.”
b.
“I frequently wet myself because I just can’t get to the bathroom in time.”
c.
“My arthritis makes me so clumsy that I can’t get my pants down in time.”
d.
“Every time I have a urinary infection, I experience incontinence.”

ANS: A

Stress incontinence occurs when intra-abdominal pressure increases and forces urine through a weakened urinary sphincter. Lifting, sneezing, coughing, and laughing can cause stress incontinence.

DIF: Cognitive Level: Application REF: 294 OBJ: 3

TOP: Stress Incontinence KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. The home health nurse suggests that the patient perform a frequent series of Kegel exercises to reduce incontinence by:

a.
increasing the tone of the bladder.
b.
reducing urinary retention.
c.
strengthening the urinary sphincter.
d.
sensitizing biofeedback.

ANS: C

Kegel exercises, if done correctly and regularly, will strengthen the pelvic floor and will help hold back the flow of urine.

DIF: Cognitive Level: Comprehension REF: 296 OBJ: 6

TOP: Kegel Exercises KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. An alert, independent, 89-year-old male resident with congestive heart failure has been on Lasix for a week. Over the past 2 days he has been frequently incontinent and does not make it to the bathroom in time. His urine is now dark amber with a strong ammonia smell. He tells the nurse that he is having spasms in his lower abdomen. The nursing diagnosis that most applies to this resident is:

a.
impaired urinary elimination.
b.
functional urinary incontinence.
c.
stress urinary incontinence
d.
urge urinary incontinence.

ANS: D

Urge urinary incontinence occurs with the physiologic changes of aging. The use of diuretics, increased bladder stimulation from urinary tract infections, and involuntary bladder spasms cause the older adult to have a feeling of urgency and result in incontinence.

DIF: Cognitive Level: Comprehension REF: 295 OBJ: 5

TOP: Urge Incontinence KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

MULTIPLE RESPONSE

1. The nurse explains that normal bowel stimulation patterns for elimination of each person are influenced by __________. (Select all that apply.)

a.
level of activity
b.
diet
c.
medication
d.
fluid intake
e.
lifestyle

ANS: A, B, D, E

Medications frequently disrupt normal bowel elimination patterns.

DIF: Cognitive Level: Knowledge REF: 286 OBJ: 1

TOP: Normal Bowel Elimination Patterns

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurse outlines age-related changes that promote constipation in the older adult, which include __________. (Select all that apply.)

a.
diminished abdominal muscle tone
b.
reduced activity level
c.
inadequate fluid intake
d.
increased dietary fiber
e.
dependence on laxatives

ANS: A, B, C, E

Increased dietary fiber and bulk help prevent constipation.

DIF: Cognitive Level: Application REF: 287 OBJ: 1

TOP: Factors Supporting Constipation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. The nurse encourages fluid intake for the older adult to prevent constipation. If fluid intake is inadequate, constipation occurs because __________. (Select all that apply.)

a.
fluid will be withdrawn from the stool
b.
the stool becomes hard and dry
c.
less mucus is formed in the colon
d.
lumen of bowel constricts because of smaller bulk
e.
peristalsis slows

ANS: A, B, C

Inadequate fluid intake causes fluid to be withdrawn from the stool for the body’s fluid needs, making the stool dry and hard. There is less mucus in the bowel from age-related changes and diminished mucus production because of decreased fluid. Slowed peristalsis is not related to fluid intake. Lumen of the bowel does not constrict because of smaller bulk.

DIF: Cognitive Level: Application REF: 287 OBJ: 6

TOP: Fluid Intake KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. The nurse assesses a risk for constipation related to pain because of the presence of conditions such as __________. (Select all that apply.)

a.
hemorrhoids
b.
anal fissures
c.
reduction of bowel mucus
d.
diminished abdominal muscle tone
e.
slowed peristalsis

ANS: A, B, C

Diminished tone and slowed peristalsis do not contribute to pain.

DIF: Cognitive Level: Application REF: 288 OBJ: 4

TOP: Pain-Related Constipation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. The nurse is alerted to the possibility of a fecal impaction when the older adult patient complains of __________. (Select all that apply.)

a.
cramping
b.
rectal pain
c.
abdominal distention
d.
anorexia
e.
passing large amounts of liquid stool

ANS: A, B, C, D

Passing large amounts of liquid stools is not a sign of a fecal impaction. All other options are indications of fecal impaction.

DIF: Cognitive Level: Application REF: 288 OBJ: 4

TOP: Fecal Impaction KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. The skin care for an older adult with diarrhea should include __________. (Select all that apply.)

a.
perineal care immediately after the diarrhea episode
b.
application of lotion to the buttocks
c.
maintenance of dry linens
d.
patting the anal area dry rather than wiping
e.
leaving excoriated areas open to the air

ANS: A, C, D, E

Lotion will not protect the skin from urine and stool. Barrier cream must be used. All other interventions listed are part of special skin care for persons with diarrhea.

DIF: Cognitive Level: Comprehension REF: 292 OBJ: 6

TOP: Diarrhea Skin Care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

7. The nurse is aware that the broad general causes of bowel incontinence are __________. (Select all that apply.)

a.
inability to recognize defecation urge related to mental impairment
b.
inability to respond to defecation urge related to immobility
c.
inflammatory bowel disease
d.
increased fiber in the diet
e.
unexpected defecation when passing gas

ANS: A, B, C, E

Fiber provides bulk to waste. All other options are causes of incontinence.

DIF: Cognitive Level: Comprehension REF: 293 OBJ: 4

TOP: Causes of Bowel Incontinence KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. The nurse knows difficulty in bowel and bladder elimination occur in the older adult as a result of __________. (Select all that apply.)

a.
daily use of senna for defecation
b.
inability to get to adequate water
c.
fear of pain with defecation
d.
total privacy during elimination
e.
use of a bedpan for elimination

ANS: A, B, C, E

A lack of privacy may be a hindrance to elimination.

DIF: Cognitive Level: Application REF: 287-288 OBJ: 2

TOP: Age-Related Changes That Affect Elimination

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

1. The nurse is aware that an adult has the urge to urinate when the bladder has approximately _____ mL of urine in it.

ANS: 300

DIF: Cognitive Level: Comprehension REF: 286 OBJ: 1

TOP: Bladder Volume KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation