Bowel Elimination

1.A student nurse is caring for a patient who has dehydration as a result of diarrhea. Diarrhea is a result of abnormally fast peristalsis in what organ?

a.
Jejunum
b.
Stomach
c.
Duodenum
d.
Colon

ANS: D

The large intestine is the primary organ of bowel elimination. If peristalsis is abnormally fast in the colon, there is less time for water to be absorbed and the stool will be watery. The stomach is part of the upper GI system. The duodenum and jejunum are part of the small intestines.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:994

OBJ: Explain the physiology of digestion, absorption, and bowel elimination.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2.The labor/delivery nurse is caring for a 33-year-old who is in labor with her first child. The patient complained to the nurse about the hemorrhoids that she has experienced during the last month of her pregnancy. She asks, “what can I do to prevent future problems with hemorrhoids?” What is the nurse’s best response?

a.
“Hemorrhoids are caused by defecation of stools that are loose and watery.”
b.
“You need to soften your stools by drinking plenty of fluids.”
c.
“You should eat less carbohydrates.”
d.
“There is nothing that you can do to prevent hemorrhoids.”

ANS: B

Hemorrhoids are dilated, engorged veins in the lining of the rectum. Increased venous pressure resulting from straining at defecation, pregnancy, and chronic illnesses, such as congestive heart failure and chronic liver disease, are causative factors. A hemorrhoid forms either within the anal canal (internal) or through the opening of the anus (external). Passage of hard stool causes hemorrhoid tissue to stretch and bleed. Hemorrhoid tissue becomes inflamed and tender, and patients complain of itching and burning. Because pain worsens during defecation, the patient sometimes ignores the urge to defecate, resulting in constipation.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:997 | 1013

OBJ: List nursing measures aimed at promoting normal elimination and defecation.

TOP:Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

3.The nurse caring for several patients on the surgical unit of the hospital. The nurse knows that constipation can be a significant health hazard and encourages the postoperative patients to drink fluids. Which one of the following patients is most at risk from complications related to constipation?

a.
A 35-year-old man with back surgery
b.
A 47-year-old woman with an abdominal hysterectomy
c.
A 29-year-old women with carpal tunnel surgery
d.
A 77-year-old man with hip surgery

ANS: B

Constipation is a significant health hazard. Straining during defecation causes problems for patients with recent abdominal, gynecological, or rectal surgery. An effort to pass a stool can cause sutures to separate, reopening a wound. In addition, patients with cardiovascular disease, diseases causing elevated intraocular pressure (glaucoma), and increased intracranial pressure need to prevent constipation and avoid using the Valsalva maneuver. Constipation is most often caused by changes in diet, medications, mobility, inflammation, environmental factors (e.g., unavailability of toilet facilities or lack of privacy), and lack of knowledge about regular bowel habits.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:994 | 996

OBJ: List nursing measures aimed at promoting normal elimination and defecation.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

4.A patient will be undergoing abdominal surgeries, which will most likely result in an ostomy. The patient asks the nurse, “What will the stool from my ostomy look like?” What is the best answer?

a.
“Your stools won’t change from what they currently are.”
b.
“The consistency of your stools will be very soft.”
c.
“The consistency of your stools will be liquid.”
d.
“The consistency of your stools will depend on the location of stoma (ostomy).”

ANS: D

The location of an ostomy determines stool consistency. The more intestine remaining, the more formed and normal the stool. For example, an ileostomy bypasses the entire large intestine, creating frequent, liquid stools. A person with a sigmoid colostomy will have a more formed stool.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:997 | 998

OBJ:Describe nursing care required to maintain structure and function of a bowel diversion.TOP:Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

5.A patient was involved in a motor vehicle accident and underwent a loop colostomy. The patient questions the nurse about what is draining out of each side of the colostomy. What is the nurse’s best response?

a.
“There is stool draining out of both sides.”
b.
“Stool is draining out the stomach side and mucus is draining from the rectum side.”
c.
“There is mucus and stool draining from both sides.”
d.
“There is stool draining out of the stomach side and nothing draining out of the rectum side.”

ANS: B

Loop colostomies are frequently performed on an emergency basis and are temporary large stomas constructed in the transverse colon. The loop ostomy has two openings through the stoma. The proximal end drains stool, and the distal portion drains mucus.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:998

OBJ:Describe nursing care required to maintain structure and function of a bowel diversion.TOP:Nursing Process: Implementation

MSC:Client Needs: Physiological Integrity

6.A 45-year-old Catholic Hispanic-American patient has been admitted to the hospital with pneumonia. On admission, the patient did not identify any food preferences or food allergies. The nurse notes that the patient has requested that the family provide all meals during the hospital stay. This is most likely related to which of the following?

a.
Food preferences
b.
Hispanic cultural traditions
c.
Religious preferences
d.
Food sensitivities

ANS: B

The intake of certain foods also reflects the patient’s culture or beliefs. Foods in various cultures have different status relating to religion, availability, cost, and tradition. For example, some Hispanic-Americans use certain hot foods (e.g., chocolate, cheese, eggs) for conditions producing fever, and cold foods (e.g., fresh vegetables, dairy foods, honey) for disorders such as cancer or headaches. Understand the patient’s cultural heritage and the role diet plays in health promotion and maintenance.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:999

OBJ: Explain the physiology of digestion, absorption, and bowel elimination.

TOP:Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

7.The home health nurse is visiting a 67-year-old widow who lives at home by herself. The patient voices a concern about constipation. What is the best way for the nurse to approach the patient’s concern?

a.
“Tell me why you think you are constipated.”
b.
“Have you noticed that your stools are hard?”
c.
“How frequently are you having a bowel movement?”
d.
“What color is your stool?”

ANS: A

In determining the patient’s bowel habits, remember “normal” is unique to each individual. Far too often nurses do not acknowledge an older adult’s problems with intestinal elimination as an important consideration in their care. Remember that what appears at the outset to be a trivial complaint may be a significant problem physically and/or psychologically. Apply this knowledge in preparing questions for the patient interview to determine the presence and extent of GI alterations. Although the other questions will help determine if there is a problem, having the patient voice her concern will direct future questions. Determine your patient’s usual pattern of bowel elimination. Usual frequency and time of day are important, but also determine if any changes in elimination patterns have occurred. Ask the patient to make suggestions about the reason for any change.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 1000 OBJ: Assess a patient’s bowel elimination pattern.

TOP:Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

8.The nurse is caring for a patient on the GI floor who has anemia. When reviewing the patient’s recent lab work, which lab test would the nurse expect to be decreased?

a.
Total bilirubin
b.
Hemoglobin and hematocrit
c.
Serum amylase
d.
Ova and parasites

ANS: B

There are no blood tests to specifically diagnose most gastrointestinal disorders, but hemoglobin and hematocrit may be done to determine if anemia from gastrointestinal (GI) bleeding is present. Liver function tests such as bilirubin and serum amylase to assess for hepatobiliary diseases and pancreatitis are possible tests that may be ordered by the health care provider. A stool sample is needed to test for ova and parasites.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1001

OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Nursing Process: Assessment

MSC:Client Needs: Physiological Integrity

9.The nurse is caring for a patient with abdominal pain. While obtaining a stool specimen for occult blood, the nurse notices that the specimen is black. The nurse recognizes that the color change may be the result of which of the following?

a.
Absence of bile
b.
Malabsorption of fat
c.
Diarrhea
d.
Iron supplements or GI bleeding

ANS: D

Blood in the stool or melena causes stool to turn black and sticky, hence the term tarry stools. Ingestion of iron supplements can also cause the stool to turn black. Stool that is white or clay-color is caused by the absence of bile. Stool that is oily or pale in color is caused by the malabsorption of fat. Liquid brown or yellow stool is caused by diarrhea.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1001-1003

OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Nursing Process: Assessment

MSC:Client Needs: Physiological Integrity

10.A student nurse is assisting with colon cancer screening at the local health care clinic. The student is completing fecal occult blood testing on the stool specimens. This test is also referred to as a(n) _____ test.

a.
melena
b.
guaiac
c.
amylase
d.
alkaline phosphatase

ANS: B

A common test is the fecal occult blood test (FOBT) or guaiac test, which measures microscopic amounts of blood in the feces. It is a useful screening test for colon cancer. Melena refers to blood in the stool that causes stool to turn black and sticky. Amylase and alkaline phosphatase are blood tests.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:1002

OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

11.A patient is concerned about intermittent constipation and is confused about all the laxatives that are available. One of the laxatives that the patient has used in the past was mineral oil. The nurse explains that this type of laxative is an example of a(n) _____ laxative.

a.
stimulant
b.
osmotic agent
c.
emollient
d.
lubricant

ANS: D

Cathartics are classified by the method by which the agent promotes defecation. Stimulant cathartics cause local irritation to the intestinal mucosa, increase intestinal motility, and inhibit reabsorption of water in the large intestine. Saline or osmotic agents contain a salt preparation that the intestines do not absorb. The cathartic draws water into the fecal mass. This osmotic action increases the bulk of the intestinal contents and enhances lubrication. Emollient or wetting agents are detergents and act as stool softeners to lower the surface tension of feces, allowing water and fat to penetrate the fecal material. Bulk-forming cathartics absorb water and increase solid intestinal bulk. The fecal bulk stretches the intestinal walls, stimulating peristalsis. Lubricants soften the fecal mass, thus easing the strain of defecation. The only lubricant laxative available is mineral oil.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1010 | 1011

OBJ: List nursing measures aimed at promoting normal elimination and defecation.

TOP:Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

12.The nurse observes a continual oozing of stool from the rectum of a patient who has been immobilized following surgery. The nurse recognizes that this condition most likely a result of which of the following?

a.
Diarrhea
b.
Flatulence
c.
Fecal impaction
d.
The Valsalva maneuver

ANS: C

An obvious sign of impaction is the inability to pass a stool for several days, despite a repeated urge to defecate. Continuous oozing of liquid stool after several days with no fecal output may indicate an impaction. Loss of appetite, abdominal distention and cramping, nausea and/or vomiting, and rectal pain also occur. Diarrhea is an increased frequency in the passage of loose stools. Flatulence is a sense of bloating and abdominal distention usually accompanied by excess gas. The Valsalva maneuver occurs when pressure is exerted to expel feces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 996 OBJ: Assess a patient’s bowel elimination pattern.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

13.To maintain normal elimination patterns in a hospitalized patient, why should the nurse encourage the patient to take time to defecate 1 hour after meals?

a.
The presence of food stimulates peristalsis.
b.
Mass colonic peristalsis occurs at this time.
c.
Irregularity helps to develop a habitual pattern.
d.
Neglecting the urge to defecate can cause diarrhea.

ANS: B

Defecation is most likely to occur after meals. If the patient attempts to defecate during the time when mass colonic peristalsis occurs, the chances of successfully evacuating the rectum are greater. When stool reaches the rectum, distention causes relaxation of the internal sphincter and awareness of the need to defecate. Establishing a consistent time for bowel hygiene is one evidenced-based practice to avoid constipation. Ignoring the urge to defecate and not taking time to defecate completely are common causes of constipation.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:994

OBJ: List nursing measures aimed at promoting normal elimination and defecation.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

14.The health care provider orders a patient to have a fecal occult blood test. To obtain an accurate result, the nurse instructs the patient to do which of the following?

a.
Submit one sample for analysis.
b.
Take extra amounts of vitamin C supplements.
c.
Stop taking aspirin 14 days prior to the beginning of the test.
d.
Refrain from ingesting red meats for 3 days before testing.

ANS: D

The patient needs to repeat the test at least three times on three separate bowel movements while the patient refrains from ingesting foods and medications that cause a false-positive or false-negative result. Foods to avoid include red meat, vitamin C, and citrus fruit and juices for 3 days. Medication such as aspirin, ibuprofen, naproxen, or other nonsteroidal antiinflammatory drugs should be avoided for 7 days.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:1001-1004OBJ:Perform a fecal occult blood test.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

15.The nurse receives a patient from the emergency department with the diagnosis of ileus. The nurse expects the health care provider to order NPO for dietary status, and insert a nasogastric tube. The nurse knows that the purpose of the nasogastric tube is to do which of the following?

a.
Decompress the stomach until peristalsis returns.
b.
Provide tube feedings until peristalsis resumes.
c.
Allow for the release of flatulence.
d.
To keep the stomach expanded until peristalsis resumes.

ANS: A

A patient cannot eat or drink fluids without causing abdominal distention and nausea and vomiting to occur. The insertion of a nasogastric (NG) tube into the stomach serves to decompress the stomach, keeping it empty until normal peristalsis returns. Flatulence (having accumulated gas) is one of the most common GI disorders. It refers to a sensation of bloating and abdominal distention accompanied by excess gas. Normally, intestinal gas escapes through the mouth (belching) or the anus.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:1011

OBJ:Describe common physiological alterations in bowel elimination.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

16.Elevating the head of the bed to the maximum allowed amount of 30 degrees for a patient in balanced suspension traction helps to promote normal elimination by which of the following?

a.
Decreasing peristaltic movement
b.
Promoting contraction of the thigh muscles
c.
Strengthening the resistance of the internal and external sphincters
d.
Exerting increased pressure on the rectum

ANS: D

To help patients evacuate contents normally and without discomfort, recommend interventions that stimulate the defecation reflex or increase peristalsis. Helping the patient into an upright sitting position increases pressure on the rectum and facilitates use of intraabdominal muscles. Patients who have had surgery have muscular weakness or mobility limitations and benefit from the use of elevated toilet seats.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:1009

OBJ: Discuss physiological and psychological factors that influence bowel elimination.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

MULTIPLE RESPONSE

1.A nurse has delegated the administration of a tap water enema to a nursing assistive personnel (NAP). The assistive personnel demonstrates understanding of the procedure when she states which of the following? (Select all that apply.)

a.
“I will lower the enema when the patient complains of cramping.”
b.
“I will speed up the enema administration when the patient complains of cramping.”
c.
“I will withdraw the tube when the patient complains of cramping.”
d.
“I will clamp the tubing when the patient complains of cramping.”
e.
“I will fill the bag with hot water because it will cool while I am administering the enema.”
f.
“I will have the patient sit on the toilet while I am administering the enema.”

ANS: A, D

When the enema is instilled too rapidly, the instillation will cause pain and cramping. The instillation should be slowed down. When a patient complains of cramping, lower the container, clamp the tube, or temporarily stop the instillation. Filling the bag with hot water demonstrates that the assistive personnel does not understand the directions for this procedure. Having the patient sit on a toilet demonstrates that the assistive personnel does not understand the proper position for administering an enema.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1023OBJ:Administer an enema.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

2.Which of the following conditions could affect the function of the digestive process? (Select all that apply.)

a.
Increase in mobility
b.
Diagnostic testing
c.
Increase in nutrition
d.
Medications
e.
Increase in fluid intake
f.
Surgery

ANS: A, B, D, F

Individuals of any age sometimes experience changes in intestinal elimination. These changes are often the result of illness, medications, diagnostic testing, or surgical intervention. Aging when accompanied by chronic illness, cognitive decline, decreased mobility, and a decrease in food and fluid intake will change digestive system function, but aging alone does not necessarily alter the digestive process.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:992

OBJ: Discuss physiological and psychological factors that influence bowel elimination.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

3.A patient with colon cancer has recently undergone surgery to remove a portion of the colon. The patient asks how often the colostomy pouching system should be changed. What is the bestresponse by the nurse?

a.
Every 3 to 7 days
b.
Every 10 to 14 days
c.
When the pouch is one third to one half full of stool
d.
Not until the system starts to leak or smell bad

ANS: A, C

An ostomy is managed with an odor-proof pouch with a skin barrier surrounding the stoma. Empty the pouch when it is one third to one half full. Change the pouching system approximately every 3 to 7 days, depending upon the patient’s individual needs.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:998

OBJ:Describe nursing care required to maintain structure and function of a bowel diversion.TOP:Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance