ch 17 Flashcards
A patient who was diagnosed with senile dementia has become incontinent of urine. The patient’s daughter asks the nurse why this is happening. What is the nurse’s best response?
a. “The patient is angry about the dementia diagnosis.”
b. “The patient is losing sphincter control due to the dementia.”
c. “The patient forgets where the bathroom is located due to the dementia.”
d. “The patient wants to leave the hospital.”
ANS: B
Anger, wanting to leave the hospital, and forgetting where the bathroom is really have no bearing on the urinary incontinence. The patient is incontinent due to the mental ability to voluntarily control the sphincter. This is happening because of the dementia.
The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patient’s elimination status. What is the nurse’s best action?
a. Speak with the patient’s family about food choices.
b. Establish a bowel and bladder program for the patient.
c. Speak with the patient about past elimination habits.
d. Establish a bedtime ritual for the patient.
ANS: B
Establishing a bowel and bladder program for the patient is a priority to be sure that adequate elimination is happening for the patient with a spinal cord injury. Speaking with the family to determine food choices is not the primary concern. Speaking with the patient to know past elimination habits does not apply, because the spinal cord injury changes elimination habits. Establishing a bedtime ritual does not apply to elimination.
The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body?
a. Large intestine
b. Stomach
c. Small intestine
d. Pancreas
ANS: C
Most digestion takes place in the small intestine. The main function of the large intestine is water absorption. The pancreas contains digestive enzymes; the stomach secrets hydrochloric acid to assist with food breakdown.
The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3–4 minutes. The patient asks the nurse why this is happening. What is the nurse’s best response?
a. “Anesthesia during surgery and pain medication after surgery may slow
peristalsis in the bowel.”
b. “Some people have a slower bowel than others, and this is nothing to be
concerned about.”
c. “The foods you eat contribute to peristalsis, so you should eat more fiber in your
diet.”
d. “Bowel peristalsis is slow because you are not walking. Get more exercise during
the day.”
ANS: A
Anesthesia and pain medication used in conjunction with the surgery are affecting the peristalsis of the bowel. Having a slower bowel, eating certain food, or lack of exercise will not have a direct effect on the bowel.
What is a primary prevention tool used for colon cancer screening?
a. Abdominal x-rays
b. Blood, urea, and nitrogen (BUN) testing
c. Serum electrolytes
d. Occult blood testing
ANS: D
Occult blood testing will reveal unseen blood in the stool, and this may signal a potentially serious bowel problem like colon cancer. BUN is used to evaluate kidney function. Serum electrolytes and abdominal x-rays are not related to colon cancer screening.
During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.)
a. Increase fiber intake.
b. Increase water consumption.
c. Decrease physical exercise.
d. Refrain from alcohol.
e. Refrain from smoking.
ANS: A, B
Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcohol and smoking have no direct effect on the quality of bowel movements.
