Elimination Flashcards
The nurse is caring for a client who reports constipation and is presently in the bathroom attempting to have a bowel movement. The client presses the call bell and tells the nurse that about feeling dizzy. What education should the nurse provide the client about this condition?
A - “There may be an issue with your colon that is causing these type of symptoms. It is unusual to feel dizzy while having a bowel movement.”
B - “This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount.”
C - “This is an indicator of heart disease and we should do an electrocardiogram to be sure that it has not caused damage to the heart.”
D - “This happens when you bear down causing an increase in blood volume to the heart and resulting in your heart rate becoming too rapid.”
B - “This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount.”
The student nurse studying bowel elimination learns that which statements accurately describe the process of peristalsis? Select all that apply.
A - Mass peristalsis often occurs after food has been ingested.
B - The sympathetic nervous system stimulates movement.
C - The autonomic nervous system innervates the muscles of the colon.
D - Peristalsis occurs every 3 to 12 minutes.
E - Mass peristaltic sweeps occur 1 to 4 times each 24-hour period in most people.
A - Mass peristalsis often occurs after food has been ingested.
C - The autonomic nervous system innervates the muscles of the colon.
D - Peristalsis occurs every 3 to 12 minutes.
E - Mass peristaltic sweeps occur 1 to 4 times each 24-hour period in most people.
A nurse is assessing the bowel elimination patterns of hospitalized clients. Which nursing actions related to the assessment process are performed correctly? Select all that apply.
A - The nurse drapes the client’s chest and pubic area and extends the client’s legs flat against the bed.
B - The nurse uses a warmed stethoscope to listen for bowel sounds in all abdominal quadrants.
C - The nurse auscultates the abdomen before inspection and palpation are performed.
D - The nurse encourages the client to drink fluids before the assessment so that the bladder is full and can be examined.
E - The nurse notes the character of bowel sounds, which are normally high-pitched, gurgling, and soft.
F - The nurse places the client in the supine position with the abdomen exposed.
B - The nurse uses a warmed stethoscope to listen for bowel sounds in all abdominal quadrants.
E - The nurse notes the character of bowel sounds, which are normally high-pitched, gurgling, and soft.
F - The nurse places the client in the supine position with the abdomen exposed.
A nurse assesses a client who has a PRN (as-needed) prescription for a small-volume cleansing enema. What result would contraindicate the safe administration of an enema? Select all that apply.
A - Platelet count of 19,500/mm3 (195.00 ×109/L)
B - Anal fissures
C - Hemoglobin of 11.1 g/dL (111.00 g/L)
D - White cell count of 12,000/mL (12.00 ×109/L)
E - Hypervolemia
F - Type 2 diabetes
A - Platelet count of 19,500/mm3 (195.00 ×109/L)
B - Anal fissures
A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented?
A - Client may have bowel sounds, but they cannot be heard.
B - All four abdominal quadrants auscultated. Bowel sounds absent.
C - Bowel sounds auscultated. Client has no bowel sounds.
D - Auscultated abdomen for bowel sounds. Bowel not functioning.
B - All four abdominal quadrants auscultated. Bowel sounds absent.
During the inspection of a client’s abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client’s abdominal assessment by next performing:
A - percussion.
B - deep palpation.
C - light palpation.
D - auscultation.
D - auscultation.
A nurse is caring for a client with fecal impaction. Which factors cause fecal impaction? Select all that apply.
A - weak abdominal muscles
B - excess intake of fibrous food
C - unrelieved constipation
D - insufficient mastication
E - severe dehydration
A - weak abdominal muscles
C - unrelieved constipation
E - severe dehydration
A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client’s statement?
A - “That’s correct, but be sure that you don’t increase your laxative doses over time.”
B - “Actually, people’s bowel patterns can vary a lot and some people don’t tend to go every day.”
C - “Most older adults only have a bowel movement every 2 to 3 days, actually, so I’d encourage you to taper off your laxatives.”
D - “Your friend is correct in her assessment, but it would likely be better to exercise and drink more instead of using medications.”
B - “Actually, people’s bowel patterns can vary a lot and some people don’t tend to go every day.”
When caring for a client with difficulty defecating, which appropriate nursing interventions would the nurse implement? Select all that apply.
A - Elevate the bed to 15 degrees when using the bedpan.
B - Encourage daily consumption of 2,000 to 3,000 mL of water.
C - Use moist heat when cleaning the perineal area.
D - Encourage the client to exercise once a week.
E - Encourage decreasing the amount of fiber in diet.
B - Encourage daily consumption of 2,000 to 3,000 mL of water.
C - Use moist heat when cleaning the perineal area.
The nurse is caring for an older adult client with diarrhea. Which finding is most important for the nurse to report to the health care provider?
A - Temperature of 99°F (37.2°C)
B - Blood pressure of 120/70 mm Hg
C - Heart rate of 88 beats/min
D - Skin turgor response of 6 seconds
D - Skin turgor response of 6 seconds
