Yoost Chapter 40 Bowel Elimination Exam
Questions And Answers (Verified And
Updated)
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
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.
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 intake related to poor appetite
c. Diarrhea related to excessive loss of fluid through stool
d. Anxiety related to incontinence with loose stools and need for clothing change
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.
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.
B
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.
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.
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.
, The nurse is caring for a patient who is recovering from bowel surgery. Which assessment finding best
indicates that the bowel is starting to resume 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.
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.
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
A
The highest priority Nursing diagnosis for this patient is impaired skin integrity because the liquid
stool from the ileostomy quickly leads to breakdown when in contact with the skin. Open sores can
lead to bacterial infection and significant discomfort for the patient. In
addition, ostomy appliances do not adhere well to open wounds, increasing the risk for continuing
skin breakdown. The other nursing diagnoses are appropriate for this patient but are not the highest
priority.
The nurse is caring for a patient who is taking narcotic pain medication after surgery. Which
breakfast choices will help prevent constipation and promote return to regular bowel function?
a. Raisin bran with skim milk, fresh fruit, and wheat toast
b. Pancakes with maple syrup, bacon, and coffee with cream
c. Omelet with cheddar cheese, green pepper, and onions
d. Bagel with cream cheese, and strawberry nonfat yogurt
A
The postoperative patient taking narcotic pain medications is at risk for developing constipation. A
high-fiber diet with plenty of liquids will help prevent this from occurring. Raisin bran, fruit, and wheat
bread are all good sources of fiber.
The nurse is caring for a patient who has not had a bowel movement for 2 days. Which is the
priority nursing intervention for this patient?
a. Obtain an order to administer a soap suds cleansing enema.
b. Teach the patient how to use the Valsalva maneuver.
c. Discontinue medications that can cause constipation.
d. Assess the patient's usual pattern of bowel movements.
D
The nurse should assess the patient's usual pattern of bowel movements to determine if it is
normal for the patient to have a bowel movement every 2 to 3 days. Patients should be taught
not to use the Valsalva maneuver because it can lead to bradycardia or death. Medications are not
independently discontinued by the nurse and this would require a conversation with the provider.
The nurse is caring for a patient who will be undergoing upper GI series testing the next day.
Which instruction will the nurse provide to the patient about the upcoming exam?
a. "The back of your throat will be sprayed with numbing medicine."
b. "You will need to have a clear liquid diet and take a laxative tonight."
Questions And Answers (Verified And
Updated)
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
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.
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 intake related to poor appetite
c. Diarrhea related to excessive loss of fluid through stool
d. Anxiety related to incontinence with loose stools and need for clothing change
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.
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.
B
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.
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.
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.
, The nurse is caring for a patient who is recovering from bowel surgery. Which assessment finding best
indicates that the bowel is starting to resume 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.
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.
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
A
The highest priority Nursing diagnosis for this patient is impaired skin integrity because the liquid
stool from the ileostomy quickly leads to breakdown when in contact with the skin. Open sores can
lead to bacterial infection and significant discomfort for the patient. In
addition, ostomy appliances do not adhere well to open wounds, increasing the risk for continuing
skin breakdown. The other nursing diagnoses are appropriate for this patient but are not the highest
priority.
The nurse is caring for a patient who is taking narcotic pain medication after surgery. Which
breakfast choices will help prevent constipation and promote return to regular bowel function?
a. Raisin bran with skim milk, fresh fruit, and wheat toast
b. Pancakes with maple syrup, bacon, and coffee with cream
c. Omelet with cheddar cheese, green pepper, and onions
d. Bagel with cream cheese, and strawberry nonfat yogurt
A
The postoperative patient taking narcotic pain medications is at risk for developing constipation. A
high-fiber diet with plenty of liquids will help prevent this from occurring. Raisin bran, fruit, and wheat
bread are all good sources of fiber.
The nurse is caring for a patient who has not had a bowel movement for 2 days. Which is the
priority nursing intervention for this patient?
a. Obtain an order to administer a soap suds cleansing enema.
b. Teach the patient how to use the Valsalva maneuver.
c. Discontinue medications that can cause constipation.
d. Assess the patient's usual pattern of bowel movements.
D
The nurse should assess the patient's usual pattern of bowel movements to determine if it is
normal for the patient to have a bowel movement every 2 to 3 days. Patients should be taught
not to use the Valsalva maneuver because it can lead to bradycardia or death. Medications are not
independently discontinued by the nurse and this would require a conversation with the provider.
The nurse is caring for a patient who will be undergoing upper GI series testing the next day.
Which instruction will the nurse provide to the patient about the upcoming exam?
a. "The back of your throat will be sprayed with numbing medicine."
b. "You will need to have a clear liquid diet and take a laxative tonight."
