NCHP Exam 3 with correct solutions.

Which interview question about the urinary system focuses on the patient's symptoms? Has anyone in your family ever had kidney problems? Do you have difficulty starting your flow of urine? Have you ever had a urinary tract infection? How much coffee do you drink per day? - answer-Do you have difficulty starting your flow of urine? Place the assessment techniques of the abdominal physical examination in the correct order. Inspection Percussion Palpation Auscultation - answer-Inspection Auscultation Percussion Palpation Cloudy urine is noted by the nurse during inspection of a urine sample. The nurse knows that this unexpected finding may occur with the presence of which substances in the urine? Select all that apply. Bacteria Mucus White blood cells Sperm Urobilin - answer-Bacteria Mucus White blood cells Sperm Match the type of urinary incontinence to its description. Loss of bladder control with an increase in intraabdominal pressure - answer-stress incontinence Match the type of urinary incontinence to its description. Sudden need to urinate, followed by bladder contraction and urination - answer-urge incontinence Match the type of urinary incontinence to its description. Physical limitation (e.g., immobility) preventing controlled elimination - answer-functional incontinence Match the type of urinary incontinence to its description. Dribbling and urinary frequency related to an inability to fully empty the bladder - answer-overflow incontinence Match each altered urinary elimination pattern with its description. Need to urinate more often than usual - answer-frequency Match each altered urinary elimination pattern with its description. Difficulty initiating urine stream - answer-hesitancy Match each altered urinary elimination pattern with its description. Inability to fully empty bladder - answer-retention Match each altered urinary elimination pattern with its description. Painful urination - answer-dysuria The nurse recognizes the following cues during assessment of a patient: urinary frequency, urgency, cloudy urine, and dysuria. Which urinary problem typically includes all of these cues? Urinary tract infection (UTI) Urinary incontinence Polyuria Kidney failure - answer-UTI A urinalysis is performed for a patient with suspected dehydration. The nurse recognizes that which urinalysis result correlates with fluid volume deficit? Elevated specific gravity Positive urine proteins Positive urine glucose Positive red blood cells - answer-Elevated specific gravity A patient has a standard creatinine clearance test ordered. Which information would the nurse include when teaching a patient about the test? Select all that apply. It is a 24-hour urine collection. A high urine creatinine clearance result suggests kidney damage. All urine must be collected during the designated time period once the test starts. The test measures how well the kidneys enable creatinine retention in the blood. High creatinine levels in the blood indicate healthy kidney function. - answer-It is a 24-hour urine collection. All urine must be collected during the designated time period once the test starts. Match the urinary function diagnostic test with its description. High-frequency sound waves used to visualize anatomic structures - answer-Ultrasound Match the urinary function diagnostic test with its description. Invasive internal exam of the urethra and bladder with lighted device - answer-Cystoscopy Match the urinary function diagnostic test with its description. Detailed x-ray cross-sectional images of the urinary system - answer-Computed tomography (CT) Match the urinary function diagnostic test with its description. X-ray using contrast medium to visualize kidneys, ureters, and bladder - answer-Intravenous pyelogram Match the urinary pattern alteration to its corresponding cue. Urine output 50 to 100 mL/24 hrs - answer-Anuria Match the urinary pattern alteration to its corresponding cue. Urine output 400 mL/24 hrs - answer-Oliguria Match the urinary pattern alteration to its corresponding cue. Urine output 2500 mL/24 hrs - answer-Polyuria Match the urinary pattern alteration to its corresponding cue. Excessive urination at night - answer-Nocturia Which conditions are general risk factors for developing urinary incontinence? Select all that apply. Urinary tract obstruction Older age Immobility Pregnancy Kidney disease - answer-Older age Immobility Pregnancy Which potential cause of kidney failure is prerenal? Renal toxicity related to illicit drugs Damage to the nephrons Urethral stricture Low cardiac output - answer-Low cardiac output Place the spread of a urinary tract infection in ascending anatomical order. Spread to the ureters, causing ureteritis (rare) Spread to the kidneys, causing pyelonephritis Spread to the urethra, causing urethritis Spread to the urinary bladder, causing cystitis Contamination of the urinary meatus by a pathogen - answer-Contamination of the urinary meatus by a pathogen Spread to the urethra, causing urethritis Spread to the urinary bladder, causing cystitis Spread to the ureters, causing ureteritis (rare) Spread to the kidneys, causing pyelonephritis Which action by the nurse may prevent a patient from urinating while using a bedpan? Placing a cover sheet over the patient and bedpan Permitting a family member to stay at the bedside Pulling bedside curtains around the patient and bed Standing outside the patient's pulled bedside curtain - answer-Permitting a family member to stay at the bedside A female patient on strict bedrest requires the use of a bedpan. Which position facilitates urination for this patient? Knees and hips fully extended Head elevated 30 degrees Head elevated nearly upright and legs and knees extended straight Head elevated nearly upright and hips and knees flexed - answer-Head elevated nearly upright and hips and knees flexed The nurse provides education about urinary tract infection prevention self-care to a female patient. Which statement by the patient indicates further teaching is needed? "I should report any burning or pain when I urinate." "I need to make sure that I wipe myself from front to back after urinating." "I plan to take a warm bubble bath every evening to relax." "I will be sure to urinate and clean my urethral area after sex." - answer-"I plan to take a warm bubble bath every evening to relax." For which reasons is urinary catheterization prescribed? Select all that apply. Visualizing the interior of the bladder Collecting a urine sample Measuring residual urine Intermittently emptying the bladder Continuously emptying the bladder - answer-Collecting a urine sample Measuring residual urine Intermittently emptying the bladder Continuously emptying the bladder Match the type of urinary catheter to its description. Single-lumen, single-use - answer-straight Match the type of urinary catheter to its description. Double-lumen indwelling with anchoring balloon - answer-foley Match the type of urinary catheter to its description. Bent at the tip and slightly stiff; used with urethral constriction - answer-coude Match the type of urinary catheter to its description. Indwelling with anchoring balloon, irrigation and drainage lumens - answer-triple foley The nurse caring for a patient with a major urethral obstruction and urinary retention anticipates a prescription for which type of catheter? Condom Suprapubic Foley Triple-lumen Foley with bladder irrigation - answer-Suprapubic For which reasons is urinary specimen collection prescribed? Select all that apply. Establishing a diagnosis of urinary tract infection (UTI) Testing the urine for illicit drugs Culturing specific bacteria infecting the urinary tract Determining the location of pain in the urinary system Monitoring a condition such as impaired kidney function - answer-Establishing a diagnosis of urinary tract infection (UTI) Testing the urine for illicit drugs Culturing specific bacteria infecting the urinary tract Monitoring a condition such as impaired kidney function Which urine tests require the collection of the specimen by the clean catch or urinary catheterization technique? Select all that apply. Urine culture Urine glucose screen Urine ketone screen Urinalysis Urine drug screen - answer-Urine culture Urinalysis Place the steps of clean catch midstream urine specimen collection in order. Cleanse the perineum and urinary meatus with antiseptic wipes from front to back. Remove the cup from the urine stream and finish urinating. Tightly cap the specimen cup. Urinate a small amount of urine into the toilet without collecting it. Pass the specimen cup into the stream of urine and collect the specimen. Open the specimen cup without touching the inside. - answer-Open the specimen cup without touching the inside. Cleanse the perineum and urinary meatus with antiseptic wipes from front to back. Urinate a small amount of urine into the toilet without collecting it. Pass the specimen cup into the stream of urine and collect the specimen. Remove the cup from the urine stream and finish urinating. Tightly cap the specimen cup. The nurse recognizes which physiologic connection between Kegel exercises and improved urinary continence? Urethral sphincter tone increases. Intraabdominal pressure is reduced. Urine volume decreases. Ureter tone increases. - answer-Urethral sphincter tone increases. Which rationale would the nurse recognize for placing a patient in the high-Fowler position to facilitate urination in a bedpan? Produces contraction of perineal muscles Increases intraabdominal pressure Maintains medical asepsis Stimulates urge to urinate - answer-Increases intraabdominal pressure The nurse provides education about fluid intake to a patient worried about recurrent urinary tract infections (UTIs). Which statement by the patient indicates that teaching was successful? "I plan to drink 1.5 to 2 liters of fluid every day." "High fluid intake flushes out my urinary system and reduces my chances of getting a UTI." "I drink a lot of coffee, so taking in enough fluids will not be a problem for me." "I will equally divide up my fluid intake for morning, afternoon, and night." - answer-"High fluid intake flushes out my urinary system and reduces my chances of getting a UTI." The UAP is assisting the nurse in the care of a patient with an indwelling urinary catheter. Which instruction would the nurse provide to the UAP to prevent urine from flowing back into the sterile bladder? Hang the urine collection bag on the patient's intravenous (IV) pole at waist height. Place the urine collection bag on the patient's mattress near his or her abdomen. Hang the patient's urine collection bag below the patient's mattress on a nonmovable part of the bed frame. Ask the patient to hold the urine collection bag at waist height while ambulating. - answer-Hang the patient's urine collection bag below the patient's mattress on a nonmovable part of the bed frame. A nurse is caring for a patient with continuous urinary bladder irrigation. Which cue indicates a complication of urinary bladder irrigation and warrants further investigation and action by the nurse? Pale yellow, dilute catheter output Catheter output greater than bladder irrigation input Decrease in hourly catheter output Mild smell to urine - answer-Decrease in hourly catheter output Which evaluation outcome indicates that a male patient with urinary incontinence using a condom catheter is improving? No signs of urinary tract infection are present. Previously macerated perineal skin shows signs of healing. Patient reports discomfort using the condom catheter. Skin breakdown is evident on the head of the penis. - answer-Previously macerated perineal skin shows signs of healing. Which equipment would the nurse use to collect a nonsterile urine sample from an ambulatory hospitalized female patient with limited manual dexterity? Bedside commode Urine hat Urine collection cup Bedpan - answer-Urine hat A sterile urine sample via catheterization is prescribed for a patient who is temporarily unable to provide a clean catch sample. Which type of urinary catheter will the nurse use to obtain the sample? Straight catheter Foley catheter Triple-lumen Foley catheter Condom catheter - answer-Straight catheter The nurse is evaluating the effectiveness of teaching a patient to independently collect a clean catch midstream urine sample for a suspected urinary tract infection (UTI). Which action by the patient indicates that further teaching is needed? Cleanses the perineum and urinary meatus with multiple antiseptic wipes from front to back Grasps the rim of the specimen cup with the forefinger inside the cup and the thumb outside the cup Passes a small amount of urine into the toilet without collecting it, then passes the cup into the urine stream Tightly caps the specimen cup and places it on a paper towel on the countertop - answer-Grasps the rim of the specimen cup with the forefinger inside the cup and the thumb outside the cup Match the nursing diagnoses with their relevant urinary cues. Inability to completely empty bladder and difficulty starting void - answer-Urinary Retention Match the nursing diagnoses with their relevant urinary cues. Dysuria, urgency, frequency, and cloudy urine - answer-UTI Match the nursing diagnoses with their relevant urinary cues. Decreased urine output, abnormal blood results, and swelling in feet - answer-Impaired Kidney Function Match the nursing diagnoses with their relevant urinary cues. Urinary urgency and inability to reach toilet in time - answer-Urinary Incontinence Which cues support the hypothesis of Risk for Urinary Infection? Select all that apply. Impaired perineal hygiene practices related to immobility Urinalysis positive for bacteria in urine History of urinary tract infections (UTIs) Urinary retention Lack of knowledge of UTI prevention practices - answer-Impaired perineal hygiene practices related to immobility History of urinary tract infections (UTIs) Urinary retention Lack of knowledge of UTI prevention practices Which cues gathered during the nursing assessment are directly relevant to the hypothesis of Urinary Retention? Select all that apply. History of hypertension Patient report of one mile of walking daily Patient report of feeling unable to fully empty his bladder Bladder distention with palpation Patient report of discomfort during bladder palpation Temperature of 37.1°C (98.9°F) - answer-Patient report of feeling unable to fully empty his bladder Bladder distention with palpation Patient report of discomfort during bladder palpation Place the hypotheses in order from highest to lowest priority. Lack of knowledge of incontinence support groups Systemic urinary tract infection with shock and multiple organ failure Skin breakdown related to urinary incontinence Painful and debilitating urethral trauma with pain rating of 7/10 - answer-Systemic urinary tract infection with shock and multiple organ failure Painful and debilitating urethral trauma with pain rating of 7/10 Skin breakdown related to urinary incontinence Lack of knowledge of incontinence support groups Match the multidisciplinary care team member with an example of urinary care they commonly provide. Documenting urine volume output under supervision of a nurse - answer-Unlicensed assistive personnel (UAP) Match the multidisciplinary care team member with an example of urinary care they commonly provide. Supervising bladder training regimen and pelvic floor muscle training plan - answer-Nurse continence specialist Match the multidisciplinary care team member with an example of urinary care they commonly provide. Teaching the patient how to manage toileting using assistive equipment - answer-Occupational therapist Match the multidisciplinary care team member with an example of urinary care they commonly provide. Placing indwelling urinary catheters - answer-Registered nurse Which solutions would the nurse generate for a hypothesis of Disturbed Body Image due to urine leakage and odor management? Select all that apply. Allowing adequate time for voiding Assistance with leakage management products Patient education about personal hygiene practices to minimize odor Patient education about urinary tract infection (UTI) prevention Individual and small group emotional support - answer-Assistance with leakage management products Patient education about personal hygiene practices to minimize odor Individual and small group emotional support Which cues support the hypothesis of Urinary Retention? Select all that apply. Hematuria Bladder palpable after voiding Urinary frequency Unexpected urinalysis result: positive for bacteria Diagnosis of prostate enlargement - answer-Bladder palpable after voiding Urinary frequency Diagnosis of prostate enlargement During assessment of a pregnant patient, the nurse recognizes the cues of urinary frequency and small volume urine leakage as supportive of the hypothesis of Urinary Incontinence. Knowledge of which physiologic process provides the rationale for this hypothesis? The prostate enlarges with age. A hormone causes relaxation of urethral sphincters. Urine output increases during pregnancy. Excess fluid intake results in less concentrated urine. - answer-A hormone causes relaxation of urethral sphincters. The nurse caring for an adult patient with a urine output of 350 mL in the past 24 hours is evaluating the previously selected hypothesis of Impaired Kidney Function. Which new cues in the patient chart indicate a need to begin the clinical judgment process again and create a new hypothesis? Select all that apply. Urinalysis negative for bacteria Serum creatinine level within expected range Specific gravity of urine above the expected range Urinalysis negative for protein Serum blood urea nitrogen (BUN)/creatinine ratio within expected range - answer-Serum creatinine level within expected range Specific gravity of urine above the expected range Urinalysis negative for protein Serum blood urea nitrogen (BUN)/creatinine ratio within expected range A patient involved in a motor vehicle accident is transferred to your facility. Multiple patient problem hypotheses are generated. Which hypothesis is the highest priority? Impaired Airway Clearance Urinary Incontinence due to spinal injury Impaired Cognition Risk for Fall-Related Injury - answer-Impaired Airway Clearance Match the solution to the expected patient outcome. Fewer urine leakage episodes within 48 hours - answer-Incontinence trigger education Match the solution to the expected patient outcome. Decreased residual urine volume after void within one day - answer-Bladder emptying technique education Match the solution to the expected patient outcome. No urinary tract infections (UTIs) one month from hospital discharge - answer-Education about UTI prevention Match the solution to the expected patient outcome. No perineal redness two weeks from hospital discharge - answer-Skin care barrier cream use training Which solutions would the nurse generate for a hypothesis of Impaired Kidney Function? Select all that apply. Monitor serum creatinine and blood urea nitrogen (BUN) level. Teach pelvic floor strengthening exercises. Assess for swelling in extremities. Provide education about urinary incontinence self-management. Monitor for cardiac arrhythmia. - answer-Monitor serum creatinine and blood urea nitrogen (BUN) level Assess for swelling in extremities. Monitor for cardiac arrhythmia. Which structure is located at the junction of the neck of the urinary bladder and the urethra? External urethral sphincter Urinary meatus Ureter Internal urethral sphincter - answer-Internal urethral sphincter List steps of normal micturition in the correct order. Nerve endings in the bladder are stimulated by distention. The brain registers a message of urgency. Urine flows out of the body through the urinary meatus. The bladder muscle contracts and the urethral sphincters relax. - answer-Nerve endings in the bladder are stimulated by distention. The brain registers a message of urgency. The bladder muscle contracts and the urethral sphincters relax. Urine flows out of the body through the urinary meatus. In which ways does pregnancy alter urinary elimination? Select all that apply. Bladder compression Increased urine output Increased urinary frequency Constriction of ureteral sphincters Decreased urinary frequency - answer-Bladder compression Increased urine output Increased urinary frequency In which way do changes in fluid intake affect urinary elimination? Increased fluid intake results in increased urine output. Decreased fluid intake results in less concentrated urine. Increased fluid intake results in more concentrated urine. Increased fluid intake results in decreased urine output. - answer-Increased fluid intake results in increased urine output. Enlargement of the prostate may directly affect which structure in the male urinary system? Kidney Ureter Urethra Urinary meatus - answer-Urethra The nurse is planning a short presentation for unit nurses that will include cultural aspects of urinary elimination. Which information would the nurse include? Urination is generally considered a public matter to people in American culture. Privacy during toileting varies culturally. Culture influences the decision to seek help for problems with urinary elimination. Most cultures are accepting of nursing care delivered by a nurse of either sex. Cultural background generally is not a priority issue in hospitalized patients. - answer-Culture influences the decision to seek help for problems with urinary elimination. The nurse recognizes which findings as normal in a urine specimen from a healthy adult? Select all that apply. Creatinine Electrolytes Bacteria Ammonia Parasites Urea - answer-Creatinine Electrolytes Ammonia Urea Place the anatomic structures in the order through which urine passes as it moves from the kidneys to the exterior of the body. Internal urethral sphincter Urinary meatus Ureter Renal pelvis External urethral sphincter Bladder - answer-Renal pelvis Ureter Bladder Internal urethral sphincter External urethral sphincter Urinary meatus Which process is directly affected by nephron damage? Regulation of blood components Voluntary control of bladder emptying Internal urethral sphincter relaxation Neurologic awareness of bladder fullness - answer-Regulation of blood components Urinary continence depends on adequate muscle tone of which structures? Select all that apply. Abdominal wall Bladder Vaginal wall Urethral sphincters Pelvic floor - answer-Bladder Urethral sphincters Pelvic floor The nurse is caring for a patient who has developed urinary retention. While reviewing the patient's medications, the nurse recognizes which medication type as known to contribute to the risk of developing urinary retention? Drugs that act on kidneys to increase urine formation and excretion Drugs that act on the autonomic nervous system Drugs that act on the heart to strengthen muscle contraction Supplements with diuretic effects - answer-Drugs that act on the autonomic nervous system Which alterations in urinary function are typical with certain surgical and diagnostic procedures? Select all that apply. Temporary urine retention with anesthesia Temporary urine incontinence with anesthesia Changes in urine color with procedures causing bleeding Increased urine concentration and decreased volume after procedures that include intravenous fluids Urinary retention with procedures causing urethral swelling - answer-Temporary urine retention with anesthesia Changes in urine color with procedures causing bleeding Urinary retention with procedures causing urethral swelling A patient newly diagnosed with kidney disease is learning about basic kidney functions during a patient education session. Which statements would the nurse include? Select all that apply. The kidneys regulate electrolytes and fluid in the blood. Kidney function does not affect blood pressure. The kidneys help maintain the body's red blood cell count. The kidneys help regulate blood pH. The kidneys synthesize the active form of vitamin K. - answer-The kidneys regulate electrolytes and fluid in the blood. The kidneys help maintain the body's red blood cell count. The kidneys help regulate blood pH. Which statement is accurate regarding the upper gastrointestinal tract? The esophagus propels the food bolus to the duodenum. The stomach is located in the left upper quadrant of the abdomen. The mouth connects the pharynx to the stomach. The chyme is extremely thin fluid of partially digested food and fluids. - answer-The stomach is located in the left upper quadrant of the abdomen. Match each segment of the small intestine with its corresponding function. Secretes chemicals that neutralize the acidity of the chyme - answer-Duodenum Match each segment of the small intestine with its corresponding function. Controls the absorption of carbohydrates and proteins - answer-Jejunum Match each segment of the small intestine with its corresponding function. Absorbs fats, bile salts, and water - answer-ileum Which characteristics are typical of the large intestine? Select all that apply. Frames the small intestine Has the cecum as the middle section Includes the rectum as the last opening Is longer and wider than the small intestine Has a mucus layer to protect the intestinal wall - answer-Frames the small intestine Has a mucus layer to protect the intestinal wall Which process moves waste products into the rectum to stimulate the urge to expel feces? Flatus Peristalsis Absorption Defecation - answer-Peristalsis Which lifestyle factors positively affect bowel elimination and result in softer stools? Select all that apply. Depression Regular physical activity Low-fiber diet Busy care routines Maintaining adequate fluid intake - answer-Regular physical activity Maintaining adequate fluid intake An obese patient would be at risk for developing which functional bowel impairment? Diarrhea Hemorrhoids Food intolerances Poor nutrient absorption - answer-Hemorrhoids Which situation likely leads to a patient developing a paralytic ileus? Pregnancy Presurgery preparations General anesthesia Parasympathetic stimulation - answer-General anesthesia Which findings can affect bowel elimination? Select all that apply. Pregnancy High blood pressure Opioid medication Urinary catheterization Pain - answer-Pregnancy Opioid medication Pain Which factor determines the stool consistency of a patient's ostomy? Anatomic location Whether it has one or two openings Whether it is permanent Anatomic dimension - answer-Anatomic location Match each type of colostomy with its anatomic location. Right side of abdomen - answer-Ascending Match each type of colostomy with its anatomic location. Upper middle to right of abdomen - answer-Transverse Match each type of colostomy with its anatomic location. Middle left quadrant - answer-Descending Match each type of colostomy with its anatomic location. Lower left quadrant - answer-Sigmoid Which characteristic is typical of ileostomies? Stools can be regulated. Well-formed stools are expected. Stoma is from the large intestine. Skin breakdown can occur more frequently. - answer-Skin breakdown can occur more frequently. Which information would the nurse share with the patient about the Kock pouch? Uses a catheter to drain the stool Allows patient to defecate through the anus Is the most common ileostomy Has no stoma - answer-Uses a catheter to drain the stool Place the organs of the gastrointestinal tract in the sequence through which a food item travels. Rectum Esophagus Anus Stomach Mouth Intestines - answer-Mouth Esophagus Stomach Intestines Rectum Anus The gastrointestinal tract has which function? Protection from bacteria Digestion of waste products Absorption of nutrients and fluids Production of potassium - answer-Absorption of nutrients and fluids Which structure is the primary organ that aids in defecation? Large intestine Small intestine Duodenum Jejunum - answer-Large intestine Place in order the segments of the small and large intestines. Cecum Jejunum Ileum Rectum Duodenum Colon - answer-Duodenum Jejunum Ileum Cecum Colon Rectum Which function does defecation serve? Expels feces Absorbs nutrients Churns the chyme Begins mechanical breakdown - answer-Expels feces Which processes are functions of the large intestine? Select all that apply. Digestion Secretion Elimination Metabolism Absorption - answer-Secretion Elimination Absorption Which information is accurate regarding the structure and function of the esophagus? Select all that apply. Causes mechanical breakdown of food Is a collapsible tube that transports a food bolus Is located in the left upper quadrant of the abdomen Connects the pharynx to the stomach Produces digestive juices, enzymes, and pepsin - answer-Is a collapsible tube that transports a food bolus Connects the pharynx to the stomach Which factors can affect a patient's bowel movements? Select all that apply. Dietary intake Medication use Marital status Pain Recent surgery - answer-Dietary intake Medication use Pain Recent surgery Which information regarding the frequency of bowel movements is accurate? Occurs once per day Happens after each meal Varies from person to person Is directly related to intake of water - answer-Varies from person to person Which amount of fluid (in ounces) is recommended for an adult to maintain healthy bowel elimination? 8 16 32 64 - answer-64 Which question addresses psychological factors that can affect a patient's bowel elimination? Has the patient ever had a problem with obesity? Does the patient have any food intolerances? What is the patient's religion? Is the patient experiencing stress? - answer-Is the patient experiencing stress? Which medications would increase the patient's risk for constipation? Select all that apply. Opioids Antacids Laxatives Cathartics Antibiotics Iron supplements - answer-Opioids Antacids Iron supplements Which type of intestinal movement would a patient with a paralytic ileus have? Fast Normal Slow None - answer-None Which information would the nurse share with a patient who has a loop colostomy? "You will have a lifelong stoma." "After your bowels heal, they will be reattached." "Your stools will drain from the abdomen indefinitely." "The lower intestine will be removed." - answer-"After your bowels heal, they will be reattached." Place the types of ostomies in order based on the consistency of stool formed (from least formed/liquid to most formed/solid). Ascending colostomy Ileostomy Descending colostomy Transverse colostomy Sigmoid colostomy - answer-Ileostomy Ascending colostomy Transverse colostomy Descending colostomy Sigmoid colostomy Which type of procedure creates no stoma on the patient's abdomen? Double-barrel colostomy Temporary colostomy Kock pouch Ileoanal pouch - answer-Ileoanal pouch Which characteristics are typical of a loop colostomy? Select all that apply. Has two distinct stomas Has one stoma with two openings Has mucus drain from the distal end of the stoma Has stool drain from the proximal end of the stoma Is a permanent type of colostomy Is usually created in an emergency - answer-Has one stoma with two openings Has mucus drain from the distal end of the stoma Has stool drain from the proximal end of the stoma Stool drainage from a sigmoid colostomy has which characteristics? Select all that apply. Liquid Well-formed Semi-formed Well-regulated Unregulated - answer-Well-formed Well-regulated Which type of ostomy causes the patient to lose a large amount of water, electrolytes, and digestive enzymes through a stoma? Ileostomy Sigmoid colostomy Descending colostomy Ileoanal pouch - answer-Ileostomy From which area would the nurse observe stool draining in a double-barrel colostomy? Proximal end Distal opening Nonfunctional end Farthest opening from the small intestine - answer-Proximal end (Distal opening drains mucus, not stool) Which question would the nurse ask first to obtain information about the patient's bowel habits? "Where is your abdominal pain?" "Do you have any bloating or gas?" "How many bowel movements do you have a day?" "What medications do you take on a regular basis?" - answer-"How many bowel movements do you have a day?" Which assessment technique for the abdomen is performed last to avoid a false finding? Palpation Inspection Auscultation Patient interview - answer-Palpation Which assessment findings indicate the patient has hyperactive bowel sounds? Select all that apply. Tinkling sound Rushing sound Fewer than five sounds per minute Sounds occur every 5 to 15 seconds High-pitched sound Soft gurgling sound - answer-Tinkling sound Rushing sound High-pitched sound The patient's stool culture will help detect which finding? Cancer Intestinal polyps Abnormal bacteria Small amounts of blood - answer-Abnormal bacteria Match the diagnostic test with the correct description. Radiographic exam; is also known as a barium swallow - answer-Upper GI Series Match the diagnostic test with the correct description. Radiographic exam; visualizes the colon and rectum - answer-Barium enema Match the diagnostic test with the correct description. Endoscopic exam; visualizes the upper gastrointestinal tract - answer-Esophagogastroduodenoscopy Match the diagnostic test with the correct description. Endoscopic exam; inserts a scope with camera into the anus - answer-Colonoscopy Which cue is irrelevant for a patient with constipation? Expels hard, pebble-like stools Does not like to exercise Has an abnormal serum creatinine level Eats low-fiber foods - answer-Has an abnormal serum creatinine level Which cues would the nurse expect to observe in a patient suffering from diarrhea? Select all that apply. Hyperactive bowel sounds Excessive straining to pass stool Abdominal pain Continuous leaking of liquid stool Urgency Hemorrhoids noted in medical history - answer-Hyperactive bowel sounds Abdominal pain Urgency Which relevant cues would the nurse share with the health care provider when consulting about a patient who has developed constipation? Select all that apply. Bed linens are soiled with stool. Graphic record shows no stool in 2 days. Patient strains while trying to have a bowel movement. Patient reports urgency and abdominal cramping. Decreased bowel sounds auscultated. - answer-Graphic record shows no stool in 2 days. Patient strains while trying to have a bowel movement. Decreased bowel sounds auscultated. Which patient is at risk for developing an impaction? One who is immobile One who is lactose intolerant One who is infected with Clostridium difficile One who is receiving enteral feedings - answer-One who is immobile Which cause would the nurse consider if the patient is experiencing flatulence? Unconsciousness Loss of nerve sensation Inability of anal sphincters to work properly Action of bacteria on chyme - answer-Action of bacteria on chyme Which question would the nurse ask to gather cues about drug-related issues for bowel elimination? "Are you using any herbal supplements?" "Do you have any bloating or gas?" "When did this start?" "Where is the pain?" - answer-"Are you using any herbal supplements?" Which finding would the nurse categorize as an expected finding for an abdominal assessment? Presence of visible peristaltic waves Nonprotruding midline umbilicus Asymmetrical abdomen Ascites - answer-Nonprotruding midline umbilicus Which information would the nurse share with the patient about how blood can be detected in a guaiac test? A small amount of feces is applied to a special medium for growing microorganisms. The stool sample is exposed to a special chemical that changes color when blood is present. Feces is placed on a slide and visualized under a microscope, noting any blood. Stool is viewed under special lighting, showing reddish streaks if blood is present. - answer-The stool sample is exposed to a special chemical that changes color when blood is present. Which action by the new nurse while performing an abdominal assessment would cause the charge nurse to intervene? Auscultates before palpates Turns off the nasogastric suction while auscultating Palpates a pulsating midline mass Communicates with the patient in a matter-of-fact manner - answer-Palpates a pulsating midline mass Which action would the nurse take when performing an abdominal assessment? Interviews the patient after the physical assessment Palpates the area of pain last Percusses the abdomen routinely Auscultates with cooled stethoscope - answer-Palpates the area of pain last Which expected assessment cue would the nurse find upon palpation of the abdomen? Hard Rough Painless Mass-filled - answer-Painless Which diagnostic study would help determine whether there is bleeding in the patient's stomach? Barium enema Lower gastrointestinal (GI) series Esophagogastroduodenoscopy Colonoscopy - answer-Esophagogastroduodenoscopy Which information would the nurse include in a teaching session about a lower gastrointestinal (GI) series? Barium is swallowed. It is a type of radiographic (x-ray) study. A colonoscope will be inserted into the rectum. The stool sample will turn blue if there is blood present. - answer-It is a type of radiographic (x-ray) study. Which cues would be anticipated in a patient with flatulence and bloating? Select all that apply. Abdominal tenseness on palpation Visible peristaltic waves Feelings of nausea Reports passing excessive gas through the rectum Reports of abdominal pressure - answer-Abdominal tenseness on palpation Reports passing excessive gas through the rectum Reports of abdominal pressure Which bowel assessment findings would the nurse report as unexpected? Select all that apply. Rebound tenderness present Active bowel sounds Steatorrhea Clay-colored, round stool Symmetrical abdomen - answer-Rebound tenderness present Steatorrhea Clay-colored, round stool How long would the nurse auscultate the abdomen before documenting no or absent bowel sounds? Record answer as a whole number. _________ minutes. - answer-5 Which findings would cause the nurse to document "active" bowel sounds? Select all that apply. Gurgling Soft High-pitched Sounds every 5 to 15 seconds Irregular pattern - answer-Gurgling Soft Sounds every 5 to 15 seconds Irregular pattern Place in the correct order the steps to perform a complete assessment of bowel function. Interview Auscultation Palpation Inspection - answer-Interview Inspection Auscultation Palpation Which patient requires immediate medical attention? A patient with a distended abdomen A patient with a mass in the abdomen A patient with hypoactive bowel sounds A patient with a hard, boardlike abdomen - answer-A patient with a hard, boardlike abdomen Which cue is irrelevant for a patient with a bowel alteration? Type of hypertension Type of bowel sounds Type of lifestyle Type of diet - answer-Type of hypertension The nurse caring for a patient suffering from chronic constipation must be aware of which potential complication? Incontinence Dehydration Clostridium difficile (C. diff) infection Fecal impaction - answer-Fecal impaction Which cause is the likely reason a patient on long-term antibiotic therapy is experiencing frequent, foul-smelling diarrhea? Foodborne pathogens Excessive laxative use Clostridium difficile Food intolerances - answer-Clostridium difficile Which location in the medical record would the nurse check to determine the date of the patient's last bowel movement? Vital signs graph Graphic chart Laboratory results Medical history - answer-Graphic chart Which characteristic describes bowel sounds auscultated in a patient with constipation? Fewer than five per minute Tinkling Soft, gurgling Rushing - answer-Fewer than five per minute Which factors could be potential sources of a patient's flatus? Select all that apply. History of recent abdominal surgery Use of bran for fiber Increased activity level Presence of milk intolerance Current diet - answer-History of recent abdominal surgery Use of bran for fiber Presence of milk intolerance Current diet The nurse understands that patients may experience diarrhea due to which causes? Select all that apply. Psychological stress Inadequate liquid intake Antibiotic use Enteral nutrition Barium enema - answer-Psychological stress Antibiotic use Enteral nutrition Which cues suggest bowel alteration due to impaction? Select all that apply. Has not had a bowel movement in 4 days Has bacteria in stool specimen Has hyperactive bowel sounds Has palpable hard fecal mass Has continuous leakage of liquid stool - answer-Has not had a bowel movement in 4 days Has palpable hard fecal mass Has continuous leakage of liquid stool Which patients are immediate concerns? Select all that apply. A teenager with absent bowel sounds A young adult who ate onions and beans A middle-aged adult with bowel incontinence A young child with diarrhea who develops dehydration An older adult who is positive for Clostridium difficile (C. diff) stool culture - answer-A teenager with absent bowel sounds A young child with diarrhea who develops dehydration An older adult who is positive for Clostridium difficile (C. diff) stool culture Match each bowel alteration to its cause. Prolonged constipation - answer-Impaction Match each bowel alteration to its cause. Paralyzed rectum muscles - answer-Incontinence Match each bowel alteration to its cause. Slowed peristalsis - answer-Constipation Match each bowel alteration to its cause. Increased peristalsis - answer-Diarrhea Which parameter would the nurse evaluate to determine the effectiveness of cool packs on a patient's hemorrhoids? Comfort level Fluid intake Fiber intake Mobility level - answer-Comfort level Which interventions would the nurse take to assist patients in maintaining hygiene needs related to elimination? Select all that apply. Promptly respond to a patient's call for toileting. Perform perineal care after bedpan use. Close the curtains around the patient's bed. Ensure correct placement on the bedpan. Monitor for breaks in the skin. - answer-Perform perineal care after bedpan use. Monitor for breaks in the skin. Which action for bowel elimination would the nurse take for a patient who is continent but completely bedbound? Prepare a bedside commode. Offer a bedpan to the patient. Assist the patient to the bathroom. Order adult diapers for the patient. - answer-Offer a bedpan to the patient. What is the maximum amount of time (in minutes) the nurse allows a patient to sit on a bedpan? Record your answer as a whole number. ______ minutes - answer-10 Which cue alerts the nurse that the patient with flatus is improving? Passes a soft, formed stool Passes a hard stool with no bradycardia Passes gas with no discomfort Passes a stool with no blood-streaked toilet paper - answer-Passes gas with no discomfort Which information regarding the purpose of an ostomy pouch would the wound, ostomy, and continence nurse share with the patient? It reduces fecal drainage. It allows for stoma assessment. It promotes odor control. It enhances self-esteem. - answer-It promotes odor control. Which action would the nurse take while providing ostomy care to a patient with a new ileostomy? Allow the unlicensed assistive personnel to clean the stoma. Apply a three-piece ostomy appliance. Collect effluent in the skin barrier. Place the wafer around the stoma. - answer-Place the wafer around the stoma. (Wafer protects the skin from the fecal output and goes around the stoma.) Which action would the nurse take while performing ostomy care on a patient with a colostomy? Make the patient clean the stoma. Mix cool water and adhesive remover to gently remove any residue. Clean the area around the stoma with antibacterial soap. Use water to clean the stoma. - answer-Use water to clean the stoma. Which technique would the nurse use to effectively evaluate proficiency in ostomy care for a patient who is having the spouse perform ostomy care? Have the patient perform a return demonstration. Have the spouse clean and pouch the stoma. Have the patient repeat the steps of the procedure. Have the spouse watch a video with the patient before discharge. - answer-Have the spouse clean and pouch the stoma. Match the type of enema with its description. Uses osmotic pressure to pull water into colon - answer-Hypertonic Cleansing Match the type of enema with its description. Lubricates rectum and softens stool to ease feces evacuation - answer-Oil Retention Match the type of enema with its description. Instills drugs to be absorbed into intestinal wall - answer-Medication Match the type of enema with its description. Stimulates peristalsis to facilitate flatus passage - answer-Carminative Which patient scenarios would prompt the nurse to question the prescription of an enema administration? Select all that apply. Patient has glaucoma Patient has a fecal impaction Patient is preoperative for rectal surgery Patient has elevated intracranial pressure Patient is recovering from transurethral resection of the prostate - answer-Patient has glaucoma Patient has elevated intracranial pressure Patient is recovering from transurethral resection of the prostate Which action would the nurse take while administering a noncommercial prepared enema to an adult patient? Angle the tubing straight into the rectum. Squeeze and roll the bottle slowly. Hold the solution bag 8 to 10 inches (20 to 25 cm) above anus. Add the castile soap after the water. - answer-Add the castile soap after the water. Which action would the nurse take when the patient reports that the enema is causing intermittent pain? Place the patient on a bedpan. Lower the enema bag. Stop the enema immediately. Notify the health care provider. - answer-Lower the enema bag. Which evaluation finding would suggest to the nurse that the patient who is taking loperamide is improving? Hard stools are becoming soft. Liquid stools are decreasing. Constipation is resolving. Stools are easy to expel. - answer-Liquid stools are decreasing. Match the nasogastric tube insertion purpose with its corresponding patient example. A 25-year-old who has just returned from surgery with absent bowel sounds - answer-Decompression of GI tract Match the nasogastric tube insertion purpose with its corresponding patient example. A 48-year-old with gastric bleeding due to multiple trauma from a car crash - answer-Compression of internal hemorrhage Match the nasogastric tube insertion purpose with its corresponding patient example. A 67-year-old stroke patient who cannot swallow foods or fluids safely - answer-Administration of medications Match the nasogastric tube insertion purpose with its corresponding patient example. An 85-year-old who swallowed an unknown quantity of medication - answer-Gastric lavage Which intervention would the nurse implement when caring for a patient who has a nasogastric tube for an intestinal obstruction? Position the air vent above the abdomen. Keep the head of the bed elevated 20 degrees. Allow the unlicensed assistive personnel to insert the tube. Pin tubing to gown to allow for movement. - answer-Position the air vent above the abdomen. Which evaluative cue would confirm to the nurse that the patient with a nasogastric tube for a bowel obstruction is progressing as expected? pH of 7 Presence of peristalsis No movement of fluid in the tube Oral temp of 98.6°F (37°C) - answer-Presence of peristalsis Which action would the nurse take when the unlicensed assistive personnel (UAP) obtains this piece of equipment (bed pan) for a patient with a hip fracture? Go with the UAP to help position the patient correctly on the piece of equipment. Inform the UAP to gently place the patient on the piece of equipment. Help the UAP obtain the correct piece of equipment. Tell the UAP to use two people to place the patient on the piece of equipment. - answer-Help the UAP obtain the correct piece of equipment. (You would need a fracture pan) Which assessment cues would alert the nurse that the patient with diarrhea is declining? Select all that apply. Has two more episodes of liquid stools Exhibits dry mucous membranes Exhibits poor skin turgor Has the same amount of watery stools Has documentation of a formed stool - answer-Has two more episodes of liquid stools Exhibits dry mucous membranes Exhibits poor skin turgor Which stoma assessment cue would alert the nurse that the patient with a bowel diversion is deteriorating? Beefy red Moist, red Moist, blue Reddish pink - answer-Moist, blue Which action would the nurse take for a patient with a newly formed bowel diversion? Perform stoma care him- or herself. Instruct patient to empty the bag when three-quarters full. Make sure there is at least ¼ inch around appliance and stoma. Apply the pouch over several skinfolds. - answer-Perform stoma care him- or herself. Which task would the nurse delegate to the unlicensed assistance personnel (UAP) for a patient's bowel elimination needs? Remove a fecal impaction in a young adult. Record intake and output for a frail older adult. Insert a nasogastric tube in a teenager. Administer a medicated enema to a middle-aged adult. - answer-Record intake and output for a frail older adult. Which action would the nurse take for a patient whose ostomy stoma is speckled white? Obtain adhesive remover. Apply a skin barrier. Notify the health care provider. Document the normal findings. - answer-Notify the health care provider. Which action would the nurse take if there are concerns during administration of the enema? If the patient cannot hold the enema solution, place the patient on a bedpan. If the patient reports cramping, raise the enema bag to a height above 18 inches (43 cm). If there is resistance upon insertion of the enema tube, insert the enema tube upon inhalation. If the sphincter is tight, make sure the temperature of the solution is over 105°F (40.5°C). - answer-If the patient cannot hold the enema solution, place the patient on a bedpan. Which patient statement would indicate to the nurse that the patient understands the teaching for an opiate-based antidiarrheal agent? "This medication speeds up my intestinal motility to clear the stool from my system." "I should take the medicine for no more than 72 hours." "It's good to know that these drugs are not habit-forming." "I need to carefully insert the suppository into my rectum using a clean disposable glove." - answer-"I should take the medicine for no more than 72 hours." For which constipated patient would the nurse administer a laxative? One who is experiencing nausea One who has been vomiting One who is allergic to opiates One who reports abdominal pain of unknown origin - answer-One who is allergic to opiates Which laxative would the nurse observe written on the medication administration record (MAR) for a patient with a prescription for a stimulant? Psyllium Docusate Mineral oil Senna - answer-Senna (Senna is a type of stimulant cathartic laxative.) For which patient would the nurse likely insert the nasogastric (NG) tube pictured here. (Salem sump tube)? One who needs a one-lumen tube One who needs gastric decompression One who requires long-term enteric feedings One who requires a Levine tube - answer-One who needs gastric decompression For which primary purpose would the nurse insert a large-bore nasogastric tube in a patient who ate a poisonous substance? Gastric lavage Enteral feedings Gastrointestinal tract decompression Medication administration - answer-Gastric lavage Which action would the nurse take first when there is no movement of fluid in the patient's nasogastric tube and the patient's abdomen is becoming distended? Notify the health care provider. Irrigate the tube with normal saline. Have the patient swallow using a glass of water. Determine the patient's last bowel movement. - answer-Irrigate the tube with normal saline. Which statements by a group of healthy adults indicate successful teaching by the nurse about colorectal health? Select all that apply. "Because I am 50, I need to have a fecal occult blood test every year." "Because I am 60, a sample of my stool should be examined for parasites every 5 years." "Because I have a family history of colorectal cancer, I should have sigmoidoscopy or colonoscopy screening every 5 to 10 years." "Because I am 25 years old and have a family history of colorectal cancer, sigmoidoscopy or colonoscopy screening should begin this year." "Because I have no personal or family history of colorectal cancer and am 50 years old, sigmoidoscopy or colonoscopy screening should begin now." - answer-"Because I am 50, I need to have a fecal occult blood test every year." "Because I have no personal or family history of colorectal cancer and am 50 years old, sigmoidoscopy or colonoscopy screening should begin now." Which information would the nurse share with a patient who wants to eat healthy and have an active lifestyle to improve digestive health? Select all that apply. Fluids should be at a tepid temperature. Ambulating 5 to 10 minutes each day increases digestion. Walking stimulates intestinal muscle contraction. Exercise should wait until at least 2 hours after eating to prevent cramping. Usually 6 to 8 glasses of fluid should be consumed per day. - answer-Walking stimulates intestinal muscle contraction. Usually 6 to 8 glasses of fluid should be consumed per day. Which actions would the nurse take for a patient who has diarrhea and is becoming dehydrated? Select all that apply. Monitor intake and output. Offer milkshakes. Encourage apple juice. Restrict fluids. Weigh daily. Assess skin turgor. - answer-Monitor intake and output. Weigh daily. Assess skin turgor. Which assessment cues alert the nurse that the patient with a fecal impaction is deteriorating? Select all that apply. Heart rate drops to 56 beats/min Respiratory rate of 16 breaths/min Removal of hard stool Blood pressure elevates from 120/60 to 142/66 mm Hg Continuation of liquid oozing - answer-Heart rate drops to 56 beats/min Blood pressure elevates from 120/60 to 142/66 mm Hg Which actions would the nurse take when performing routine ostomy care on a patient with an ileostomy? Select all that apply. Measure the stoma. Assess the pouch seal. Irrigate the ostomy with water using a catheter. Gently wash the stoma and peristomal area with water. Provide a 30-minute "resting" time before applying the new pouch. - answer-Measure the stoma. Assess the pouch seal. Gently wash the stoma and peristomal area with water. Which nursing actions would the nurse perform directly after completion of a cleansing enema to an ambulatory patient? Select all that apply. Assisting the patient onto the bedpan Assisting the patient to the bathroom Ensuring that nonskid shoes/socks are in place Placing the patient in Sims position on left side Placing the patient in a position of comfort for the specific enema retention time - answer-Assisting the patient to the bathroom Ensuring that nonskid shoes/socks are in place Which cues would alert the nurse that a patient with a nasogastric tube is experiencing aspiration? Select all that apply. Fever Increased output of gastric fluid Congested lung sounds Shortness of breath Decreased peristalsis - answer-Fever Congested lung sounds Shortness of breath After how many enemas would the nurse notify the health care provider when the patient's bowel return for cleansing enemas is still brown? Record your answer as a whole number. ________ enemas - answer-3 Place the steps of ostomy care for a patient in the correct order. Measure the stoma. Prepare the new pouch to fit stoma. Remove and dispose of the used ostomy pouch. Cleanse the area surrounding the stoma. Apply the new pouch. Assess the integrity of the stoma and peristomal skin. - answer-Remove and dispose of the used ostomy pouch. Cleanse the area surrounding the stoma. Assess the integrity of the stoma and peristomal skin. Measure the stoma. Prepare the new pouch to fit stoma. Apply the new pouch. Based on the image below (commercial enema preparation), which type of enema is the nurse administering to a patient? Hypertonic Isotonic Hypotonic Tap water - answer-Hypertonic (The image is a commercial enema preparation, a hypertonic/small volume, which uses osmotic pressure to draw fluid from interstitial spaces into the colon.) For which patient would the nurse obtain this piece of equipment (bedside commode)? A completely bedbound patient A patient who is unable to ambulate even with assistance A patient requiring a lift device for transfer to a chair A patient who has difficulty ambulating to the bathroom - answer-A patient who has difficulty ambulating to the bathroom Which cues support the hypothesis of Constipation for a patient? Select all that apply. Limited mobility Receives narcotic pain medication Decreased fluid intake Female sex Hyperactive bowel sounds - answer-Limited mobility Receives narcotic pain medication Decreased fluid intake Which interpretation would the nurse make about a patient who says, "I only had one bowel movement this week"? This is abnormal. The patient is constipated. This may be an expected or unexpected finding. The patient has a fecal impaction. - answer-This may be an expected or unexpected finding. Match the hypotheses to their cues. Seeping liquid stool - answer-Fecal impaction Match the hypotheses to their cues. Unable to control stools - answer-Bowel incontinence Match the hypotheses to their cues. Immobile patient - answer-Impaired self-toileting Match the hypotheses to their cues. Blood-streaked stools - answer-Hemorrhoid Which cues would prompt the nurse to develop a hypothesis of Dehydration for a patient? Select all that apply. Numerous semiliquid stools Output more than intake Dry mouth Abdominal stoma No bowel movement in several days - answer-Numerous semiliquid stools Output more than intake Dry mouth Which overall elimination goal is appropriate for a patient with a decrease in the frequency of bowel movements? Prevent diarrhea. Maintain normal defecation. Enhance body image. Relieve constipation. - answer-Relieve constipation. Which hypothesis would the nurse address first for a patient having continuous seepage of liquid stool? Impaired Ability to Manage Stoma Care Constipation Fecal Impaction Impaired Self-Toileting - answer-Fecal Impaction Which solution would the nurse consider for a patient with constipation who is on bed rest? Ambulation Consultation with a wound, ostomy, and continence nurse (WOCN) Consumption of foods that produce gas Patient education about fluid needs - answer-Patient education about fluid needs Which outcome would the nurse include for a patient with a hypothesis of reluctant to care for stoma? Patient will be able to wear a pouch only when in public. Patient will state one good aspect about body. Patient will contribute to self-care after toileting. Patient will assist with ileostomy care daily. - answer-Patient will assist with ileostomy care daily. Which SMART outcomes would the nurse add to a plan of care for a patient with dehydration? Select all that apply. Patient will have moist mucous membranes. Patient will have supple skin turgor within 48 hours. Patient will have good urine output. Patient will have a moist mouth throughout hospital stay. Patient will have adequate fluid intake at breakfast. - answer-Patient will have supple skin turgor within 48 hours. Patient will have a moist mouth throughout hospital stay. (specific, realistic, measurable, patient-centered. attainable, and has a time frame) Which cue would prompt the nurse to select a hypothesis of Bowel Incontinencefor a patient? Abdominal distention noted on inspection No stool in 3 days per patient report Intermittent soiling from soft feces Hypoactive bowel sounds - answer-Intermittent soiling from soft feces Which hypothesis would the nurse develop for a patient who states, "I can't stand to look at the stoma or this colostomy bag"? Disturbed Body Image Impaired Self-Toileting Risk for Impaired Skin Integrity Diarrhea - answer-Disturbed Body Image Which primary pathophysiologic process would the nurse conclude is occurring in a patient who has a hypothesis of Diarrhea? Quick transit time reducing water absorption Engorged rectal veins Neurologic impairment to control bowels Exposed skin to stool enzymes - answer-Quick transit time reducing water absorption The nurse would consider which pathophysiologic factor when caring for a patient with dementia whose bed linens are soiled several times a day? Altered mobility issues Impaired neurologic status Impaired muscular functioning Altered gastrointestinal transit time - answer-Impaired neurologic status Which hypothesis would the nurse select for a patient who has hyperactive bowel sounds, abdominal cramping, and liquid stools? Fecal Impaction Bowel Incontinence Diarrhea Constipation - answer-Diarrhea The nurse would develop a hypothesis of Risk for Impaired Skin Integrity for which patient? A patient with an ostomy created from the ileum A patient whose intake is less than output A patient whose abdomen is distended A patient with active bowel sounds - answer-A patient with an ostomy created from the ileum Which patient situation would the nurse prioritize as the most critical? Choking on food, closing airway Having hypoactive bowel sounds Experiencing severe flatulence Passing excessive watery stools - answer-Choking on food, closing airway The nurse recognizes that the outcome of "Patient will pass soft stools daily during rehabilitation" directly applies to which hypothesis? Constipation Dehydration Impaired Self-Toileting Risk for Impaired Skin Integrity - answer-Constipation Which member of the multidisciplinary team would the nurse include in caring for a patient who has impaired manual dexterity for toileting? Nutritionist/dietitian Physical therapist Mental health professional Wound, ostomy, and continence nurse - answer-Physical therapist Which solution would the nurse consider for a patient with flatulence who is in traction? Consultation with a mental health professional Institution of isolation precautions Ambulation of patient Avoidance of foods that produce gas - answer-Avoidance of foods that produce gas Which overall goal would the nurse focus on while caring for a patient with severe diarrhea? Maintain normal elimination patterns. Prevent dehydration. Re