NURS 20030 EXAM 3 UPDATED ACTUAL QUESTIONS
AND CORRECT ANSWERS
Question:
large intestine
Answer:
-Primary organ of bowel elimination
-Extends from the ileocecal valve to the anus
-Functions ~~Absorption of water ~~Formation of feces ~~Expulsion of feces
from the body
Question:
small intestine
Answer:
-Secretes enzymes aiding in protein and carb digestion
-3 Parts: duodenum, jejunum & ileum -Function: ~~Receive liver and
pancreases juices for digestion ~~Food digestion and nutrient absorption in
the bloodstream
Question:
process of peristalsis
Answer:
-Peristalsis is under control of the nervous system. -Contractions occur every 3
to 12 minutes. -Mass peristalsis sweeps occur one to four times each 24-hour
period. -One-third to one-half of food waste is excreted in stool within 24
hours.
Question:
variables influencing bowel elimination
Answer:
-Developmental considerations -Daily patterns -Food and fluid -Activity and
muscle tone -Lifestyle -Psychological variables -Pathologic conditions
-Medications -Diagnostic studies -Surgery and anesthesia
Question:
developmental considerations
Answer:
-Infants: Characteristics of stool and frequency depend on formula or breast
feedings. -Toddler: Physiologic maturity is the first priority for bowel
training/Voluntary bowel control btwn 22-36 mos -Child, adolescent, adult:
Defecation patterns vary in quantity, frequency, and rhythmicity. 1-2 / day to 1
every other 2-3 days -Older adult: Constipation is often a chronic problem;
diarrhea and fecal incontinence may result from physiologic or lifestyle
changes resulting in a decrease in motility.
Question:
foods affecting bowel elimination
, Answer:
-Constipating foods: cheese, lean meat, eggs, pasta -Foods with laxative effect:
fruits and vegetables, bran, chocolate, alcohol, coffee -Gas
(flatulence)-producing foods: onions, cabbage, beans, cauliflower
Question:
Effect of medications on stool
Answer:
-Aspirin, anticoagulants: pink to red to black stool -Iron salts: black stool
(patients need accurate assessment of number of BM with stool softener
administration when taking iron tx) -Antacids: white discoloration or
speckling in stool -Antibiotics: green-gray color
Question:
physical assessment of the abdomen
Answer:
-Inspection: observe contour, any masses, scars, or distention
-Auscultation: listen for bowel sounds in all quadrants ~~Note frequency and
character, audible clicks, and flatus. ~~Describe bowel sounds as hypoactive,
hyperactive, absent or infrequent.
-Percussion and palpations: performed by advanced practice professionals
Question:
inspection and palpation
Answer:
-Lesions, ulcers, fissures (linear break on the margin of the anus),
inflammation, and external hemorrhoids -Ask the patient to bear down as
though having a bowel movement. -Assess for the appearance of internal
hemorrhoids or fissures and fecal masses. -Inspect perineal area for skin
irritation secondary to diarrhea or fecal incontinence.
Question:
stool collection
Answer:
-Medical aseptic technique is imperative. -Hand hygiene, before and after
glove use, is essential. -Wear disposable gloves. -Do not contaminate outside of
container with stool. -Obtain stool and package, label, and transport according
to agency policy (in a plastic biohazard/sealable bag) -Occult Blood, culture
and sensitivity, pus, ova and parasites -Void first so that urine is not in stool
sample. -Defecate into the container rather than toilet bowl. -Do not place
toilet tissue in the bedpan or specimen container. -Notify nurse when
specimen is available.
Question:
occult blood testing
Answer:
-To test stool sample for presence of hidden blood ~~Hemoccult or fecal occult
blood test
---Uses a solution of guaiac to test for presence of blood
---Using small wooden blade smear small amount of stool on testing slide to
test for presence of occult blood.
,Question:
types of direct visualization studies (endoscopy)
Answer:
-Esophagogastroduodenoscopy -Colonoscopy -Sigmoidoscopy -Wireless
capsule endoscopy
Question:
indirect visualization studies
Answer:
-KUB -Upper gastrointestinal (UGI) -Small bowel series -Barium enema
-Abdominal ultrasound -Magnetic resonance imaging (MRI) -Abdominal CT
scan ~~Noninvasive procedures take precedence over invasive pro-cedures
Question:
patient outcomes for normal bowel elimination
Answer:
-Patient has a soft, formed bowel movement every 1 to 3 days without
discomfort. -The relationship between bowel elimination and diet, fluid, and
exercise is explained. -Patient should seek medical evaluation if changes in
stool color or consistency persist.
Question:
promoting regular bowel habits
Answer:
-Timing
-Positioning
-Privacy
-Nutrition/Hydration
-Exercise ~~Abdominal ~~Thigh strengthening ~~Postural muscles
Question:
individuals at high risk for constipation
Answer:
-Patients on bedrest taking constipating medicines -Patients with reduced
fluids or bulk in their diet
-Patients who are depressed -Patients with central nervous system disease or
local lesions that cause pain while defecating
Question:
nursing measures for the patient with diarrhea
Answer:
-Answer call bells immediately. -Prevents falls!! -Remove the cause of diarrhea
whenever possible (e.g., medication). -If there is impaction, obtain physician
order for rectal examination. -Give special care to the region around the anus.
Question:
Nursing Measures for the Patient With Fecal Incontinence
Answer:
•Targeted toileting
•Pericare with barrier cream
•Keep skin and linens clean
, •Frequent skin assessments
•Rectal Tubes/Incontinence Devices
Question:
preventing food poisoning
Answer:
-Never buy food with damaged packaging. -Take items requiring refrigeration
home immediately. -Wash hands and surfaces often. -Use separate cutting
boards for foods. -Thoroughly wash all fruits and vegetables before eating. -Do
not wash meat, poultry, or eggs to prevent spreading microorganisms to sink
and other kitchen surfaces. -Never use raw eggs in any form. -Do not eat
seafood raw or if it has an unpleasant odor.
Question:
methods of emptying the colon of feces
Answer:
-Enemas -Rectal suppositories -Oral intestinal lavage -Digital removal of stool
Question:
types of enemas
Answer:
-Cleansing
-Retention ~~Oil ~~Carminative ~~Medicated ~~Anthelmintic
-Large volume
-Small volume
Question:
retention enemas
Answer:
-Oil-retention: lubricate the stool and intestinal mucosa, easing defecation
-Carminative: help expel flatus from the rectum -Medicated: provide
medications absorbed through the rectal mucosa -Anthelmintic: destroy
intestinal parasites
Question:
bowel training programs
Answer:
-Manipulate factors within the patient's control. ~~Food and fluid intake,
exercise, and time for defecation ~~Eliminate a soft, formed stool at regular
intervals without laxatives.
-When achieved, continue to offer assistance with toileting at the successful
time.
Question:
nasogastric tube
Answer:
-Inserted to decompress or drain the stomach of fluid or unwanted stomach
contents -Used to allow the gastrointestinal tract to rest before or after
abdominal surgery to promote healing -Inserted to monitor gastrointestinal
bleeding
AND CORRECT ANSWERS
Question:
large intestine
Answer:
-Primary organ of bowel elimination
-Extends from the ileocecal valve to the anus
-Functions ~~Absorption of water ~~Formation of feces ~~Expulsion of feces
from the body
Question:
small intestine
Answer:
-Secretes enzymes aiding in protein and carb digestion
-3 Parts: duodenum, jejunum & ileum -Function: ~~Receive liver and
pancreases juices for digestion ~~Food digestion and nutrient absorption in
the bloodstream
Question:
process of peristalsis
Answer:
-Peristalsis is under control of the nervous system. -Contractions occur every 3
to 12 minutes. -Mass peristalsis sweeps occur one to four times each 24-hour
period. -One-third to one-half of food waste is excreted in stool within 24
hours.
Question:
variables influencing bowel elimination
Answer:
-Developmental considerations -Daily patterns -Food and fluid -Activity and
muscle tone -Lifestyle -Psychological variables -Pathologic conditions
-Medications -Diagnostic studies -Surgery and anesthesia
Question:
developmental considerations
Answer:
-Infants: Characteristics of stool and frequency depend on formula or breast
feedings. -Toddler: Physiologic maturity is the first priority for bowel
training/Voluntary bowel control btwn 22-36 mos -Child, adolescent, adult:
Defecation patterns vary in quantity, frequency, and rhythmicity. 1-2 / day to 1
every other 2-3 days -Older adult: Constipation is often a chronic problem;
diarrhea and fecal incontinence may result from physiologic or lifestyle
changes resulting in a decrease in motility.
Question:
foods affecting bowel elimination
, Answer:
-Constipating foods: cheese, lean meat, eggs, pasta -Foods with laxative effect:
fruits and vegetables, bran, chocolate, alcohol, coffee -Gas
(flatulence)-producing foods: onions, cabbage, beans, cauliflower
Question:
Effect of medications on stool
Answer:
-Aspirin, anticoagulants: pink to red to black stool -Iron salts: black stool
(patients need accurate assessment of number of BM with stool softener
administration when taking iron tx) -Antacids: white discoloration or
speckling in stool -Antibiotics: green-gray color
Question:
physical assessment of the abdomen
Answer:
-Inspection: observe contour, any masses, scars, or distention
-Auscultation: listen for bowel sounds in all quadrants ~~Note frequency and
character, audible clicks, and flatus. ~~Describe bowel sounds as hypoactive,
hyperactive, absent or infrequent.
-Percussion and palpations: performed by advanced practice professionals
Question:
inspection and palpation
Answer:
-Lesions, ulcers, fissures (linear break on the margin of the anus),
inflammation, and external hemorrhoids -Ask the patient to bear down as
though having a bowel movement. -Assess for the appearance of internal
hemorrhoids or fissures and fecal masses. -Inspect perineal area for skin
irritation secondary to diarrhea or fecal incontinence.
Question:
stool collection
Answer:
-Medical aseptic technique is imperative. -Hand hygiene, before and after
glove use, is essential. -Wear disposable gloves. -Do not contaminate outside of
container with stool. -Obtain stool and package, label, and transport according
to agency policy (in a plastic biohazard/sealable bag) -Occult Blood, culture
and sensitivity, pus, ova and parasites -Void first so that urine is not in stool
sample. -Defecate into the container rather than toilet bowl. -Do not place
toilet tissue in the bedpan or specimen container. -Notify nurse when
specimen is available.
Question:
occult blood testing
Answer:
-To test stool sample for presence of hidden blood ~~Hemoccult or fecal occult
blood test
---Uses a solution of guaiac to test for presence of blood
---Using small wooden blade smear small amount of stool on testing slide to
test for presence of occult blood.
,Question:
types of direct visualization studies (endoscopy)
Answer:
-Esophagogastroduodenoscopy -Colonoscopy -Sigmoidoscopy -Wireless
capsule endoscopy
Question:
indirect visualization studies
Answer:
-KUB -Upper gastrointestinal (UGI) -Small bowel series -Barium enema
-Abdominal ultrasound -Magnetic resonance imaging (MRI) -Abdominal CT
scan ~~Noninvasive procedures take precedence over invasive pro-cedures
Question:
patient outcomes for normal bowel elimination
Answer:
-Patient has a soft, formed bowel movement every 1 to 3 days without
discomfort. -The relationship between bowel elimination and diet, fluid, and
exercise is explained. -Patient should seek medical evaluation if changes in
stool color or consistency persist.
Question:
promoting regular bowel habits
Answer:
-Timing
-Positioning
-Privacy
-Nutrition/Hydration
-Exercise ~~Abdominal ~~Thigh strengthening ~~Postural muscles
Question:
individuals at high risk for constipation
Answer:
-Patients on bedrest taking constipating medicines -Patients with reduced
fluids or bulk in their diet
-Patients who are depressed -Patients with central nervous system disease or
local lesions that cause pain while defecating
Question:
nursing measures for the patient with diarrhea
Answer:
-Answer call bells immediately. -Prevents falls!! -Remove the cause of diarrhea
whenever possible (e.g., medication). -If there is impaction, obtain physician
order for rectal examination. -Give special care to the region around the anus.
Question:
Nursing Measures for the Patient With Fecal Incontinence
Answer:
•Targeted toileting
•Pericare with barrier cream
•Keep skin and linens clean
, •Frequent skin assessments
•Rectal Tubes/Incontinence Devices
Question:
preventing food poisoning
Answer:
-Never buy food with damaged packaging. -Take items requiring refrigeration
home immediately. -Wash hands and surfaces often. -Use separate cutting
boards for foods. -Thoroughly wash all fruits and vegetables before eating. -Do
not wash meat, poultry, or eggs to prevent spreading microorganisms to sink
and other kitchen surfaces. -Never use raw eggs in any form. -Do not eat
seafood raw or if it has an unpleasant odor.
Question:
methods of emptying the colon of feces
Answer:
-Enemas -Rectal suppositories -Oral intestinal lavage -Digital removal of stool
Question:
types of enemas
Answer:
-Cleansing
-Retention ~~Oil ~~Carminative ~~Medicated ~~Anthelmintic
-Large volume
-Small volume
Question:
retention enemas
Answer:
-Oil-retention: lubricate the stool and intestinal mucosa, easing defecation
-Carminative: help expel flatus from the rectum -Medicated: provide
medications absorbed through the rectal mucosa -Anthelmintic: destroy
intestinal parasites
Question:
bowel training programs
Answer:
-Manipulate factors within the patient's control. ~~Food and fluid intake,
exercise, and time for defecation ~~Eliminate a soft, formed stool at regular
intervals without laxatives.
-When achieved, continue to offer assistance with toileting at the successful
time.
Question:
nasogastric tube
Answer:
-Inserted to decompress or drain the stomach of fluid or unwanted stomach
contents -Used to allow the gastrointestinal tract to rest before or after
abdominal surgery to promote healing -Inserted to monitor gastrointestinal
bleeding
