Study Guide for Fundamentals of Nursing The Art and Science of Nursing Care

CHAPTER 38

PRACTICING FOR NCLEX

MULTIPLE CHOICE QUESTIONS

1.d 2.c 3.b 4.b 5.a

6.d 7.b 8.c

ALTERNATE-FORMAT QUESTIONS

Multiple Response Questions

1.a, c, d, f

2.b, c, f

3.c, d, f

4.b, e, f

5.a, c, d, e

6.b, d, e

7.c, d, e

8.a, c

9.b, d, f

Prioritization Questions

1.

3. a.Direct manipulation of the bowel during
   surgery inhibits peristalsis, causing a condition
   termed paralytic ileus. This temporary stoppage
   lasts 24 to 48 hours.
   b.Inhalation of anesthetic agents inhibits peristal-
   sis by blocking parasympathetic impulses to the
   intestinal musculature.


4. a.Inspection: The nurse observes the contour of
   the abdomen, noting any masses or areas of
   distention.
   b.Auscultation: The nurse uses a warmed
   stethoscope to listen for bowel sounds in a
   systematic, clockwise manner in all abdominal
   quadrants.
   c. Percussion: The nurse percusses all quadrants of
   the abdomen in a systematic, clockwise manner
   to identify any masses, fluid, or air.
   d.Palpation: Light and deep palpations in each
   quadrant are performed; tenderness, muscular
   resistance, enlargement of organs, and masses
   are noted.


5. a.Developmental considerations: The stool char-
   acteristics of an infant depend on whether the
   infant is being fed breast milk or formula.
   b.Daily patterns: A change in a person’s daily rou-
   tine may lead to constipation.
   c. Food and fluids: Both the type and the amount
   of foods eaten affect elimination.
   d.Activity and muscle tone: Regular exercise
   improves gastrointestinal motility.
   e.Lifestyle: A person’s daily schedule, occupation,
   and leisure activities may contribute to a habit
   of defecating at regular times or to an irregular
   pattern.
   f. Psychological variables: In some people, anxiety
   may have a direct effect on gastrointestinal
   motility, and diarrhea accompanies periods of
   high anxiety.
   g.Medications: Medications may influence the
   appearance of the stool—for instance, iron
   salts result in a black stool from the oxidation
   of iron.
   h.Diagnostic studies: Patients may need to fast for
   tests, which may alter elimination patterns.
   6.Sample answer:
   When were you first diagnosed with diverticular
   disease? How long have you had the pain? Have
   you ever had this pain before? How often do you
   move your bowels? What do your stools look
   like? Have you noticed any changes in stool
   lately? What is your regular diet like? Are there
   any foods you avoid? Are there any foods that
   help relieve the pain?


6. a.Daily fluid intake of 2,000 to 3,000 mL
   b.Increased intake of high-fiber foods
   c. Regular exercise
   d.Acceptance of bowel elimination as a normal
   process of life

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:

ANSWER KEY 401

bh f egc ad

hbeg f ad c

2.

DEVELOPING YOUR KNOWLEDGE BASE

IDENTIFICATION

1. a.Rectum
   b.Internal anal sphincter
   c. External anal sphincter
   d.Anal valve
   e.Anal canal


2. a.Sigmoid colostomy—formed
   b.Descending colostomy—formed
   c. Transverse (single B) colostomy—soft
   d.Ascending colostomy—soft to liquid
   e.Ileostomy—liquid
   MATCHING EXERCISES
   1.h 2.a 3.d 4.f 5.c
   6.e 7.b 8.g 9.a 10.d
   11.c 12.e 13.b, f 14.g 15.a
   16.h 17.b 18.d 19.i 20.c
   21.e 22.k 23.g 24.f 25.a
   26.m 27.h 28.b 29.n 30.c
   31.i 32.q 33.o 34.r 35.d
   36.l 37.p 38.e 39.k 40.j
   SHORT ANSWER
   
   
   1. a.Completion of absorption
      b.Manufacture of certain vitamins
      c. Formation of feces
      d.Expulsion of feces from the body
   
   
   2. a.One is situated in the medulla.
      b.A subsidiary center is situated in the spinal cord.
   
   
   
   

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