Unit IV (Bowel)

Question 1

What techniques does the nurse use for abdominal assessment? Which order?

Answer 1

Inspection, Auscultation, Palpitation.

Look, Listen, Feel

Question 2

The nurse notes the patient to have a larger than normal abdomen. What term would be used to describe the abdomen?

Answer 2

Protuberant.

Question 3

What are the normal/acceptable terms used to describe the abdomen? Define each.

Answer 3

Flat- Self explanatory
Rounded- Convex
Scaphoid- Concave

Question 4

The nurse reports the patient’s abdominal girth to be 42”. What does girth measure?

Answer 4

Girth measures circumference of the abdomen.

Question 5

What landmarks outline the abdomen?

Answer 5

Costal margins to symphysis pubis.

Question 6

What does the nurse visually inspect the abdomen for?

Answer 6

Contour, Symmetry, Girth.

Question 7

What does the nurse expect to hear when auscultating bowel sounds?

Answer 7

‘Soft Clicks and gurgles’

Question 8

Define peristalsis.

Answer 8

Rhythmic smooth muscle contractions of intestinal wall that propels intestinal contents towards the anus.

Question 9

After auscultating the LUQ for one minute, the nurse notes occurence of only two bowel sounds. What is this termed?

Answer 9

Hypoactive bowel sounds.

Question 10

After auscultating the LLQ for one minutes, the nurse notes occurence of rapid continuous bowel sounds. What is this termed?

Answer 10

Hyperactive bowel sounds.

Question 11

How long does the nurse need to auscultate Each quadrant to accurately determine absent bowel sounds.

Answer 11

5 minutes.

Question 12

What does the nurse assess for while palpating the abdomen during a bowel focused assessment?

Answer 12

Firmness

Question 13

How deep does the nurse press to palpate the abdomen during a bowel-focused assessment?

Answer 13

1/2-1”

Question 14

What influences the color of stool?

What gives stool its normal color?

Answer 14

Diet and medications.

Bile Pigmentation

Question 15

What influences the consistency of the patients stool?

Answer 15

Diet, Fluid Intake, Gastric Motility, Medications

Question 16

Normal stool shape:

Answer 16

Tubular 1” diameter.

Question 17

Abnormally shaped stool can indicate:

Answer 17

Intestinal problems.

Question 18

How is frequency of bowel movement noted/recorded?

Answer 18

X1, X2, X3, etc….

Question 19

The collection of hardened stool in rectum or sigmoid colon that prevents passage of stool is termed:

Answer 19

Fecal Impaction

Question 20

What is the cause of fecal impaction?

Answer 20

Prolonged retention or accumulation of fecal matter in the colon.

Question 21

What s/s does the nurse monitor the pt for with a suspected fecal impaction?

Answer 21

Liquid brown seepage from rectum, abdominal distention, decreased appetite, nausea, flatus.

Question 22

What instructions should the nurse give to the patient providing a stool culture?

Answer 22

Do not contaminate with urine or toilet tissue.

Question 23

What does the nurse observe the stool specimen for?

Answer 23

Visible blood, mucus, pus.

Question 24

What anaerobic organism infects the GI tract following antibiotic therapy?

Answer 24

Colstridium Difficle

Question 25

What does a hemoccult detect?

Answer 25

Microscopic blood in stool.

Question 26

What solution is used in the hemoccult to test for blood in the stool?

Answer 26

Guiac

Question 27

The nurse performing a hemoccult test understands the stool smear will turn what color to indicate a positive result?

Answer 27

Blue

Question 28

What invasive diagnostic procedure produced an xray of the large intestine.

Answer 28

Barium Enema

Question 29

A Barium Enema observes for:

Answer 29

GI obstruction, and disease.

Question 30

What should the nurse encourage the patient to do following a barium enema?

Answer 30

Increase fluid intake, keeping the barium in liquid form.

Question 31

What does the nurse assess following a barium enema?

Answer 31

Bowel sounds and bowel movements

Question 32

Normal bowel sounds occur every

Answer 32

5-15 seconds

Question 33

Sx of Clostridium difficle

Answer 33

Diarrhea and dehydration

Question 34

Capsule endoscopy

Answer 34

Swallow pill with camera to take pictures of GI and detect cancer and ulcers

Question 35

Colonoscopy

Answer 35

Visual exam of lining of large intestine with scope | -From anus to ileum-

Question 36

Radiography studies

Answer 36

``` Abdominal x-ray CT scan Barium enema Endoscopy -colonoscopy -sigmoidoscopy ```

Question 37

Geriatric considerations

Answer 37

``` Increase -fatty tissue in trunk -constipation (laxative abuse) Decrease -peristalsis -gastric secretions -motility/sphincter tone -muscle tone of intestines & abdomen -fiber & fluids - ```

Question 38

Laxative abuse in the elderly can cause

Answer 38

Low k+ which may cause dysrhythmia

Question 39

What cause bowel sounds

Answer 39

Air & liquid moving through GI tract

Question 40

Borborygmi

Answer 40

Noisy loud "growling" sounds

Question 41

Hyperactive bowel sounds

Answer 41

Loud, gurgling rushed sounds | more than 35/min

Question 42

Hypoactive bowel sounds

Answer 42

Soft, low, widely separated sounds | Less than 5/min

Question 43

What does the nurse do if bowel sounds are absent

Answer 43

Report immediately because it may be a complication such as Obstruction Peritonitis Paralytic ileus

Question 44

Procedure for auscultation bowel sounds

Answer 44

1) place patient in supine position with knees flexed 2) warm the diaphragm 3) place it on the beginning quadrant (mentally divide abdomen into 4 quadrants) 4) listen 5 min in EACH quadrant before determining absent bowel sounds 5) document presence/absence of bowel sounds

Question 45

How often do bowel sounds normally occur

Answer 45

5-20 sec

Question 46

Frequency of bowel sounds is related to

Answer 46

Presence of food in GI tract or state of digestion

Question 47

Normal bowel sounds occur every

Answer 47

5-15 seconds

Question 48

Sx of Clostridium difficle

Answer 48

Diarrhea and dehydration

Question 49

Capsule endoscopy

Answer 49

Swallow pill with camera to take pictures of GI and detect cancer and ulcers

Question 50

Colonoscopy

Answer 50

Visual exam of lining of large intestine with scope | -From anus to ileum-

Question 51

Radiography studies

Answer 51

``` Abdominal x-ray CT scan Barium enema Endoscopy -colonoscopy -sigmoidoscopy ```

Question 52

Geriatric considerations

Answer 52

``` Increase -fatty tissue in trunk -constipation (laxative abuse) Decrease -peristalsis -gastric secretions -motility/sphincter tone -muscle tone of intestines & abdomen -fiber & fluids - ```

Question 53

Laxative abuse in the elderly can cause

Answer 53

Low k+ which may cause dysrhythmia

Question 54

What cause bowel sounds

Answer 54

Air & liquid moving through GI tract

Question 55

Borborygmi

Answer 55

Noisy loud "growling" sounds

Question 56

Hyperactive bowel sounds

Answer 56

Loud, gurgling rushed sounds | more than 35/min

Question 57

Hypoactive bowel sounds

Answer 57

Soft, low, widely separated sounds | Less than 5/min

Question 58

What does the nurse do if bowel sounds are absent

Answer 58

Report immediately because it may be a complication such as Obstruction Peritonitis Paralytic ileus

Question 59

Procedure for auscultation bowel sounds

Answer 59

1) place patient in supine position with knees flexed 2) warm the diaphragm 3) place it on the beginning quadrant (mentally divide abdomen into 4 quadrants) 4) listen 5 min in EACH quadrant before determining absent bowel sounds 5) document presence/absence of bowel sounds

Question 60

How often do bowel sounds normally occur

Answer 60

5-20 sec

Question 61

Frequency of bowel sounds is related to

Answer 61

Presence of food in GI tract or state of digestion