Chapter 21 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

Chapter 21 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

• The nurse is caring for a client with abdominal distention who is unable to expel What type 1) of enema would the nurse anticipate administering?

1. A) Cleansing enema B) Carminative enema
2. C) Retention enema D) Soapsuds enema

Answer: B

Explanation: A)       A carminative enema is used to reduce abdominal distention by helping to expel flatus. A cleansing enema is used to eliminate feces. Soapsuds enemas are a type of cleansing enema. Retention enemas introduce oil or medication into the rectum

and sigmoid colon. They are retained for a relatively long period.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. A carminative enema is used to reduce abdominal distention by helping to expel A cleansing enema is used to eliminate feces. Soapsuds enemas are a type of cleansing enema. Retention enemas introduce oil or medication into the rectum

and sigmoid colon. They are retained for a relatively long period.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. A carminative enema is used to reduce abdominal distention by helping to expel A cleansing enema is used to eliminate feces. Soapsuds enemas are a type of cleansing enema. Retention enemas introduce oil or medication into the rectum

and sigmoid colon. They are retained for a relatively long period.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. A carminative enema is used to reduce abdominal distention by helping to expel A cleansing enema is used to eliminate feces. Soapsuds enemas are a type of cleansing enema. Retention enemas introduce oil or medication into the rectum

and sigmoid colon. They are retained for a relatively long period.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

Objective: Learning Outcome 21-1: Define the key terms used in the skills of fecal elimination.

 

• The nurse is caring for a client with a colostomy who has continuous liquid drainage with a fecal 2) The nurse recognizes this client has a/n:

1. A) B) Ascending colostomy.
2. C) Transverse D) Descending colostomy.

Answer: B

Explanation: A)      An ascending colostomy drains liquid that cannot be regulated but, because of the presence of enzymes, has a fecal odor. An ileostomy is similar but, because of the lack of enzymes, generally does not have much of an odor. A transverse colostomy drains mushy drainage because some of the liquid has been reabsorbed. A descending colostomy produces increasingly solid fecal drainage, and can be regulated.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. An ascending colostomy drains liquid that cannot be regulated but, because of the presence of enzymes, has a fecal An ileostomy is similar but, because of the lack of enzymes, generally does not have much of an odor. A transverse colostomy drains mushy drainage because some of the liquid has been reabsorbed. A descending colostomy produces increasingly solid fecal drainage, and can be regulated.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. An ascending colostomy drains liquid that cannot be regulated but, because of the presence of enzymes, has a fecal An ileostomy is similar but, because of the lack of enzymes, generally does not have much of an odor. A transverse colostomy drains mushy drainage because some of the liquid has been reabsorbed. A descending colostomy produces increasingly solid fecal drainage, and can be regulated.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. An ascending colostomy drains liquid that cannot be regulated but, because of the presence of enzymes, has a fecal An ileostomy is similar but, because of the lack of enzymes, generally does not have much of an odor. A transverse colostomy drains mushy drainage because some of the liquid has been reabsorbed. A descending colostomy produces increasingly solid fecal drainage, and can be regulated.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

Objective: Learning Outcome 21-1: Define the key terms used in the skills of fecal elimination.

• The nurse is caring for a client who complains of frequent constipation, and recognizes that all of 3) the following factors could contribute to this condition except:

1. Inadequate fluid
2. Repeated inhibition of the urge to
3. Inadequate fiber
4. The presence of Escherichia

Answer: D

Explanation: A)      The bowel normally contains Escherichia coli, and its presence would not contribute to constipation. Inadequate fluid intake or fiber intake could result in constipation, and correcting these generally is the first recommendation for treatment. Clients who frequently resist the urge to defecate can develop constipation because of the expansion of the rectum to accommodate accumulated feces, eventually losing sensitivity to the need to defecate.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. The bowel normally contains Escherichia coli, and its presence would not contribute to Inadequate fluid intake or fiber intake could result in constipation, and correcting these generally is the first recommendation for treatment. Clients who frequently resist the urge to defecate can develop constipation because of the expansion of the rectum to accommodate accumulated feces, eventually losing sensitivity to the need to defecate.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. The bowel normally contains Escherichia coli, and its presence would not contribute to Inadequate fluid intake or fiber intake could result in constipation, and correcting these generally is the first recommendation for treatment. Clients who frequently resist the urge to defecate can develop constipation because of the expansion of the rectum to accommodate accumulated feces, eventually losing sensitivity to the need to defecate.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. The bowel normally contains Escherichia coli, and its presence would not contribute to Inadequate fluid intake or fiber intake could result in constipation, and correcting these generally is the first recommendation for treatment. Clients who frequently resist the urge to defecate can develop constipation because of the expansion of the rectum to accommodate accumulated feces, eventually losing sensitivity to the need to defecate.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

Objective: Learning Outcome 21-2: Describe factors that affect fecal elimination.

• The nurse is caring for a 15-month-old child whose mother states, “No matter what I do, I cannot 4) get her to use the toilet for bowel What would you suggest I do?” The nurse’s best response would be:
  1. “I would suggest you consult her pediatrician for further testing, because she should be able to control her “
  2. B) “I would suggest you consult a pediatric psychologist to determine why she is resistant to

potty training.”

1. “Resistance to toilet training can be very She really isn’t old enough to control her need to stool yet, and probably won’t gain control until she is 18-24 months.”
2. “I bet you get tired of changing Have you tried offering her a reward when she stools in the toilet?”

Answer: C

Explanation: A)      Children generally do not gain control of defecation until 18-24 months of age, so there is no need for further testing or psychological counseling. Recognizing the mother’s concern and providing information regarding normal development of bowel control is the best nursing response. Behavior modification in a child of this age is unlikely to be successful, and continued incontinence could increase the mother’s frustration if she doesn’t understand normal development.

Cognitive Level: Analysis

Client Need: Psychosocial Integrity

Nursing Process: Implementation

1. Children generally do not gain control of defecation until 18-24 months of age, so there is no need for further testing or psychological Recognizing the mother’s concern and providing information regarding normal development of bowel control is the best nursing response. Behavior modification in a child of this age is unlikely to be successful, and continued incontinence could increase the mother’s frustration if she doesn’t understand normal development.

Cognitive Level: Analysis

Client Need: Psychosocial Integrity

Nursing Process: Implementation

1. Children generally do not gain control of defecation until 18-24 months of age, so there is no need for further testing or psychological Recognizing the mother’s concern and providing information regarding normal development of bowel control is the best nursing response. Behavior modification in a child of this age is unlikely to be successful, and continued incontinence could increase the mother’s frustration if she doesn’t understand normal development.

Cognitive Level: Analysis

Client Need: Psychosocial Integrity

Nursing Process: Implementation

1. Children generally do not gain control of defecation until 18-24 months of age, so there is no need for further testing or psychological Recognizing the mother’s concern and providing information regarding normal development of bowel control is the best nursing response. Behavior modification in a child of this age is unlikely to be successful, and continued incontinence could increase the mother’s frustration if she doesn’t understand normal development.

Cognitive Level: Analysis

Client Need: Psychosocial Integrity

Nursing Process: Implementation

Objective: Learning Outcome 21-2: Describe factors that affect fecal elimination.