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WorksheetsIntestinal Obstruction and Clinical Signs
Total questions: 85
Worksheet time: 43mins
Non-mechanical obstruction is also known as paralytic ileus or adynamic ileus.
True
False
Hypovolemia is a common complication of intestinal obstruction.
True
False
An obstruction high in the small intestine often results in metabolic acidosis.
True
False
Intussusception is twisting of the intestine.
True
False
Volvulus is telescoping of a segment of the intestine within itself.
True
False
Hypokalemia is the most common electrolyte disturbance that predispose the patient to intestinal obstruction.
True
False
Intestinal obstruction due to phytobezoar is a mechanical obstruction.
False
True
Ileus is a paralytic or functional variety of obstruction.
False
True
In order, the main clinical signs of bowel obstruction include nausea or vomiting, colicky abdominal pain, and blockage of gas or stool.
True
False
Nausea and vomiting may be caused from anesthetic agents or narcotics, delayed gastric emptying, slowed peristalsis, resumption of oral intake too soon after surgery.
False
True
Which key feature does the nurse most likely find when performing a physical assessment on the patient with a small-bowel obstruction?
Minimal or no vomiting.
Metabolic acidosis.
Visible peristaltic waves in the upper and middle abdomen.
No major fluid and electrolyte imbalances.
Crohn’s disease can cause a mechanical obstruction.
False
True
What does nursing care of the patient with intestinal obstruction who reports discomfort in the early diagnostic period consist of?
Administration of opioid analgesics.
Placing the patient in a semi-Fowler’s position.
Providing the patient with fluids.
Offering the patient semi-soft food.
Which intervention apply to patients with fluid volume deficit related to an intestinal obstruction?
Offer ice chips to suck on before surgery.
Provide frequent mouth care with lemon glycerin swabs.
Assess for edema from third spacing.
Offer a small glass of water.
Which observation of the patient with an intestinal obstruction does the nurse report immediately?
Urinary output of 1000 ml in an 8 hour period.
The patient’s request for something to drink.
Abdominal pain changing from colicky to constant discomfort.
The patient who is changing positions frequently.
Which discharge information should a nurse include for a patient recovering from intestinal obstruction caused by fecal impaction?
Limit physical activity during recovery
Provide a written description of a low‑fiber diet
Report abdominal distention, nausea or vomiting, and constipation
Decrease overall fluid intake to prevent diarrhea
During teaching about colostomy care, which statement is correct to include?
The stoma will enlarge within 6 to 8 weeks of surgery
Use a moisturizing soap to cleanse the peristomal skin
Apply the colostomy bag while skin sealant is still damp
An antifungal cream or powder may be used if a fungal rash develops
Which statement about care of a patient with a colostomy is correct?
A healthy stoma should be dry to touch
The stoma should protrude about 5 cm from the abdominal wall
A slight amount of edema is normal in the initial postoperative period
On palpation the stoma should feel firm and noncompressible
The nurse should immediately report all but which sign or symptom related to a colostomy?
Unusual bleeding from the stoma
Mucocutaneous separation at the stoma
Liquid stool immediately postoperatively
Signs of ischemia and necrosis
After colostomy surgery, which intervention should the nurse employ?
Cover the stoma with a dry, sterile dressing
Apply a pouching system as soon as possible
Expect the colostomy to start functioning on day 1
Make a hole in the pouch to let gas escape
Patients with pancreatitis often have Turner’s sign described as a gray‑blue discoloration of the abdomen and periumbilical area.
Only in chronic cases
Cannot be determined
False
True
The pain of acute pancreatitis is often described as intense, boring, and continuous.
Only with gallstones
Depends on meal timing
False
True
Diagnosis of acute pancreatitis typically follows severe abdominal pain in the mid‑epigastric area or left upper quadrant.
Only with back radiation
Only if amylase is normal
False
True
Abdominal pain is the prominent symptom of pancreatitis.
True
False
Only in mild disease
Only with vomiting present
Anticholinergics are given to increase vagal stimulation, motility, and pancreatic flow.
Only with hypotension
True
False
Only with ileus
Pain management for acute pancreatitis should begin with rapid infusion of opioids using patient‑controlled analgesia (PCA).
Only for chronic pain
True
False
Only after NPO ends
Helping the patient assume a supine position decreases the abdominal pain of pancreatitis.
Only after ambulation
False
Only with antacids
True
Patients in early stages of acute pancreatitis are usually maintained NPO.
True
False
Only with mild pain
Only if intubated
What is the priority nursing diagnosis for acute pancreatitis?
Acute pain related to pancreatic inflammation
Risk for infection related to necrotic pancreatic tissue
Nausea related to pancreatic disease
Risk for deficient fluid volume related to abnormal and normal routines
Which diagnostic test is the most accurate in verifying a diagnosis of acute pancreatitis?
Trypsine
Lipase
Alkaline phosphatase
Alanine aminotransferase
The patient with acute pancreatitis is at risk for paralytic (adynamic) ileus. Which action provides the nurse with the best indication of bowel function?
Asking about passing flatus or stool
Auscultation of bowel sounds
Obtaining abdominal CT with contrast
Observing nasogastric drainage contents
Which drug is contraindicated for a patient with paralytic ileus?
Cefuroxime (Zinacef)
Ranitidine (Zantac)
Dicyclomine (Bentyl)
Papaverine (Pavabid)
A patient recovering from acute pancreatitis receives diet teaching. Which patient statement shows successful learning?
I will avoid eating chocolate
I am eating tacos for my first meal
I will eat the usual three meals daily
I will limit protein amount in my diet
Complications of pancreatitis such as pancreatic pseudocyst and abscess may necessitate surgical drainage.
False
True
If pancreatitis is caused by biliary tract obstruction, a laparotomy for common bile duct exploration and release of obstruction may be performed.
False
True
Postoperative care: Monitor drainage tubes for patency by assessing for kinks in the tubes.
True
False
Postoperative care: Maintain the ordered drain suction pressure and system integrity.
False
True
Postoperative care: Record the output amount from the drain and describe the character of the drainage.
False
True
Postoperative care: Provide meticulous skin care and dressing changes; assess for tissue deterioration.
True
False
Collaborate with an enterostomal therapist (ET) for measures to promote skin integrity.
False
True
Peritonitis is caused by contamination of the peritoneal cavity by bacteria or chemicals.
False
True
Continuous ambulatory peritoneal analysis can cause peritonitis.
True
False
White blood cell counts are often decreased with peritonitis.
False
True
Abdominal wall rigidity is a classic finding in patients with peritonitis.
True
False
The fluid shift that occurs in peritonitis may result in which of following?
Significant increase in circular volume
Increased bowel motility caused by increased fluid volume
Intracellular fluid moving into the peritoneal cavity
Eventual renal failure and electrolyte imbalance
The source of inflammation in peritonitis rarely comes from
Gastrointestinal tract
Internal reproductive organs
Abdominal gunshot wound
The bloodstream
A rare cause of peritonitis is
Perforated peptic ulcer
Appendicitis
Peritoneal dialysis
Bowel perforation secondary to cancer, penetrating wound
Which complication is not due to peritonitis:
Paralytic ileus
Adhesion of small intestine
Abscess formation
Intraabdominal haemorrhage
The respiratory problems that may accompany peritonitis are a result of which factor?
Fluid shifts to thoracic cavity
Decreased pressure against the diaphragm
Associated pain interfering with ventilation
Decreased oxygen demands related to the infectious process
Which nursing intervention is part of nonsurgical management for the patient with peritonitis?
Administer NSAIDs for pain
Monitor weekly weight and intake and output
Insert a nasogastric tube to decompress the stomach
Order a breakfast tray when the patient is hungry
What are the cardinal signs of peritonitis?
Fever and headache
Dizziness and vomiting
Nausea and loss of appetite
Abdominal pain and tenderness
Which character of abdominal pain is not observed in peritonitis
More intense near the site of inflammation
Intermittent
Constant and diffuse
Movement aggravates pain
Which assessment is not priority in diagnostic of peritonitis
CT scan of the abdomen
Abdominal x-ray
Blood cell count
Peritoneal lavage
Nursing intervention for the patient with peritonitis preoperatively don’t include
Place the patient on bed rest
Obtain a history and assess the abdomen
Give broad-spectrum antibiotics
Give foods when the patient arrive at hospital
Nursing intervention for the patient with peritonitis postoperatively don’t include
Report any manifestation of sepsis
Assess vital signs
Immobilize the patient on the bed
Monitor the fluid and electrolyte balance
The nurse is instructing the patient about home care after an exploratory laparotomy for peritonitis. Which statement by the patient indicates that teaching has been effective?
“I will call the health care provider for a temperature greater than 38°C”
“I will stop taking the antibiotics if diarrhea develops”
“It is normal for the incision site to be warm”
“I will resume activity with my bowling league this week for exercise”
The nurse assesses a patient with a nursing diagnosis of Disturbed Sensory Perception. Which motor and sensory findings are expected below the level of injury?
Independent movement; no sense of pain or touch
Partial motor function; full sense of pain and temperature
No independent movement; full sense of touch or position
No motor function; no sensation to touch, position, and vibration
A patient with a cervical neck injury can spontaneously move the legs when attempting to move in bed but is not using or moving the arms or hands. What is this observation consistent with?
Anterior cord syndrome
Posterior cord syndrome
Central cord syndrome
Brown-Sequard syndrome
A high-speed motor vehicle crash patient with probable cervical spine fracture arrives with altered mental status and flaccid extremities. What is the priority assessment?
Assess respiratory pattern and ensure a patent airway
Assess for loss of motor function and sensation
Check mental status using the Glasgow Coma Scale
Observe for intra-abdominal bleeding and hemorrhage
An emergency department nurse monitors a patient with a gunshot wound to the mid-back for spinal shock. What findings should be monitored?
Tachycardia and a change in level of consciousness
Decreased blood pressure, bradycardia, and flaccid paralysis
Decreased respiratory rate and loss of pain and touch
Paralytic ileus and loss of bowel and bladder function
Which neurologic assessment technique tests proprioceptive function?
Touch skin with a safety pin to distinguish sharp or dull
Ask the patient to elevate both arms and extend wrists and fingers
Have the patient close eyes and move toes up or down; patient identifies positions
Have the patient sit with legs dangling; use reflex hammer to test reflexes
A patient with an upper spinal cord injury is at risk for autonomic dysreflexia. Which nursing diagnosis is the priority?
Nausea
Acute Pain, Headache
Impaired Physical Mobility
Risk for Ineffective Tissue Perfusion, Cerebral
Which intervention targets and helps prevent autonomic dysreflexia in a patient with a recent SCI?
Monitor urinary output and check for bladder distention
Keep the patient immobilized with neck and back braces
Keep the room warm and control environmental stimuli
Frequently perform passive ROM exercises
What is a potential adverse outcome of autonomic dysreflexia in a patient with SCI?
Aspiration and pneumonia
Hypertensive crisis
Paralytic ileus
Heat stroke
After an SCI, a patient develops autonomic dysfunction including a neurogenic bladder. Which nursing diagnosis is the priority?
Risk for Urinary Incontinence: urge
Risk for Self-Care Deficit: toileting
Risk for Fluid Volume Deficit: polyuria
Risk for Infection: urinary tract
Turns the patient by pulling on the top of the halo device.
Recommended approach to protect pin sites
Best practice to support cervical alignment
Safe repositioning technique with halo traction
Incorrect method that risks device displacement
Positions the patient with the head and neck in alignment.
Only needed when removing immobilization device
Contraindicated during halo traction repositioning
Appropriate for maintaining spinal precautions
Unnecessary unless pain is reported by patient
Supports the head and neck area during the repositioning.
Done after patient is fully turned onto side
Performed only by physical therapist staff
Not recommended with halo fixator in place
Essential to prevent cervical spine movement
The nurse is caring for several patients with SCIs. Which task is best to delegate to the nursing assistant?
Insert a Foley catheter and report urine characteristics
Check for skin breakdown under immobilization devices
Encourage incentive spirometry and evaluate technique
Log roll the patient and place bedpan for toileting
The patient with an SCI has paraplegia and paraparesis. The nurse assesses both calves for swelling, tenderness, and redness due to increased risk for which condition?
Contractures of joints
Deep vein thrombosis
Bone fractures
Pressure ulcers
A bladder retraining program was initiated for a long-term care patient after SCI with urinary retention and overflow incontinence. Which is an expected outcome of the training program?
Takes bethanechol one hour prior to voiding
Independently performs intermittent catheterization
Demonstrates a predictable voiding pattern
Uses warm water over perineum to stimulate voiding
Paralysis of lateral gaze indicates a lesion of cranial nerve
III
II
VI
IV
A primary brain injury is caused by
An external force
ICP
An internal force
Abnormal brain tissue growth
A 16-year-old football player is confused after being struck in the head. He does not remember much, waking in the hospital two hours after the hit. This client most likely is suffering from
Locked-in syndrome
Severe brain injury
Moderate brain injury
Concussion
The nurse is educating 7-year-old children on preventing brain injury. One of the most important things to tell them is to
Always wear supportive shoes when playing
Look both ways before crossing the street
Always wear knee and arm pads when riding
Always wear a helmet when riding
A client responds only to pain by withdrawing his hand and curses frequently after a fall. Using the Glasgow Coma Scale, the nurse rates this patient as a
12
15
4
9
A common medication given to help decrease intracranial pressure is
Mannitol
Lasix
Ibuprofen
Aspirin
The most important nursing diagnosis when caring for a client with an open skull fracture is
Risk for impaired skin integrity
Risk for infection
The consensual pupillary response is tested by:
Asking the client if he or she has trouble closing his or her eyes
Evaluating the ability of the client’s eyes to converge
Directing a light toward one eye and observing the pupil on the opposite side
Instructing the client to cover one eye while you observe the opposite eye for extraocular movements
Which factor is most likely to depress nerve cell activity in the patient with a neurologic disorder?
IV infusion of theophylline
Low oxygen saturation and hypoxia
Metabolic alkalosis
Drinking too much coffee
Which statement about the Glasgow Coma Scale (GCS) is correct?
It is a thorough neurologic assessment tool.
It establishes a baseline for eye opening and motor and verbal response.
It establishes a baseline cognitive function.
A score of 15 indicates serious neurologic impairment with poor prognosis
The nurse is assessing several patients using the GCS. Which factors indicate the most serious neurologic presentation based on the GCS information?
Eye opening to sound, localizes pain, confused conversation
Eye opening to sound, obeys commands, inappropriate words
Eye opening spontaneous, obeys commands, confused conversation
Eye opening to pain, abnormal flexion, incomprehensible sounds
The nurse performing neurologic checks every 4 hours for the patient who sustained a head injury. Which early sign indicates a decline in neurologic status?
Loss of remote memory
Decorticate posturing
Change in level of consciousness
Nonreactive, dilated pupil
A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time?
Insert NG tube.
Keep neck stabilized.
Monitor pulse and blood pressure frequently.
Establish IV access and start fluid replacement.
A nurse is caring for a client who has just been admitted from surgery for the evacuation of a subdural hematoma. Which of the following is the priority assessment?
Oxygen saturation level
Cranial nerve function
Glasgow Coma Scale
