NCLEX Practice Exam for Gastrointestinal Diseases 3

1.  Which of the following complications is thought to be the most common cause of appendicitis?

  1. A fecalith
  2. Bowel kinking
  3. Internal bowel occlusion
  4. Abdominal bowel swelling

2. Which of the following terms best describes the pain associated with appendicitis?

  1. Aching
  2. Fleeting
  3. Intermittent
  4. Steady

3. Which of the following nursing interventions should be implemented to manage a client with appendicitis?

  1. Assessing for pain
  2. Encouraging oral intake of clear fluids
  3. Providing discharge teaching
  4. Assessing for symptoms of peritonitis

4. Which of the following definitions best describes gastritis?

  1. Erosion of the gastric mucosa
  2. Inflammation of a diverticulum
  3. Inflammation of the gastric mucosa
  4. Reflux of stomach acid into the esophagus

5. Which of the following substances is most likely to cause gastritis?

  1. Milk
  2. Bicarbonate of soda, or baking soda
  3. Enteric coated aspirin
  4. Nonsteriodal anti-imflammatory drugs

6. Which of the following definitions best describes diverticulosis?

  1. An inflamed outpouching of the intestine
  2. A noninflamed outpouching of the intestine
  3. The partial impairment of the forward flow of intestinal contents
  4. An abnormal protrusion of an organ through the structure that usually holds it.

7. Which of the following types of diets is implicated in the development of diverticulosis?

  1. Low-fiber diet
  2. High-fiber diet
  3. High-protein diet
  4. Low-carbohydrate diet

8. Which of the following mechanisms can facilitate the development of diverticulosis into diverticulitis?

  1. Treating constipation with chronic laxative use, leading to dependence on laxatives
  2. Chronic constipation causing an obstruction, reducing forward flow of intestinal contents
  3. Herniation of the intestinal mucosa, rupturing the wall of the intestine
  4. Undigested food blocking the diverticulum, predisposing the area to bacteria invasion.

9. Which of the following symptoms indicated diverticulosis?

  1. No symptoms exist
  2. Change in bowel habits
  3. Anorexia with low-grade fever
  4. Episodic, dull, or steady midabdominal pain

10.  Which of the following tests should be administered to a client suspected of having diverticulosis?

  1. Abdominal ultrasound
  2. Barium enema
  3. Barium swallow
  4. Gastroscopy

11.  Medical management of the client with diverticulitis should include which of the following treatments?

  1. Reduced fluid intake
  2. Increased fiber in diet
  3. Administration of antibiotics
  4. Exercises to increase intra-abdominal pressure

12.  Crohn’s disease can be described as a chronic relapsing disease. Which of the following areas in the GI system may be involved with this disease?

  1. The entire length of the large colon
  2. Only the sigmoid area
  3. The entire large colon through the layers of mucosa and submucosa
  4. The small intestine and colon; affecting the entire thickness of the bowel

13.  Which area of the alimentary canal is the most common location for Crohn’s disease?

  1. Ascending colon
  2. Descending colon
  3. Sigmoid colon
  4. Terminal ileum

14.  Which of the following factors is believed to be linked to Crohn’s disease?

  1. Constipation
  2. Diet
  3. Hereditary
  4. Lack of exercise

15.  Which of the following factors is believed to cause ulcerative colitis?

  1. Acidic diet
  2. Altered immunity
  3. Chronic constipation
  4. Emotional stress

16.  Fistulas are most common with which of the following bowel disorders?

  1. Crohn’s disease
  2. Diverticulitis
  3. Diverticulosis
  4. Ulcerative colitis

17.  Which of the following areas is the most common site of fistulas in client’s with Crohn’s disease?

  1. Anorectal
  2. Ileum
  3. Rectovaginal
  4. Transverse colon

18.  Which of the following associated disorders may a client with ulcerative colitis exhibit?

  1. Gallstones
  2. Hydronephrosis
  3. Nephrolithiasis
  4. Toxic megacolon

19.  Which of the following associated disorders may the client with Crohn’s disease exhibit?

  1. Ankylosing spondylitis
  2. Colon cancer
  3. Malabsorption
  4. Lactase deficiency

20.  Which of the following symptoms may be exhibited by a client with Crohn’s disease?

  1. Bloody diarrhea
  2. Narrow stools
  3. N/V
  4. Steatorrhea

21.  Which of the following symptoms is associated with ulcerative colitis?

  1. Dumping syndrome
  2. Rectal bleeding
  3. Soft stools
  4. Fistulas

22.  If a client had irritable bowel syndrome, which of the following diagnostic tests would determine if the diagnosis is Crohn’s disease or ulcerative colitis?

  1. Abdominal computed tomography (CT) scan
  2. Abdominal x-ray
  3. Barium swallow
  4. Colonoscopy with biopsy

23.  Which of the following interventions should be included in the medical management of Crohn’s disease?

  1. Increasing oral intake of fiber
  2. Administering laxatives
  3. Using long-term steroid therapy
  4. Increasing physical activity

24.  In a client with Crohn’s disease, which of the following symptoms should not be a direct result from antibiotic therapy?

  1. Decrease in bleeding
  2. Decrease in temperature
  3. Decrease in body weight
  4. Decrease in the number of stools

25.  Surgical management of ulcerative colitis may be performed to treat which of the following complications?

  1. Gastritis
  2. Bowel herniation
  3. Bowel outpouching
  4. Bowel perforation

26.  Which of the following medications is most effective for treating the pain associated with irritable bowel disease?

  1. Acetaminophen
  2. Opiates
  3. Steroids
  4. Stool softeners

27.  During the first few days of recovery from ostomy surgery for ulcerative colitis, which of the following aspects should be the first priority of client care?

  1. Body image
  2. Ostomy care
  3. Sexual concerns
  4. Skin care

28.  Colon cancer is most closely associated with which of the following conditions?

  1. Appendicitis
  2. Hemorrhoids
  3. Hiatal hernia
  4. Ulcerative colitis

29.  Which of the following diets is most commonly associated with colon cancer?

  1. Low-fiber, high fat
  2. Low-fat, high-fiber
  3. Low-protein, high-carbohydrate
  4. Low carbohydrate, high protein

30.  Which of the following diagnostic tests should be performed annually over age 50 to screen for colon cancer?

  1. Abdominal CT scan
  2. Abdominal x-ray
  3. Colonoscopy
  4. Fecal occult blood test

31.  Radiation therapy is used to treat colon cancer before surgery for which of the following reasons?

  1. Reducing the size of the tumor
  2. Eliminating the malignant cells
  3. Curing the cancer
  4. Helping the bowel heal after surgery

32.  Which of the following symptoms is a client with colon cancer most likely to exhibit?

  1. A change in appetite
  2. A change in bowel habits
  3. An increase in body weight
  4. An increase in body temperature

33.  A client has just had surgery for colon cancer. Which of the following disorders might the client develop?

  1. Peritonitis
  2. Diverticulosis
  3. Partial bowel obstruction
  4. Complete bowel obstruction

34.  A client with gastric cancer may exhibit which of the following symptoms?

  1. Abdominal cramping
  2. Constant hunger
  3. Feeling of fullness
  4. Weight gain

35.  Which of the following diagnostic tests may be performed to determine if a client has gastric cancer?

  1. Barium enema
  2. Colonoscopy
  3. Gastroscopy
  4. Serum chemistry levels

36.  A client with gastric cancer can expect to have surgery for resection. Which of the following should be the nursing management priority for the preoperative client with gastric cancer?

  1. Discharge planning
  2. Correction of nutritional deficits
  3. Prevention of DVT
  4. Instruction regarding radiation treatment

37.  Care for the postoperative client after gastric resection should focus on which of the following problems?

  1. Body image
  2. Nutritional needs
  3. Skin care
  4. Spiritual needs

38.  Which of the following complications of gastric resection should the nurse teach the client to watch for?

  1. Constipation
  2. Dumping syndrome
  3. Gastric spasm
  4. Intestinal spasms

39.  A client with rectal cancer may exhibit which of the following symptoms?

  1. Abdominal fullness
  2. Gastric fullness
  3. Rectal bleeding
  4. Right upper quadrant pain

40.  A client with which of the following conditions may be likely to develop rectal cancer?

  1. Adenomatous polyps
  2. Diverticulitis
  3. Hemorrhoids
  4. Peptic ulcer disease

41.  Which of the following treatments is used for rectal cancer but not for colon cancer?

  1. Chemotherapy
  2. Colonoscopy
  3. Radiation
  4. Surgical resection

42.  Which of the following conditions is most likely to directly cause peritonitis?

  1. Cholelithiasis
  2. Gastritis
  3. Perforated ulcer
  4. Incarcerated hernia

43.  Which of the following symptoms would a client in the early stages of peritonitis exhibit?

  1. Abdominal distention
  2. Abdominal pain and rigidity
  3. Hyperactive bowel sounds
  4. Right upper quadrant pain

44.  Which of the following laboratory results would be expected in a client with peritonitis?

  1. Partial thromboplastin time above 100 seconds
  2. Hemoglobin level below 10 mg/dL
  3. Potassium level above 5.5 mEq/L
  4. White blood cell count above 15,000

45.  Which of the following therapies is not included in the medical management of a client with peritonitis?

  1. Broad-spectrum antibiotics
  2. Electrolyte replacement
  3. I.V. fluids
  4. Regular diet

46.  Which of the following aspects is the priority focus of nursing management for a client with peritonitis?

  1. Fluid and electrolyte balance
  2. Gastric irrigation
  3. Pain management
  4. Psychosocial issues

47.  A client with irritable bowel syndrome is being prepared for discharge. Which of the following meal plans should the nurse give the client?

  1. Low fiber, low-fat
  2. High fiber, low-fat
  3. Low fiber, high-fat
  4. High-fiber, high-fat

48.  A client presents to the emergency room, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts him at risk for which of the following?

  1. Metabolic acidosis with hyperkalemia
  2. Metabolic acidosis with hypokalemia
  3. Metabolic alkalosis with hyperkalemia
  4. Metabolic alkalosis with hypokalemia

49.  Five days after undergoing surgery, a client develops a small-bowel obstruction. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?

  1. Imbalanced nutrition: Less than body requirements
  2. Acute pain
  3. Deficient fluid volume
  4. Excess fluid volume

50.  When teaching an elderly client how to prevent constipation, which of the following instructions should the nurse include?

  1. “Drink 6 glasses of fluid each day.”
  2. “Avoid grain products and nuts.”
  3. “Add at least 4 grams of brain to your cereal each morning.”
  4. “Be sure to get regular exercise.”

51.  In a client with diarrhea, which outcome indicates that fluid resuscitation is successful?

  1. The client passes formed stools at regular intervals
  2. The client reports a decrease in stool frequency and liquidity
  3. The client exhibits firm skin turgor
  4. The client no longer experiences perianal burning.

52.  When teaching a community group about measures to prevent colon cancer, which instruction should the nurse include?

  1. “Limit fat intake to 20% to 25% of your total daily calories.”
  2. “Include 15 to 20 grams of fiber into your daily diet.”
  3. “Get an annual rectal examination after age 35.”
  4. “Undergo sigmoidoscopy annually after age 50.”

53.  A 30-year old client experiences weight loss, abdominal distention, crampy abdominal pain, and intermittent diarrhea after birth of her 2nd child. Diagnostic tests reveal gluten-induced enteropathy. Which foods must she eliminate from her diet permanently?

  1. Milk and dairy products
  2. Protein-containing foods
  3. Cereal grains (except rice and corn)
  4. Carbohydrates

54.  After a right hemicolectomy for treatment of colon cancer, a 57-year old client is reluctant to turn while on bed rest. Which action by the nurse would be appropriate?

  1. Asking a co-worker to help turn the client
  2. Explaining to the client why turning is important.
  3. Allowing the client to turn when he’s ready to do so
  4. Telling the client that the physician’s order states he must turn every 2 hours

55.  A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings. Before starting a continuous feeding, the nurse should place the client in which position?

  1. Semi-Fowlers
  2. Supine
  3. Reverse Trendelenburg
  4. High Fowler’s

56.  An enema is prescribed for a client with suspected appendicitis. Which of the following actions should the nurse take?

  1. Prepare 750 ml of irrigating solution warmed to 100*F
  2. Question the physician about the order
  3. Provide privacy and explain the procedure to the client
  4. Assist the client to left lateral Sim’s position

57.  The client being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test?

  1. Fast for 8 hours before the test
  2. Eat a regular supper and breakfast
  3. Continue to take all oral medications as scheduled.
  4. Monitor own bowel movement pattern for constipation

58.  The nurse is monitoring a client for the early signs of dumping syndrome. Which symptom indicates this occurrence?

  1. Abdominal cramping and pain
  2. Bradycardia and indigestion
  3. Sweating and pallor
  4. Double vision and chest pain

59.  The nurse is preparing a discharge teaching plan for the client who had an umbilical hernia repair. Which of the following would the nurse include in the plan?

  1. Restricting pain medication
  2. Maintaining bedrest
  3. Avoiding coughing
  4. Irrigating the drain

60.  The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician?

  1. Bloody diarrhea
  2. Hypotension
  3. A hemoglobin of 12 mg/dL
  4. Rebound tenderness

61.  The nurse is reviewing the record of a client with Crohn’s disease. Which of the following stool characteristics would the nurse expect to note documented on the client’s record?

  1. Chronic constipation
  2. Diarrhea
  3. Constipation alternating with diarrhea
  4. Stool constantly oozing from the rectum

62.  The nurse is performing a colostomy irrigation on a client. During the irrigation, a client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?

  1. Notify the physician
  2. Increase the height of the irrigation
  3. Stop the irrigation temporarily.
  4. Medicate with dilaudid and resume the irrigation

63.  The nurse is teaching the client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do?

  1. Increase fluid intake
  2. Reduce the amount of irrigation solution
  3. Perform the irrigation in the evening
  4. Place heat on the abdomen

64.  The nurse is reviewing the physician’s orders written for a client admitted with acute pancreatitis. Which physician order would the nurse question if noted on the client’s chart?

  1. NPO status
  2. Insert a nasogastric tube
  3. An anticholinergic medication
  4. Morphine for pain

65.  The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse would assess the client for which of the following most frequent symptom(s) of duodenal ulcer?

  1. Pain that is relieved by food intake
  2. Pain that radiated down the right arm
  3. N/V
  4. Weight loss

66.  The nurse instructs the ileostomy client to do which of the following as a part of essential care of the stoma?

  1. Cleanse the peristomal skin meticulously
  2. Take in high-fiber foods such as nuts
  3. Massage the area below the stoma
  4. Limit fluid intake to prevent diarrhea.

67.  The client who has undergone creation of a colostomy has a nursing diagnosis of Disturbed body image. The nurse would evaluate that the client is making the most significant progress toward identified goals if the client:

  1. Watches the nurse empty the colostomy bag
  2. Looks at the ostomy site
  3. Reads the ostomy product literature
  4. Practices cutting the ostomy appliance

68.  The nurse is assessing for stoma prolapse in a client with a colostomy. The nurse would observe which of the following if stoma prolapse occurred?

  1. Sunken and hidden stoma
  2. Dark- and bluish-colored stoma
  3. Narrowed and flattened stoma
  4. Protruding stoma

69.  The client with a new colostomy is concerned about the odor from the stool in the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor?

  1. Yogurt
  2. Broccoli
  3. Cucumbers
  4. Eggs

70.  The nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client needs further instructions if the client stated to eat which of the following foods to make the stools less watery?

  1. Pasta
  2. Boiled rice
  3. Bran
  4. Low-fat cheese

71.  The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate post-op period for which of the following most frequent complications of this type of surgery?

  1. Intestinal obstruction
  2. Fluid and electrolyte imbalance
  3. Malabsorption of fat
  4. Folate deficiency

72.  The nurse is doing pre-op teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?

  1. “I will need to drain the pouch regularly with a catheter.”
  2. “I will need to wear a drainage bag for the rest of my life.”
  3. “The drainage from this type of ostomy will be formed.”
  4. “I will be able to pass stool from my rectum eventually.”

73.  The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation?

  1. Distilled water
  2. Tap water
  3. Sterile water
  4. Lactated Ringer’s

74.  A nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen is distended and the bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

  1. Administer dilaudid
  2. Notify the physician
  3. Call and ask the operating room team to perform the surgery as soon as possible
  4. Reposition the client and apply a heating pad on a warm setting to the client’s abdomen.

75.  The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is:

  1. Severe and unrelenting, located in the epigastric area and radiating to the back.
  2. Severe and unrelenting, located in the left lower quadrant and radiating to the groin.
  3. Burning and aching, located in the epigastric area and radiating to the umbilicus.
  4. Burning and aching, located in the left lower quadrant and radiating to the hip.

76.  The client with Crohn’s disease has a nursing diagnosis of acute pain. The nurse would teach the client to avoid which of the following in managing this problem?

  1. Lying supine with the legs straight
  2. Massaging the abdomen
  3. Using antispasmodic medication
  4. Using relaxation techniques

77.  A client with ulcerative colitis has an order to begin salicylate medication to reduce inflammation. The nurse instructs the client to take the medication:

  1. 30 minutes before meals
  2. On an empty stomach
  3. After meals
  4. On arising

78.  During the assessment of a client’s mouth, the nurse notes the absence of saliva. The client is also complaining of pain near the area of the ear. The client has been NPO for several days because of the insertion of a NG tube. Based on these findings, the nurse suspects that the client is developing which of the following mouth conditions?

  1. Stomatitis
  2. Oral candidiasis
  3. Parotitis
  4. Gingivitis

79.  The nurse evaluates the client’s stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?

  1. The stoma is slightly edematous
  2. The stoma is dark red to purple
  3. The stoma oozes a small amount of blood
  4. The stoma does not expel stool

80.  When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply.

  1. Assessing the client’s bowel sounds
  2. Providing skin care following bowel movements
  3. Evaluating the client’s response to antidiarrheal medications
  4. Maintaining intake and output records
  5. Obtaining the client’s weight.

81.  Which goal of the client’s care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis?

  1. Promoting self-care and independence
  2. Managing diarrhea
  3. Maintaining adequate nutrition
  4. Promoting rest and comfort

82.  A client’s ulcerative colitis symptoms have been present for longer than 1 week. The nurse recognizes that the client should be assessed carefully for signs of which of the following complications?

  1. Heart failure
  2. DVT
  3. Hypokalemia
  4. Hypocalcemia

83.  A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 pounds since the exacerbation of his ulcerative colitis. The nurse should anticipate that the physician will order which of the following treatment approaches to help the client meet his nutritional needs?

  1. Initiate continuous enteral feedings
  2. Encourage a high protein, high-calorie diet
  3. Implement total parenteral nutrition
  4. Provide six small meals a day.

84. Digoxin preparations and absorbents should not be given simultaneously. As a nurse, you are aware that if these agents are given simultaneously, which of the following will occur?

  1. Increased absorption of digoxin
  2. Decreased absorption of digoxin
  3. Increased absorption of the absorbent
  4. Decreased absorption of the absorbent

85. When used with hyperacidic disorders of the stomach, antacids are given to elevate the gastric pH to:

  1. 2.0
  2. 4.0
  3. 6.0
  4. >8.0

86. One of your patients is receiving digitalis orally and is also to receive an antacid at the same time. Your most appropriate action, based on the pharmacokinetics of antacids, is to:

  1. Delay the digitalis for 1 to 2 hours until the antacid is absorbed
  2. Give the antacid at least 2 to 4 hours before administering the digitalis
  3. Administer both medications as ordered and document in nurse’s notes
  4. Contact the physician regarding the drug interaction and request a change in the time of dosing of the drugs.

87.  The nurse would teach patients that antacids are effective in treatment of hyperacidity because they:

  1. Neutralize gastric acid
  2. Decrease stomach motility
  3. Decrease gastric pH
  4. Decrease duodenal pH

88. The nurse would monitor for which of the following adverse reactions to aluminum-containing antacids such as aluminum hydroxide (Amphojel)?

  1. Diarrhea
  2. Constipation
  3. GI upset
  4. Fluid retention

89. The nurse would question an order for which type of antacid in patients with chronic renal failure?

  1. Aluminum-containing antacids
  2. Calcium-containing antacids
  3. Magnesium-containing antacids
  4. All of the above.

90.  The nurse would monitor a patient using sodium bicarbonate to treat gastric hyperacidity for signs and symptoms of:

  1. Metabolic alkalosis
  2. Metabolic acidosis
  3. Hyperkalemia
  4. Hypercalcemia

91. Which of the following nursing diagnoses is appropriate for a patient receiving famotidine (Pepcid)?

  1. Increased risk for infection due to immunosuppresion
  2. Potential risk for bleeding related to thrombocytopenia.
  3. Aleration in urinary elimination related to retention
  4. Alteration in tissue perfusion related to hypertension

92.  Histamine2-receptor antagonists:

  1. Compete with histamine for binding sites on the parietal cells
  2. Irreversibly bind to H+/K+ATPase
  3. Cause a decrease in stomach pH
  4. Decrease signs and symptoms of allergies related to histamine release

93.  Proton pump inhibitors:

  1. Gastric ulcer formation
  2. GERD
  3. Achlorhydria
  4. Diverticulosis

94.  A patient unable to tolerate oral medications may be prescribed which of the following proton pump inhibitors to be administered intravenously?

  1. lansoprazole (Prevacid)
  2. omeprazole (Prilosec)
  3. pantoprazole (Protonix)
  4. esomeprazole (Nexium)

95.  When administering sucralfate (Carafate) to a patient with a nasogastric tube, it is important to:

  1. Crush the tablet into a fine powder before mixing with water
  2. Administer with a bolus tube feeding
  3. Allow the tablet to dissolve in water before administering
  4. Administer with an antacid for maximum benefit

96.  Sucralfate (Carafate) achieves a therapeutic effect by:

  1. Neutralizing gastric acid
  2. Enhancing gastric absorption
  3. Forming a protective barrier around gastric mucosa
  4. Inhibiting gastric acid secretion

97.  To avoid fecal impaction, psyllium (Metamucil) should be administered with at least how many ounces of fluid?

  1. 4
  2. 6
  3. 8
  4. 10

98.  Bismuth subsalicylate (Pepto-Bismol), as an absorbent, has which of the following mechanisms of action?

  1. Decreased GI motility
  2. Decreased gastric secretions
  3. Increased fluid absorption
  4. Binding to diarrhea-causing bacteria for excretion

99.  Side effects of loperamide (Imodium) include all of the following except?

  1. Diarrhea
  2. epigastric pain
  3. Dry mouth
  4. Anorexia

100.  The mechanism of action of diphenoxylate (Lotomil) is:

  1. An increase in intestinal excretion of water
  2. An increase in intestinal motility
  3. A decrease in peristalsis in the intestinal wall
  4. A decrease in the reabsorption of water in the bowel

101.  Milk of Magnesium alleviates constipation by:

  1. Increasing water absorption into the colon
  2. Lubricating the passage of stool
  3. Increasing bulk within the colon
  4. Stimulating nerves that regulate defecation

102.  Lactulose, a hyperosmotic laxative, also functions to:

  1. Decrease peripheral edema
  2. Correct sodium imbalances
  3. Reduce ammonia levels
  4. Alleviate galactose intolerance
Answers and Rationales
  1. A. A fecalith is a fecal calculus, or stone, that occludes the lumen of the appendix and is the most common cause of appendicitis. Bowel wall swelling, kinking of the appendix, and external occlusion, not internal occlusion, of the bowel by adhesions can also be causes of appendicitis.
  2. D. The pain begins in the epigastrium or periumbilical region, then shifts to the right lower quadrant and becomes steady. The pain may be moderate to severe.
  3. D. The focus of care is to assess for peritonitis, or inflammation of the peritoneal cavity. Peritonitis is most commonly caused by appendix rupture and invasion of bacteria, which could be lethal. The client with appendicitis will have pain that should be controlled with analgesia. The nurse should discourage oral intake in preparation of surgery. Discharge teaching is important; however, in the acute phase, management should focus on minimizing preoperative complications and recognizing when such may be occurring.
  4. C. Gastritis is an inflammation of the gastric mucosa that may be acute (often resulting from exposure to local irritants) or chronic (associated with autoimmune infections or atrophic disorders of the stomach). Erosion of the mucosa results in ulceration. Inflammation of a diverticulum is called diverticulitis; reflux of stomach acid is known as gastroesophageal disease.
  5. D. NSAIDS are a common cause of gastritis because they inhibit prostaglandin synthesis. Milk, once thought to help gastritis, has little effect on the stomach mucosa. Bicarbonate of soda, or baking soda, may be used to neutralize stomach acid, but it should be used cautiously because it may lead to metabolic acidosis. ASA with enteric coating shouldn’t contribute significantly to gastritis because the coating limits the aspirin’s effect on the gastric mucosa.
  6. B. Diverticulosis involves a noninflamed outpouching of the intestine. Diverticulitis involves an inflamed outpouching. The partial impairment of forward flow of the intestine is an obstruction; abnormal protrusion of an organ is a hernia.
  7. A. Low-fiber diets have been implicated in the development of diverticula because these diets decrease the bulk in the stool and predispose the person to the development of constipation. A high-fiber diet is recommended to help prevent diverticulosis. A high-protein or low-carbohydrate diet has no effect on the development of diverticulosis.
  8. D. Undigested food can block the diverticulum, decreasing blood supply to the area and predisposing the area to invasion of bacteria. Chronic laxative use is a common problem in elderly clients, but it doesn’t cause diverticulitis. Chronic constipation can cause an obstruction—not diverticulitis. Herniation of the intestinal mucosa causes an intestinal perforation.
  9. A. Diverticulosis is an asymptomatic condition. The other choices are signs and symptoms of diverticulitis.
  10. B. A barium enema will cause diverticula to fill with barium and be easily seen on x-ray. An abdominal US can tell more about structures, such as the gallbladder, liver, and spleen, than the intestine. A barium swallow and gastroscopy view upper GI structures.
  11. C. Antibiotics are used to reduce the inflammation. The client isn’t typically isn’t allowed anything orally until the acute episode subsides. Parenteral fluids are given until the client feels better; then it’s recommended that the client drink eight 8-ounce glasses of water per day and gradually increase fiber in the diet to improve intestinal motility. During the acute phase, activities that increase intra-abdominal pressure should be avoided to decrease pain and the chance of intestinal obstruction.
  12. D. Crohn’s disease can involve any segment of the small intestine, the colon, or both, affecting the entire thickness of the bowel. Answers A and C describe ulcerative colitis, answer B is too specific and therefore, not likely.
  13. D. Studies have shown that the terminal ileum is the most common site for recurrence in clients with Crohn’s disease. The other areas may be involved but aren’t as common.
  14. C. Although the definite cause of Crohn’s disease is unknown, it’s thought to be associated with infectious, immune, or psychological factors. Because it has a higher incidence in siblings, it may have a genetic cause.
  15. B. Several theories exist regarding the cause of ulcerative colitis. One suggests altered immunity as the cause based on the extraintestinal characteristics of the disease, such as peripheral arthritis and cholangitis. Diet and constipation have no effect on the development of ulcerative colitis. Emotional stress can exacerbate the attacks but isn’t believed to be the primary cause.
  16. A. The lesions of Crohn’s disease are transmural; that is, they involve all thickness of the bowel. These lesions may perforate the bowel wall, forming fistulas with adjacent structures. Fistulas don’t develop in diverticulitis or diverticulosis. The ulcers that occur in the submucosal and mucosal layers of the intestine in ulcerative colitis usually don’t progress to fistula formation as in Crohn’s disease.
  17. A. Fistulas occur in all these areas, but the anorectal area is most common because of the relative thinness of the intestinal wall in this area.
  18. D. Toxic megacolon is extreme dilation of a segment of the diseased colon caused by paralysis of the colon, resulting in complete obstruction. This disorder is associated with both Crohn’s disease and ulcerative colitis. The other disorders are more commonly associated with Crohn’s disease.
  19. C. Because of the transmural nature of Crohn’s disease lesions, malaborption may occur with Crohn’s disease. Ankylosing spondylitis and colon cancer are more commonly associated with ulcerative colitis. Lactase deficiency is caused by a congenital defect in which an enzyme isn’t present.
  20. D. Steatorrhea from malaborption can occur with Crohn’s disease. N/V, and bloody diarrhea are symptoms of ulcerative colitis. Narrow stools are associated with diverticular disease.
  21. B. In ulcerative colitis, rectal bleeding is the predominant symptom. Soft stools are more commonly associated with Crohn’s disease, in which malabsorption is more of a problem. Dumping syndrome occurs after gastric surgeries. Fistulas are associated with Crohn’s disease.
  22. D. A colonoscopy with biopsy can be performed to determine the state of the colon’s mucosal layers, presence of ulcerations, and level of cytologic development. An abdominal x-ray or CT scan wouldn’t provide the cytologic information necessary to diagnose which disease it is. A barium swallow doesn’t involve the intestine.
  23. C. Management of Crohn’s disease may include long-term steroid therapy to reduce the inflammation associated with the deeper layers of the bowel wall. Other management focuses on bowel rest (not increasing oral intake) and reducing diarrhea with medications (not giving laxatives). The pain associated with Crohn’s disease may require bed rest, not an increase in physical activity.
  24. C. A decrease in body weight may occur during therapy due to inadequate dietary intake, but isn’t related to antibiotic therapy. Effective antibiotic therapy will be noted by a decrease in temperature, number of stools, and bleeding.
  25. D. Perforation, obstruction, hemorrhage, and toxic megacolon are common complications of ulcerative colitis that may require surgery. Herniation and gastritis aren’t associated with irritable bowel diseases, and outpouching of the bowel is diverticulosis.
  26. C. The pain with irritable bowel disease is caused by inflammation, which steroids can reduce. Stool softeners aren’t necessary. Acetaminophen has little effect on the pain, and opiate narcotics won’t treat its underlying cause (I feel this is untrue—dilaudid will helpanything!)
  27. B. Although all of these are concerns the nurse should address, being able to safely manage the ostomy is crucial for the client before discharge.
  28. D. Chronic ulcerative colitis, granulomas, and familial polposis seem to increase a person’s chance of developing colon cancer. The other conditions listed have no known effect on colon cancer risk.
  29. A. A low-fiber, high-fat diet reduced motility and increases the chance of constipation. The metabolic end products of this type of diet are carcinogenic. A low-fat, high-fiber diet is recommended to prevent colon cancer.
  30. D. Surface blood vessels of polyps and cancers are fragile and often bleed with the passage of stools. Abdominal x-ray and CT scan can help establish tumor size and metastasis. A colonoscopy can help locate a tumor as well as polyps, which can be removed before they become malignant.
  31. A. Radiation therapy is used to treat colon cancer before surgery to reduce the size of the tumor, making it easier to be resected. Radiation therapy isn’t curative, can’t eliminate the malignant cells (though it helps define tumor margins), can could slow postoperative healing.
  32. B. The most common complaint of the client with colon cancer is a change in bowel habits. The client may have anorexia, secondary abdominal distention, or weight loss. Fever isn’t associated with colon cancer.
  33. A. Bowel spillage could occur during surgery, resulting in peritonitis. Complete or partial bowel obstruction may occur before bowel resection. Diverticulosis doesn’t result from surgery or colon cancer.
  34. C. The client with gastric cancer may report a feeling of fullness in the stomach, but not enough to cause him to seek medical attention. Abdominal cramping isn’t associated with gastric cancer. Anorexia and weight loss (not increased hunger or weight gain) are common symptoms of gastric cancer.
  35. A. gastroscopy will allow direct visualization of the tumor. A colonoscopy or a barium enema would help diagnose colon cancer. Serum chemistry levels don’t contribute data useful to the assessment of gastric cancer.
  36. B. Client’s with gastric cancer commonly have nutritional deficits and may be cachectic. Discharge planning before surgery is important, but correcting the nutrition deficit is a higher priority. At present, radiation therapy hasn’t been proven effective for gastric cancer, and teaching about it preoperatively wouldn’t be appropriate. Prevention of DVT also isn’t a high priority to surgery, though it assumes greater importance after surgery.
  37. B. After gastric resection, a client may require total parenteral nutrition or jejunostomy tube feedings to maintain adequate nutritional status.
  38. B. Dumping syndrome is a problem that occurs postprandially after gastric resection because ingested food rapidly enters the jejunum without proper mixing and without the normal duodenal digestive processing. Diarrhea, not constipation, may also be a symptom. Gastric or intestinal spasms don’t occur, but antispasmidics may be given to slow gastric emptying.
  39. C. Rectal bleeding is a common symptom of rectal cancer. Rectal cancer may be missed because other conditions such as hemorrhoids can cause rectal bleeding. Abdominal fullness may occur with colon cancer, gastric fullness may occur with gastric cancer, and right upper quadrant pain may occur with liver cancer.
  40. A. A client with adenomatous polyps has a higher risk for developing rectal cancer than others do. Clients with diverticulitis are more likely to develop colon cancer. Hemorrhoids don’t increase the chance of any type of cancer. Clients with peptic ulcer disease have a higher incidence of gastric cancer.
  41. C. A client with rectal cancer can expect to have radiation therapy in addition to chemotherapy and surgical resection of the tumor. A colonoscopy is performed to diagnose the disease. Radiation therapy isn’t usually indicated in colon cancer.
  42. C. The most common cause of peritonitis is a perforated ulcer, which can pour contaminates into the peritoneal cavity, causing inflammation and infection within the cavity. The other conditions don’t by themselves cause peritonitis. However, if cholelithiasis leads to rupture of the gallbladder, gastritis leads to erosion of the stomach wall, or an incarcerated hernia leads to rupture of the intestines, peritonitis may develop.
  43. B. Abdominal pain causing rigidity of the abdominal muscles is characteristic of peritonitis. Abdominal distention may occur as a late sign but not early on. Bowel sounds may be normal or decreased but not increased. Right upper quadrant pain is chatacteristic of cholecystitis or hepatitis.
  44. D. Because of infection, the client’s WBC count will be elevated. A hemoglobin level below 10 mg/dl may occur from hemorrhage. A PT time longer than 100 seconds may suggest disseminated intravascular coagulation, a serious complication of septic shock. A potassium level above 5.5 mEq/L may indicate renal failure.
  45. D. The client with peritonitis usually isn’t allowed anything orally until the source of peritonitis is confirmed and treated. The client also requires broad-spectrum antibiotics to combat the infection. I.V. fluids are given to maintain hydration and hemodynamic stability and to replace electrolytes.
  46. A. Peritonitis can advance to shock and circulatory failure, so fluid and electrolyte balance is the priority focus of nursing management. Gastric irrigation may be needed periodically to ensure patency of the nasogastric tube. Although pain management is important for comfort and psychosocial care will address concerns such as anxiety, focusing on fluid and electrolyte imbalance will maintain hemodynamic stability.
  47. B. The client with irritable bowel syndrome needs to be on a diet that contains at least 25 grams of fiber per day. Fatty foods are to be avoided because they may precipitate symptoms.
  48. D. Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive loss of these substances, such as from vomiting, can lead to metabolic alkalosis and hypokalemia.
  49. C. Fluid shifts to the site of the bowel obstruction, causing a fluid deficit in the intravascular spaces. If the obstruction isn’t resolved immediately, the client may experience an imbalanced nutritional status (less than body requirements); however, deficient fluid volume takes priority. The client may also experience pain, but that nursing diagnosis is also of lower priority than deficient fluid volume.
  50. D. Exercise helps prevent constipation. Fluids and dietary fiber promote normal bowel function. The client should drink eight to ten glasses of fluid each day. Although adding bran to cereal helps prevent constipation by increasing dietary fiber, the client should start with a small amount and gradually increase the amount as tolerated to a maximum of 2 grams a day.
  51. C. A client with diarrhea has a nursing diagnosis of Deficient fluid volume related to excessive fluid loss in the stool. Expected outcomes include firm skin turgor, moist mucous membranes, and urine output of at least 30 ml/hr. The client also has a nursing diagnosis of diarrhea, with expected outcomes of passage of formed stools at regular intervals and a decrease in stool frequency and liquidity. The client is at risk for impaired skin integrity related to irritation from diarrhea; expected outcomes for this diagnosis include absence of erythema in perianal skin and mucous membranes and absence of perianal tenderness or burning.
  52. A. To help prevent colon cancer, fats should account for no more than 20% to 25% of total daily calories and the diet should include 25 to 30 grams of fiber per day. A digital rectal examination isn’t recommended as a stand-alone test for colorectal cancer. For colorectal cancer screening, the American Cancer society advises clients over age 50 to have a flexible sigmoidoscopy every 5 years, yearly fecal occult blood tests, yearly fecal occult blood tests PLUS a flexible sigmoidoscopy every 5 years, a double-contrast barium enema every 5 years, or a colonoscopy every 10 years.
  53. C. To manage gluten-induced enteropathy, the client must eliminate gluten, which means avoiding all cereal grains except for rice and corn. In initial disease management, clients eat a high calorie, high-protein diet with mineral and vitamin supplements to help normalize nutritional status.
  54. B. The appropriate action is to explain the importance of turning to avoid postoperative complications. Asking a coworker to help turn the client would infringe on his rights. Allowing him to turn when he’s ready would increase his risk for postoperative complications. Telling him he must turn because of the physician’s orders would put him on the defensive and exclude him from participating in care decision.
  55. A. To prevent aspiration of stomach contents, the nurse should place the client in semi-Fowler’s position. High Fowler’s position isn’t necessary and may not be tolerated as well as semi-Fowler’s.
  56. B. Enemas are contraindicated in an acute abdominal condition of unknown origin as well as after recent colon or rectal surgery or myocardial infarction. The other answers are correct only when enema administration is appropriate.
  57. A. A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the GI tract. The client should fast for 8 to 12 hours before the test, depending on the physician instructions. Most oral medications also are withheld before the test. After the procedure the nurse must monitor for constipation, which can occur as a result of the presence of barium in the GI tract.
  58. C. Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
  59. C. Bedrest is not required following this surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A drain is not used in this surgical procedure, although the client may be instructed in simple dressing changes. Coughing is avoided to prevent disruption of the tissue integrity, which can occur because of the location of this surgical procedure.
  60. D. Rebound tenderness may indicate peritonitis. Blood diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the physician.
  61. B. Crohn’s disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration and severity. The other option are not associated with diarrhea.
  62. C. If cramping occurs during a colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. Increasing the height of the irrigation will cause further discomfort. The physician does not need to be notified. Medicating the client for pain is not the most appropriate action (damn).
  63. A. To enhance effectiveness of the irrigation and fecal returns, the client is instructed to increase fluid intake and prevent constipation.
  64. D. Meperidine (Demerol) rather than morphine is the medication of choice because morphine can cause spasm in the sphincter of Oddi.
  65. A. The most frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as burning, heavy, sharp, or “hungry” pain that often localizes in the midepigastric area. The client with duodenal ulcer usually does not experience weight loss or N/V. These symptoms are usually more typical in the client with a gastric ulcer.
  66. A. The peristomal skin must receive meticulous cleansing because the ileostomy drainage has more enzymes and is more caustic to the skin than colostomy drainage. Foods such as nuts and those with seeds will pass through the ileostomy. The client should be taught that these foods will remain undigested. The area below the ileostomy may be massaged if needed if the ileostomy becomes blocked by high fiber foods. Fluid intake should be maintained to at least six to eight glasses of water per day to prevent dehydration.
  67. D. The client is expected to have a body image disturbance after colostomy. The client progresses through normal grieving stages to adjust to this change. The client demonstrates the greatest deal of acceptance when the client participates in the actual colostomy care. Each of the incorrect options represents an interest in colostomy care but is a passive activity. The correct option shows the client is participating in self-care.
  68. D. A prolapsed stoma is one which the bowel protruded through the stoma. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with dusky or bluish color. A stoma with a narrowed opening at the level of the skin or fascia is said to be stenosed.
  69. A. The client should be taught to include deodorizing foods in the diet, such a beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas forming food as well. Broccoli, cucumbers, and eggs are gas forming foods.
  70. C. Foods that help thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese. Bran is high in dietary fiber and thus will increase output of watery stool by increasing propulsion through the bowel. Ileostomy output is liquid. Addition or elimination of various foods can help thicken or loosen this liquid drainage.
  71. B. A major complication that occurs most frequent following an ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from happening. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.
  72. A. A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining to about 3 times a day or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucus drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastamosis were created. This type of operation is a two-stage procedure.
  73. B. Warm tap water or saline solution is used to irrigate a colostomy. If the tap water is not suitable for drinking, then bottled water should be used.
  74. B. Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.
  75. A. The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back.
  76. A. The pain associated with Crohn’s disease is alleviated by the use of analgesics and antispasmodics and also is reduced by having the client practice relaxation techniques, applying local cold or heat to the abdomen, massaging the abdomen, and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen, which could aggravate the inflamed intestinal tissues as the abdominal muscles are stretched.
  77. C. Salicylate compounds act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and to increase fluid intake throughout the day. This medication needs to be taken after meals to reduce GI irritation.
  78. D. The lack of saliva, pain near the area of the ear, and the prolonged NPO status of the client should lead the nurse to suspect the development of parotitis, or inflammation of the parotid gland. Parotitis usually develops in cases of dehydration combined with poor oral hygiene or when clients have been NPO for an extended period. Preventative measures include the use of sugarless hard candy or gum to stimulate saliva production, adequate hydration, and frequent mouth care. Stomatitis (inflammation of the mouth) produces excessive salivation and a sore mouth.
  79. B. A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early post-op period. The colostomy would typically not begin functioning until 2-4 days after surgery.
  80. B, D, and E. The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client’s weight. Assessing the client’s bowel sounds and evaluating the client’s response to medication are registered nurse activities that cannot be delegated.
  81. B. Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing the frequency of stools is the first goal of treatment. The other goals are ongoing and will be best achieved by halting the exacerbation. The client may receive antidiarrheal medications, antispasmodic agents, bulk hydrophilic agents, or anti-inflammatory drugs.
  82. C. Excessive diarrhea causes significant depletion of the body’s stores of sodium and potassium as well as fluid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, DVT, or hypocalcemia.
  83. C. Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client’s nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into 6 small meals does not allow the bowel to rest. A high-calorie, high-protein diet will worsen the client’s symptoms.
  84. B.
  85. A.
  86. D.
  87. A. Antacids work by neutralizing gastric acid, which would cause an increase in pH. They do not affect gastric motility.
  88. B. Aluminum- and calcium-containing antacids cause constipation, magnesium-containing antacids cause diarrhea, and sodium-containing antacids cause sodium and fluid retention.
  89. C. Magnesium-containing antacids can cause hypermagnesemia in patients with chronic renal failure. Aluminum-containing antacids may be used as a phosphate binder in patients with chronic renal failure. Calcium-containing antacids are also appropriate because these patients may be hypocalcemic.
  90. A. Solutions containing sodium bicarbonate (a base) can cause metabolic alkalosis. Serum K and serum calcium would decrease with alkalosis, not increase.
  91. B. A serious side effect of famotidine is thrombocytopenia, which is manifested by a decrease in platelet count and an increased risk of bleeding.
  92. A. Histamine receptor blocking agents decrease gastric acid by competing with histamine for binding sites on the parietal cells.
  93. C. Because the proton pump inhibitors stop the final step of acid secretion, they can block up to 90% of acid secretion, leading to achlorhydria (without acid).
  94. C. Pantoprazole is the only proton pump inhibitor that is available for intravenous administration. The other medications in this category may only be administered orally.
  95. C. It is important to give sucralfate on an empty stomach so that it may dissolve and form a protective barrier over the gastric mucosa. The tablet form will not dissolve in water when crushed; it must be left whole and allowed to dissolve. Crushing the medication so that it will not dissolve could lead to clogging of the nasogastric tube and decreased effectiveness of the drug.
  96. C. Sucralfate has a local effect only on the gastric mucosa. It forms a pastelike substance in the stomach, which adheres to the gastric lining, protecting against adverse effects related to gastric acid. It also stimulates healing of any ulcerated areas of the gastric mucosa.
  97. C. Bulk-forming laxatives must be given with at least 8 ounces of liquid plus additional liquid each day to prevent intestinal obstruction.
  98. D. Absorbent antidiarrheal medications bind to diarrhea-causing bacteria to form a nonabsorbable complex, which is then excreted in the stool.
  99. A. Side effects associated with loperamide include CNS fatigue and dizziness, epigastric pain, abdominal cramps, nausea, dry mouth, vomiting, and anorexia. Diarrhea is an indication, not a side effect.
  100. C. Diphenoxylate acts on the smooth muscle of the intestinal tract to inhibit GI motility and excessive propulsion of the GI tract (peristalsis).
  101. A. Milk of Magnesia is a saline laxative that increases osmotic pressure to draw water into the colon.
  102. C. Lactulose reduces blood ammonia levels by forcing ammonia from the blood into the colon. It is useful in treating patients with hepatic encephalopathy.