Nokea
A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning
- A. , what should the nurse plan to assess more frequently than is routine?
- B. Apical pulse
- C. Bowel sounds
- D. Breath sounds
Correct Answer: D
Rationale: The correct answer is D: Breath sounds. In an unconscious stroke patient, airway patency and adequate oxygenation are critical. Assessing breath sounds more frequently than routine helps monitor for respiratory distress, such as aspiration or pneumonia. Apical pulse (B) may be important but not as immediately life-threatening as respiratory status. Bowel sounds (C) may indicate bowel function but are not as urgent as assessing breathing. By prioritizing breath sounds, the nurse can ensure timely intervention in case of respiratory compromise.
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The role of parietal cells is to:
- A. Secretes hydrogen ions and chloride ions into lumen and are responsible for maintaining the acidic pH
- B. alkaline mucous for shielding the epithelium from hydrochloric acid
- C. Secretes histamine which stimulates gastric acid secretion
- D. Secretes gastric lipase
Correct Answer: A
Rationale: The correct answer is A because parietal cells secrete hydrogen ions and chloride ions into the lumen, which combine to form hydrochloric acid, maintaining the acidic pH of the stomach essential for digestion. Option B is incorrect as alkaline mucous is produced by goblet cells, not parietal cells. Option C is incorrect as histamine is secreted by enterochromaffin-like cells, not parietal cells. Option D is incorrect as gastric lipase is primarily secreted by chief cells in the stomach.
What manifestation in the patient does the nurse recognize as an early sign of hepatic encephalopathy?
- A. Manifests asterixis
- B. Becomes unconscious
- C. Has increasing oliguria
- D. Is irritable and lethargic
Correct Answer: D
Rationale: The correct answer is D: Is irritable and lethargic. Early signs of hepatic encephalopathy often include behavioral changes like irritability and lethargy due to impaired brain function from liver dysfunction. This is because the liver is unable to properly detoxify ammonia, leading to its accumulation in the bloodstream and affecting brain function. Asterixis, unconsciousness, and oliguria are more severe manifestations seen in later stages of hepatic encephalopathy. Therefore, recognizing irritability and lethargy in a patient would prompt early intervention to prevent further progression of hepatic encephalopathy.
Priority Decision: In instituting a bowel training program for a patient with fecal incontinence, what should the nurse first plan to do?
- A. Teach the patient to use a perianal pouch.
- B. Insert a rectal suppository at the same time every morning.
- C. Place the patient on a bedpan 30 minutes before breakfast.
- D. Assist the patient to the bathroom at the time of the patient's normal defecation.
Correct Answer: D
Rationale: The correct answer is D because assisting the patient to the bathroom at the time of their normal defecation helps establish a routine for bowel movements, which is crucial in bowel training. This step maximizes the chances of success by utilizing the body's natural cues. Teaching the patient to use a perianal pouch (A) does not address the underlying issue of incontinence. Inserting a rectal suppository (B) may provide temporary relief but does not promote long-term bowel control. Placing the patient on a bedpan (C) at a specific time does not actively involve the patient in the process of bowel training.
The hydrogen ions that form hydrochloric acid of the stomach come from
- A. lactic acid.
- B. carbonic acid.
- C. citric acid.
- D. acetic acid.
Correct Answer: B
Rationale: The correct answer is B: carbonic acid. Carbonic acid is produced when carbon dioxide reacts with water in the stomach, forming hydrogen ions that combine with chloride ions to create hydrochloric acid. Lactic acid (A), citric acid (C), and acetic acid (D) do not directly contribute to the formation of hydrochloric acid in the stomach. Therefore, they are incorrect choices for this question.
Which of the following statements about the stomach is FALSE?
- A. there are no enzymes secreted in the stomach to digest carbohydrate
- B. pepsin (from pepsinogen) is released to digest proteins
- C. amino acids are absorbed through the stomach wall and go directly to the liver
- D. the appetite regulatory peptide, ghrelin, is released by the stomach
Correct Answer: C
Rationale: The correct answer is C because amino acids are not absorbed through the stomach wall; they are absorbed in the small intestine. In the stomach, gastric juices break down proteins into peptides. Option A is incorrect because the stomach secretes pepsin to digest proteins. Option B is also incorrect as pepsinogen is converted to pepsin for protein digestion. Option D is incorrect since ghrelin, the appetite hormone, is indeed released by the stomach.