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A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), what should the nurse plan to assess more frequently than is routine?
- A. Apical pulse
- B. Bowel sounds
- C. Breath sounds
- D. Abdominal girth
Correct Answer: C
Rationale: The correct answer is C: Breath sounds. Given the patient's history of GERD, there is an increased risk of aspiration pneumonia due to the reflux of gastric contents into the lungs. Therefore, assessing breath sounds more frequently is crucial to monitor for signs of respiratory distress or pneumonia.
A: Apical pulse is important but not directly related to the patient's history of GERD.
B: Bowel sounds are relevant for assessing GI function but not specifically impacted by GERD.
D: Abdominal girth is more related to abdominal distension or organ enlargement rather than GERD complications.
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A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis?
- A. Increase ambulation.
- B. Decrease fluid intake.
- C. Increase protein intake.
- D. Offer the client the bedpan every 2 hr.
Correct Answer: A
Rationale: The correct answer is A: Increase ambulation. Ambulation helps stimulate peristalsis by promoting movement in the gastrointestinal tract. This movement aids in preventing or alleviating paralytic ileus, a common postoperative complication. Increasing ambulation helps to increase muscle tone and activity in the intestines, promoting bowel motility.
Summary of other choices:
B: Decrease fluid intake - This is incorrect because adequate hydration is essential for promoting peristalsis and preventing constipation.
C: Increase protein intake - Protein intake is important for wound healing and overall nutrition but does not directly impact peristalsis.
D: Offer the client the bedpan every 2 hr - While providing opportunities for toileting is important, it does not directly promote peristalsis like ambulation does.
The optimum pH for trypsin and chymotrypsin is about
- A. 1-3.
- B. 5-7.
- C. 7-9.
- D. 10-12.
Correct Answer: C
Rationale: The correct answer is C (7-9) because trypsin and chymotrypsin are proteolytic enzymes that function optimally in slightly basic environments. At pH 7-9, these enzymes maintain their structural integrity and catalytic activity. Choices A, B, and D are incorrect because trypsin and chymotrypsin are not acidic enzymes, so pH ranges 1-3 and 10-12 would denature and inactivate them, while pH 5-7 is still on the acidic side, not optimal for these enzymes.
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.
A hiatal hernia is a weakness in the _____ muscle, which allows a portion of the digestive tract to enter the thoracic cavity.
- A. diaphragm
- B. stomach
- C. intestinal
- D. thoracic wall
Correct Answer: A
Rationale: The correct answer is A: diaphragm. The diaphragm is a dome-shaped muscle that separates the thoracic and abdominal cavities. A hiatal hernia occurs when the stomach pushes through the opening in the diaphragm known as the esophageal hiatus, allowing a portion of the stomach to enter the thoracic cavity. The other choices, B: stomach, C: intestinal, and D: thoracic wall, are incorrect because a hiatal hernia specifically involves a weakness in the diaphragm muscle, not in these other structures. The stomach is the organ affected by the hernia, but the primary issue lies in the diaphragm's weakness. The intestinal and thoracic wall choices are not directly related to the development of a hiatal hernia.
The accessory digestive organs include all of the following, EXCEPT:
- A. tongue
- B. liver
- C. pancreas
- D. stomach
Correct Answer: D
Rationale: The correct answer is D, stomach. The stomach is not considered an accessory digestive organ as it is part of the gastrointestinal tract. The accessory digestive organs aid in the digestion process but are not part of the tract itself. The tongue, liver, and pancreas are all considered accessory digestive organs as they play crucial roles in digestion, such as producing enzymes and bile. The stomach's main function is to store and break down food through mechanical and chemical digestion, making it a primary organ in the digestive system rather than an accessory one.