Nokea
A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?
- A. Epigastric discomfort
- B. Dyspepsia
- C. Constipation
- D. Hematemesis
Correct Answer: D
Rationale: The correct answer is D, Hematemesis. This is the priority finding because it indicates upper gastrointestinal bleeding, which can be life-threatening. The nurse should address this immediately to prevent further complications. Epigastric discomfort (A) and dyspepsia (B) are common symptoms of peptic ulcer disease but do not indicate active bleeding. Constipation (C) is not directly related to peptic ulcer disease and does not pose an immediate threat to the client's health.
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Which of these structures is found in the small intestine?
- A. Villi
- B. Hepatic portal vein
- C. Goblet cells
- D. Mesenteries
Correct Answer: A
Rationale: The correct answer is A: Villi. Villi are finger-like projections lining the small intestine that increase surface area for nutrient absorption. This structure is crucial for efficient digestion and absorption of nutrients. The other choices are incorrect because:
B: Hepatic portal vein - This structure is not found in the small intestine but connects the intestines to the liver.
C: Goblet cells - While present in the small intestine, they are not a defining structure of the small intestine.
D: Mesenteries - These are connective tissues that support and hold organs in place, not a structure specific to the small intestine.
In preparing a client for a colonoscopy procedure, which task is most suitable to delegate to the nursing assistant?
- A. Explain the need for clear liquids 1-3 days prior to procedure.
- B. Reinforce NPO status 8 hours prior to procedure.
- C. Administer laxatives 1-3 days prior to procedure.
- D. Administer an enema the night before the procedure.
Correct Answer: B
Rationale: Step 1: Delegation Principle - The task should be within the nursing assistant's scope of practice.
Step 2: NPO reinforcement is a basic instruction that does not require clinical judgment.
Step 3: Nursing assistant can remind the client about NPO status without interpreting medical information.
Step 4: Administering laxatives (C) and enema (D) require clinical judgment and should be done by licensed staff.
Step 5: Explaining the need for clear liquids (A) involves providing medical information, not just a reminder.
This region of the large intestine has a simple columnar epithelium in its tunica mucosa, smooth muscle in its tunica muscularis, and epiploic appendages attach to its outer surface. This region is called the
- A. cecum.
- B. colon.
- C. rectum.
- D. anal canal.
Correct Answer: B
Rationale: The correct answer is B: colon. The colon is characterized by having a simple columnar epithelium in its tunica mucosa, smooth muscle in its tunica muscularis, and epiploic appendages attached to its outer surface. The cecum (A) is a pouch-like structure at the beginning of the large intestine. The rectum (C) is the final segment of the large intestine before the anal canal (D). The anal canal is lined by stratified squamous epithelium, not simple columnar epithelium like the colon.
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.
A client with an ileostomy wants to know why to avoid fibrous vegetables. What should be the nurse's response?
- A. They cause gas formation.
- B. They cause stomal obstruction.
- C. They are difficult to digest.
- D. They increase the risk of diarrhea.
Correct Answer: B
Rationale: The correct answer is B because fibrous vegetables can potentially cause stomal obstruction in clients with an ileostomy due to their indigestible nature, leading to blockages in the stoma. This can result in severe complications and require medical intervention. Gas formation (choice A) is a common issue with high-fiber foods but is not specific to fibrous vegetables. Fibrous vegetables are not necessarily difficult to digest (choice C) for most individuals, although they may be harder for those with reduced gut function. While fibrous vegetables may contribute to loose stools, they do not directly increase the risk of diarrhea (choice D) in the same way they can cause stomal obstruction.