Nokea
A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which of the following statements indicates to the nurse that the client understands the instructions?
- A. I will lie on my left side to sleep at night.'
- B. I will lie on my right side to sleep at night.'
- C. I will sleep on my back with my head flat.'
- D. I will sleep on my stomach with my head flat.'
Correct Answer: A
Rationale: The correct answer is A: "I will lie on my left side to sleep at night." This position helps prevent acid from flowing back into the esophagus due to the angle of the stomach in relation to the esophagus. Lying on the right side can worsen reflux. Sleeping on the back with the head flat can also worsen symptoms as gravity can allow acid to flow back up. Sleeping on the stomach with the head flat is not recommended as it can put pressure on the stomach, leading to increased reflux.
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Identify one nursing intervention indicated for each of the following desired outcomes of tube feeding.
- A. Prevention of aspiration
- B. Prevention of diarrhea
- C. Maintenance of tube patency
- D. Maintenance of tube placement
Correct Answer: A
Rationale: The correct answer is A: Prevention of aspiration. This is essential in tube feeding to avoid the risk of food or liquid entering the lungs, causing aspiration pneumonia. Nursing interventions for this include ensuring proper positioning during and after feeding, checking residual volumes before each feeding, and using the appropriate tube size and placement.
Incorrect Choices:
B: Prevention of diarrhea - Diarrhea is not directly related to tube feeding complications, but rather to factors such as infection, medication side effects, or underlying conditions.
C: Maintenance of tube patency - While important, this focuses on ensuring the tube remains clear and functional, not directly related to preventing aspiration.
D: Maintenance of tube placement - Ensuring proper tube placement is crucial for effective feeding but does not directly address the risk of aspiration.
A patient with a history of peptic ulcer disease is hospitalized with symptoms of a perforation. During the initial assessment
- A. what should the nurse expect the patient to report?
- B. Vomiting of bright-red blood
- C. Projectile vomiting of undigested food
- D. Sudden, severe upper abdominal pain and back pain
Correct Answer: C
Rationale: The correct answer is C: Projectile vomiting of undigested food. In a patient with a perforated peptic ulcer, the sudden opening in the stomach lining allows food to pass into the abdominal cavity, leading to projectile vomiting of undigested food. This symptom is a classic sign of a perforation and requires immediate medical attention. Choice A is incorrect because vomiting of bright-red blood is more indicative of upper gastrointestinal bleeding, not a perforation. Choice B is incorrect as vomiting undigested food is more common in conditions like gastroparesis, not perforated ulcers. Choice D is incorrect as severe upper abdominal pain and back pain are symptoms of a perforation but not as specific as projectile vomiting of undigested food.
The lips are lined by ______ epithelium.
- A. moist stratified squamous
- B. dry stratified squamous
- C. simple columnar
- D. pseudostratified columnar
Correct Answer: A
Rationale: The correct answer is A: moist stratified squamous epithelium. The lips require a moist lining to prevent dehydration and facilitate movement. Stratified squamous epithelium is ideal for areas subjected to wear and tear, like the lips. The stratified nature provides protection, while the squamous cells allow flexibility and ease of movement. The moist aspect is crucial to maintain hydration and prevent drying out.
Summary:
- Choice B (dry stratified squamous) is incorrect because the lips need a moist lining.
- Choice C (simple columnar) is incorrect because columnar epithelium is not typically found on the lips.
- Choice D (pseudostratified columnar) is incorrect as it is not the most suitable type of epithelium for the lips' functions.
After eating or drinking dairy products like cheese and milk, you have intestinal cramps, bloating and diarrhea. You most likely have
- A. lactose intolerance.
- B. diabetes mellitus, Type I.
- C. heartburn.
- D. peritonitis.
Correct Answer: A
Rationale: The correct answer is A: lactose intolerance. This is due to the inability to digest lactose, the sugar found in dairy products, leading to symptoms like intestinal cramps, bloating, and diarrhea. This is a common condition caused by a deficiency of lactase enzyme.
Choice B: Diabetes mellitus, Type I, is incorrect as it is an autoimmune condition affecting insulin production, not digestion of dairy products.
Choice C: Heartburn is incorrect as it is a symptom of acid reflux, not related to dairy product intolerance.
Choice D: Peritonitis is incorrect as it is an inflammation of the abdominal lining, usually caused by infection or injury, not related to dairy product intolerance.
When assessing a client for acute pancreatitis, which of the following symptoms will the nurse observe?
- A. Increased thirst and urination
- B. Hypertension and nausea
- C. Rapid breathing and pulse rate
- D. Frothy, foul-smelling stools
Correct Answer: C
Rationale: The correct answer is C: Rapid breathing and pulse rate. In acute pancreatitis, inflammation of the pancreas can lead to systemic complications, including respiratory distress and tachycardia. This occurs due to the release of inflammatory mediators affecting the respiratory and cardiovascular systems. Increased thirst and urination (Choice A) are more indicative of diabetes or renal issues. Hypertension and nausea (Choice B) are not typical symptoms of acute pancreatitis. Frothy, foul-smelling stools (Choice D) are more likely linked to malabsorption disorders rather than acute pancreatitis. Rapid breathing and pulse rate are key signs that indicate the severity of the condition and the need for prompt intervention.