Nokea
A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?
- A. Gallstones
- B. Hypolipidemia
- C. COPD
- D. Diabetes mellitus
Correct Answer: A
Rationale: The correct answer is A: Gallstones. Acute pancreatitis is commonly caused by gallstones or alcohol consumption. Gallstones can block the pancreatic duct, leading to inflammation. Hypolipidemia, COPD, and diabetes mellitus are not directly associated with pancreatitis. This history finding helps the nurse identify the potential cause and plan appropriate care.
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The gallbladder contracts in response to
- A. vagal stimulation only.
- B. cholecystokinin and vagal stimulation.
- C. cholecystokinin and secretin.
- D. a low pH of chyme.
Correct Answer: B
Rationale: The gallbladder contracts in response to cholecystokinin and vagal stimulation. Cholecystokinin is released in response to the presence of fatty acids and amino acids in the duodenum, signaling the gallbladder to contract and release bile. Vagal stimulation also plays a role in gallbladder contraction by transmitting signals from the brain to the gallbladder. Secretin is primarily involved in stimulating pancreatic secretion, not gallbladder contraction. A low pH of chyme does not directly stimulate gallbladder contraction.
A client has diarrhea due to a high carbohydrate and electrolyte content of the fluid in the tube feeding. Which of the following nursing actions will be most appropriate?
- A. Instructing the client to remain in a semi-Fowler's position
- B. Consulting the physician about decreasing the infusion rate
- C. Administering the tube feedings continuously
- D. Maintaining the tube patency
Correct Answer: B
Rationale: Reducing the infusion rate allows better absorption of nutrients and decreases the risk of osmotic diarrhea.
Following a Billroth II procedure
- A. a patient develops dumping syndrome. The nurse should explain that the symptoms associated with this problem are caused by
- B. distention of the smaller stomach by too much food and fluid intake.
- C. hyperglycemia caused by uncontrolled gastric emptying into the small intestine.
- D. irritation of the stomach lining by reflux of bile salts because the pylorus has been removed.
Correct Answer: D
Rationale: Dumping syndrome occurs when food moves too rapidly into the small intestine, causing fluid to shift into the bowel and leading to symptoms like nausea, diarrhea, and abdominal cramping.
In the colon, which is benign and has no significant tendency to undergo malignant transformation?
- A. familial polyposis
- B. juvenile polyp
- C. villous adenoma
- D. carcinoid tumors
Correct Answer: B
Rationale: The correct answer is B: juvenile polyp. Juvenile polyps are benign growths commonly found in the colon and rectum of children. They have no significant tendency to undergo malignant transformation due to their non-neoplastic nature. They are typically small, solitary, and have a smooth surface. Familial polyposis (choice A) is a hereditary condition characterized by numerous polyps in the colon, which can progress to colorectal cancer. Villous adenomas (choice C) are precancerous lesions with a higher risk of malignant transformation. Carcinoid tumors (choice D) are neuroendocrine tumors that can be found in various parts of the body, including the gastrointestinal tract, and have the potential to be malignant.
Which of the following is not a component of gastric juice?
- A. Pepsinogen
- B. Hydrochloric acid
- C. Bile
- D. Mucus
Correct Answer: C
Rationale: The correct answer is C: Bile. Bile is not a component of gastric juice; it is produced by the liver and stored in the gallbladder to aid in digestion in the small intestine. Pepsinogen, hydrochloric acid, and mucus are all components of gastric juice. Pepsinogen is the inactive form of pepsin, an enzyme that breaks down proteins. Hydrochloric acid helps in the digestion of food and kills bacteria. Mucus protects the stomach lining from the acidic environment.