Nokea
A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action?
- A. Place the client in a supine position postoperatively.
- B. Encourage ambulation once fully awake.
- C. Offer the client ice cream postoperatively.
- D. Instruct the client not to lift over 4.5 kg (10 lb).
Correct Answer: D
Rationale: The correct answer is D: Instruct the client not to lift over 4.5 kg (10 lb).
Rationale:
1. Lifting restrictions are crucial post-laparoscopic cholecystectomy to prevent strain on the surgical site.
2. Lifting heavy objects can lead to complications such as incisional hernias or wound dehiscence.
3. Following lifting restrictions aids in the proper healing of the surgical incisions.
4. Placing the client in a supine position (A) may be uncomfortable due to gas used during surgery. Ambulation (B) is important but not the priority immediately post-op. Offering ice cream (C) is not relevant to postoperative care.
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Which of the following instructions should the nurse provide to a client who is asymptomatic of colonic cancer, but whose stool test results are positive for blood?
- A. Add fiber to the diet
- B. Undergo a colonoscopy
- C. Use warm soaks
- D. Use a stool softener
Correct Answer: B
Rationale: A positive fecal occult blood test may indicate colorectal cancer, and a colonoscopy is required for further investigation and diagnosis.
The defaecation reflex:
- A. Is initiated by stretching the anal canal
- B. Is integrated in a control center in the lumbar spinal cord
- C. Is integrated in a control center in the sacral spinal cord
- D. Is controlled by the vagus nerve
Correct Answer: C
Rationale: The correct answer is C because the defecation reflex is integrated in a control center in the sacral spinal cord. This is due to the presence of the parasympathetic nerves that control the smooth muscles of the colon and rectum in the sacral region. The sacral spinal cord is responsible for coordinating the reflexive relaxation of the internal anal sphincter and contraction of the rectum during defecation. Choices A and B are incorrect because the initiation and integration of the defecation reflex do not involve the anal canal stretching or the lumbar spinal cord. Choice D is incorrect as the defecation reflex is not controlled by the vagus nerve, which is primarily responsible for the parasympathetic innervation of organs in the thorax and upper abdomen.
Which single statement below, about the stomach, is actually correct?
- A. Acid secretion occurs in response to secretion of the hormone, carbonic anhydrase
- B. Glands called Peyer's patches are responsible for acid secretion
- C. The vagus nerve inhibits acid secretion after a meal has been consumed
- D. Pepsinogen and gastric lipase are two enzymes secreted into the lumen of the stomach
Correct Answer: D
Rationale: The correct answer is D because pepsinogen and gastric lipase are indeed two enzymes secreted into the lumen of the stomach. Pepsinogen is converted to pepsin, an enzyme that breaks down proteins, while gastric lipase helps in the digestion of fats.
A is incorrect because carbonic anhydrase is not a hormone but an enzyme involved in acid secretion.
B is incorrect because Peyer's patches are actually found in the small intestine, not the stomach, and they are involved in the immune system.
C is incorrect because the vagus nerve stimulates, rather than inhibits, acid secretion in response to a meal.
In summary, D is correct as it accurately describes enzymes secreted in the stomach, while the other choices contain factual inaccuracies about stomach function.
Where are most digestive enzymes activated?
- A. stomach
- B. small intestine
- C. liver
- D. pancreas
Correct Answer: B
Rationale: The correct answer is B: small intestine. Digestive enzymes are activated in the small intestine to break down nutrients. Firstly, enzymes are secreted by the pancreas into the small intestine, where they act on carbohydrates, proteins, and fats. Secondly, bile from the liver helps in the digestion of fats. The stomach mainly secretes gastric juices for protein digestion, not enzymes for overall digestion. The liver produces bile, not digestive enzymes. The pancreas secretes various digestive enzymes, but they become activated in the small intestine.
A client is visited by the dietitian following a colostomy procedure. Which of the following is the primary nutrition concern for this type of client?
- A. Fiber.
- B. Small frequent meals.
- C. Chewing food thoroughly.
- D. Fluids and electrolytes.
Correct Answer: D
Rationale: Maintaining fluid and electrolyte balance is crucial for colostomy clients, as water absorption is affected.