Nokea
After several days of antibiotic therapy for pneumonia, an older hospitalized patient develops watery diarrheWhich action should the nurse take first?
- A. Notify the health care provider.
- B. Obtain a stool specimen for analysis.
- C. Teach the patient about hand washing.
- D. Place the patient on contact precautions.
Correct Answer: D
Rationale: The correct answer is D, placing the patient on contact precautions. This is important because the patient has developed watery diarrhea after antibiotic therapy, which could indicate a Clostridium difficile infection. Placing the patient on contact precautions helps prevent the spread of this highly contagious infection to other patients and healthcare workers. It is the first priority to ensure the safety of others in the healthcare setting.
A: Notifying the health care provider can be done after placing the patient on contact precautions.
B: Obtaining a stool specimen for analysis is important but should be done after initiating contact precautions.
C: Teaching the patient about hand washing is important for infection control but is not the first priority when dealing with a potential infectious disease outbreak.
You may also like to solve these questions
Which phase of deglutition involves contraction of the longitudinal muscle layer of the muscularis?
- A. voluntary phase
- B. buccal phase
- C. pharyngeal phase
- D. esophageal phase
Correct Answer: D
Rationale: The correct answer is D: esophageal phase. During the esophageal phase of deglutition, the longitudinal muscle layer of the muscularis contracts to help propel the bolus of food downwards towards the stomach. This contraction occurs in a coordinated manner to create peristaltic waves that push the food along the esophagus. In contrast, the voluntary phase (A) involves the conscious initiation of swallowing, the buccal phase (B) involves the tongue pushing the bolus towards the pharynx, and the pharyngeal phase (C) involves the initiation of the swallowing reflex and closure of the airway to prevent aspiration.
To evaluate the effect of nutritional interventions for a patient with protein-calorie malnutrition, what is the best indicator for the nurse to use?
- A. Height and weight
- B. Weight in relation to ideal body weight
- C. Body mass index (BMI)
- D. Mid-upper arm circumference and triceps skinfold
Correct Answer: D
Rationale: The correct answer is D. Mid-upper arm circumference and triceps skinfold are commonly used indicators to assess muscle and fat reserves in individuals with protein-calorie malnutrition. Mid-upper arm circumference reflects muscle mass, while triceps skinfold measures body fat. These indicators provide a comprehensive assessment of the patient's nutritional status, making them the best choice for evaluating the effectiveness of nutritional interventions.
A: Height and weight do not provide a specific assessment of muscle and fat reserves and may not accurately reflect changes in nutritional status.
B: Weight in relation to ideal body weight does not differentiate between muscle and fat mass, making it less specific for assessing protein-calorie malnutrition.
C: BMI is a general indicator of weight status and does not specifically measure muscle and fat reserves, making it less suitable for evaluating nutritional interventions in patients with protein-calorie malnutrition.
What is the function of the gallbladder?
- A. producing bile
- B. storing bile
- C. secreting digestive enzymes
- D. neutralizing stomach acid
Correct Answer: B
Rationale: The correct answer is B: storing bile. The gallbladder functions to store bile produced by the liver and release it into the small intestine to aid in digestion. Bile helps in the breakdown of fats. Choices A, C, and D are incorrect because the gallbladder does not produce bile (the liver does), secrete digestive enzymes (pancreas does), or neutralize stomach acid (function of the stomach and duodenum).
In planning a treatment and prevention program of chronic fecal incontinence for an elderly client, which intervention should you try first?
- A. Administer a glycerin suppository 15 minutes before evacuation time.
- B. Insert a rectal tube at specified intervals each day.
- C. Assist the client to the bedpan or toilet 30 minutes after meals.
- D. Use incontinence briefs or adult-sized diapers.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to the bedpan or toilet 30 minutes after meals. This intervention is appropriate as it aligns with the natural physiological process of bowel movements after meals, increasing the likelihood of successful evacuation. This timing can help establish a routine and promote regular bowel movements, potentially reducing episodes of fecal incontinence.
Choice A is incorrect because administering a glycerin suppository may not address the underlying cause of fecal incontinence and may not promote regular bowel movements. Choice B is incorrect as inserting a rectal tube is an invasive intervention that should only be considered after less invasive methods have been exhausted. Choice D is incorrect as using incontinence briefs or adult-sized diapers only manages the symptoms without addressing the root cause or promoting bowel regularity.
Which enzyme is responsible for breaking down proteins in the stomach?
- A. Amylase
- B. Protease
- C. Lipase
- D. Pepsin
Correct Answer: D
Rationale: Pepsin is the correct answer as it is the enzyme specifically produced by gastric chief cells in the stomach to break down proteins into peptides. It works optimally in the acidic environment of the stomach. Amylase (choice A) breaks down carbohydrates, protease (choice B) refers to a general term for enzymes that break down proteins, and lipase (choice C) breaks down fats, making them incorrect for this question.