Nokea
An individual has the following symptoms: jaundice, pale in color, liver with a buildup of connective tissue. This individual most likely has
- A. gastritis.
- B. pancreatitis.
- C. gall stones.
- D. cirrhosis.
Correct Answer: D
Rationale: The correct answer is D: cirrhosis. Jaundice, pale skin, and liver with connective tissue buildup are classic symptoms of cirrhosis - a condition characterized by scarring of the liver due to long-term damage. Jaundice occurs when the liver is unable to properly process bilirubin, leading to yellowing of the skin and eyes. The pale color can be due to anemia often seen in cirrhosis. The buildup of connective tissue is indicative of fibrosis and scarring in the liver. Gastritis (A) is inflammation of the stomach lining, pancreatitis (B) is inflammation of the pancreas, and gallstones (C) are solid particles that form in the gallbladder. These conditions do not typically present with the combination of symptoms described.
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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.
The nurse is caring for a patient who returns to the floor at lunchtime after undergoing an upper GI (UGI) series. Which action is most important for the nurse to perform first?
- A. Administer a laxative.
- B. Educate the patient about the possibility of white stools.
- C. Offer the patient a small snack.
- D. Provide oral care.
Correct Answer: A
Rationale: The correct answer is A: Administer a laxative. After an upper GI series, it is important to help the patient eliminate the contrast dye used during the procedure. Administering a laxative will facilitate the removal of the dye from the gastrointestinal tract. This is crucial to prevent any potential complications or adverse effects from the contrast dye.
Explanation for incorrect choices:
B: Educating the patient about the possibility of white stools is not the most immediate concern after an upper GI series. While this information is important for the patient to know, it is not the most urgent action to take.
C: Offering the patient a small snack may be appropriate after the procedure, but ensuring the elimination of the contrast dye through a laxative is more critical.
D: Providing oral care is important for overall patient comfort and hygiene, but it is not the priority immediately following an upper GI series.
Which of the following teaching strategies would the nurse plan for a client with an anal fissure?
- A. Teach the client strategies to relieve diarrhea
- B. Instruct the client to not eat any fiber
- C. Teach the client how to insert a suppository
- D. Teach the client how to apply ice
Correct Answer: D
Rationale: The correct answer is D: Teach the client how to apply ice. Applying ice helps reduce inflammation and pain associated with anal fissures. It constricts blood vessels, decreases blood flow, and numbs the area, promoting healing.
A: Teaching strategies to relieve diarrhea is not directly related to managing anal fissures.
B: Instructing the client to not eat any fiber is incorrect because fiber helps soften stools and prevent constipation, which can worsen anal fissures.
C: Teaching the client how to insert a suppository may not be necessary for managing anal fissures unless prescribed by a healthcare provider for specific reasons.
Eleanor, a 62 y.o. woman with diverticulosis is your patient. Which interventions would you expect to include in her care?
- A. Low-fiber diet and fluid restrictions.
- B. Total parenteral nutrition and bed rest.
- C. High-fiber diet and administration of psyllium.
- D. Administration of analgesics and antacids.
Correct Answer: C
Rationale: Rationale:
C is correct as high-fiber diet helps prevent diverticulitis episodes. Psyllium adds bulk to stool, reducing strain on the colon. A is incorrect as low-fiber diet worsens diverticulosis. B is inappropriate as TPN is not first-line and bed rest can worsen symptoms. D is incorrect as analgesics and antacids do not address the underlying cause.
In report, the nurse learns that the patient has a transverse colostomy. What should the nurse expect when providing care for this patient?
- A. Semiliquid stools with increased fluid requirements
- B. Liquid stools in a pouch and increased fluid requirements
- C. Formed stools with a pouch, needing irrigation, but no fluid needs
- D. Semiformed stools in a pouch with the need to monitor fluid balance
Correct Answer: A
Rationale: The correct answer is A: Semiliquid stools with increased fluid requirements. A transverse colostomy is located in the upper part of the colon, where stool consistency is more liquid. This type of colostomy typically produces semiliquid stools due to the shorter transit time in the colon, leading to increased fluid requirements to prevent dehydration.
Summary of other choices:
B: Liquid stools in a pouch and increased fluid requirements - Incorrect because transverse colostomies produce semiliquid stools, not entirely liquid.
C: Formed stools with a pouch, needing irrigation, but no fluid needs - Incorrect as transverse colostomies do not produce formed stools, and fluid intake is necessary.
D: Semiformed stools in a pouch with the need to monitor fluid balance - Incorrect because transverse colostomies produce semiliquid stools, not semiformed, and increased fluid intake is needed.