Nokea
Priority Decision: A patient is admitted to the emergency department with acute abdominal pain. What nursing intervention should the nurse implement first?
- A. Measurement of vital signs
- B. Administration of prescribed analgesics
- C. Assessment of the onset, location, intensity, duration, and character of the pain
- D. Physical assessment of the abdomen for distention, bowel sounds, and pigmentation changes
Correct Answer: C
Rationale: The correct answer is C. Assessing the onset, location, intensity, duration, and character of the pain is the priority because it helps determine the potential cause of the abdominal pain. This information guides further interventions and informs the healthcare team about the urgency of the situation.
Choice A (Measurement of vital signs) can be important but assessing the pain characteristics takes precedence as it directly informs the urgency of the situation.
Choice B (Administration of prescribed analgesics) should be delayed until the cause of the pain is identified to prevent masking symptoms that could aid in diagnosis.
Choice D (Physical assessment of the abdomen) is important but assessing the pain characteristics comes first to guide the physical assessment and subsequent interventions.
You may also like to solve these questions
Stimulation by the parasympathetic nervous system will cause the ______ anal sphincter to ______.
- A. external; relax
- B. external; contract
- C. internal; contract
- D. internal; relax
Correct Answer: D
Rationale: The correct answer is D because the parasympathetic nervous system is responsible for promoting rest and digest functions. The internal anal sphincter is controlled by the autonomic nervous system, specifically the parasympathetic division. When stimulated by the parasympathetic nervous system, the internal anal sphincter will relax, allowing for defecation to occur.
A: The external anal sphincter is under voluntary control, not affected by the parasympathetic nervous system.
B: The external anal sphincter contracts voluntarily, not influenced by the parasympathetic nervous system.
C: The internal anal sphincter contracts under sympathetic stimulation, not parasympathetic.
Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)?
- A. Ranitidine absorbs the excess gastric acid.
- B. Ranitidine decreases gastric acid secretion.
- C. Ranitidine constricts the blood vessels near the ulcer.
- D. Ranitidine covers the ulcer with a protective material.
Correct Answer: B
Rationale: Rationale: Ranitidine is an H2 receptor antagonist that works by blocking the action of histamine on the stomach cells, thereby reducing gastric acid secretion. This helps in healing and preventing further damage to the ulcer. Option A is incorrect as ranitidine doesn't absorb excess gastric acid; it reduces its production. Option C is incorrect as ranitidine doesn't constrict blood vessels. Option D is incorrect as ranitidine doesn't cover the ulcer but rather decreases acid secretion to promote healing.
A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?
- A. Fatty stools
- B. Straw-colored urine
- C. Tenderness in the left upper abdomen
- D. Ecchymosis of the extremities
Correct Answer: A
Rationale: The correct answer is A: Fatty stools. Common bile duct obstruction leads to inadequate bile flow into the intestines, resulting in malabsorption of fats. This causes fatty stools due to the presence of undigested fats. Straw-colored urine (B) is a normal finding. Tenderness in the left upper abdomen (C) is more indicative of splenic issues. Ecchymosis of the extremities (D) is unrelated to common bile duct obstruction.
What role do the teeth play in digestion?
- A. chemical digestion
- B. mechanical digestion
- C. enzymatic digestion
- D. absorption
Correct Answer: B
Rationale: The correct answer is B: mechanical digestion. Teeth play a crucial role in breaking down food into smaller pieces through physical chewing, which is a form of mechanical digestion. This process increases the surface area of food particles, making it easier for enzymes to further break down nutrients during chemical digestion in the stomach and intestines. Choice A (chemical digestion) is incorrect because teeth do not directly participate in chemical breakdown of food. Choice C (enzymatic digestion) is incorrect as enzymes are not produced by teeth but by salivary glands and other digestive organs. Choice D (absorption) is incorrect as teeth are not involved in absorbing nutrients; absorption primarily occurs in the small intestine.
The muscular contractions, which move material through the digestive tract, are called:
- A. peristalsis
- B. deglutition.
- C. mass movements.
- D. segmental contractions.
Correct Answer: A
Rationale: The correct answer is A: peristalsis. Peristalsis refers to the wave-like muscular contractions that propel food through the digestive tract. First, circular muscles contract behind the food bolus creating a narrowing, then longitudinal muscles contract ahead of the bolus, pushing it forward. This coordinated movement helps move food along the digestive tract efficiently. Deglutition (B) refers to the act of swallowing, not the movement of food through the digestive tract. Mass movements (C) refer to large, powerful contractions that occur in the colon to move feces. Segmental contractions (D) are localized contractions that mix and churn food in the intestines, not the primary mechanism for moving food along the digestive tract.