Nokea
Priority Decision: A postoperative patient has a nursing diagnosis of pain related to effects of medication and decreased GI motility as evidenced by abdominal pain and distention and inability to pass flatus. Which nursing intervention is most appropriate for this patient?
- A. Ambulate the patient more frequently.
- B. Assess the abdomen for bowel sounds.
- C. Place the patient in high Fowler's position.
- D. Withhold opioids because they decrease bowel motility.
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Ambulating the patient more frequently helps to stimulate GI motility, reduce abdominal distention, and promote passage of flatus. Movement aids in peristalsis, which can alleviate postoperative GI issues.
Summary of Incorrect Choices:
B: Assessing bowel sounds is important but does not directly address the issue of stimulating GI motility or addressing the patient's pain and distention.
C: Placing the patient in a high Fowler's position may improve respiratory function but does not specifically target GI motility or pain relief.
D: Withholding opioids may be necessary in some cases, but pain management is crucial for postoperative care. There are other ways to address decreased GI motility without completely withholding pain medications.
You may also like to solve these questions
A nurse is providing discharge teaching to a client who has gastroesophageal reflux disease. Which of the following statements by the client indicates an understanding of the teaching?
- A. The type of foods I eat does not affect this condition.'
- B. I will sleep on my left side.'
- C. I will eat a snack just before going to bed.'
- D. I will sleep with the head of my bed elevated.'
Correct Answer: D
Rationale: The correct answer is D. Elevating the head of the bed helps prevent acid reflux by keeping the stomach acid from flowing back into the esophagus while sleeping. This position helps gravity keep the acid in the stomach. Choice A is incorrect because certain foods can indeed trigger or worsen GERD symptoms. Choice B is incorrect as sleeping on the left side may worsen symptoms due to the position of the stomach. Choice C is incorrect as eating right before bed can increase the risk of acid reflux.
Which statement about intestinal 'brakes' and 'accelerators' is FALSE?
- A. Dietary starch is a potent stimulator of small intestinal motility because it causes insulin release from the pancreas
- B. Food in the stomach causes gastrin release, which stimulates acid secretion
- C. Short-chain fatty acids which move from colon to caecum (reflux) promote ileo-caecal motility
- D. The arrival of lipid in the duodenum causes an immediate reduction in motility and a switch from the 'fasting' to the 'feeding' pattern.
Correct Answer: A
Rationale: The correct answer is A because dietary starch does not cause insulin release from the pancreas, but rather stimulates the release of incretin hormones like glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP). These incretins help regulate blood sugar levels postprandially and do not directly affect intestinal motility.
Incorrect choices:
B: Food in the stomach causing gastrin release is true and stimulates acid secretion.
C: Short-chain fatty acids moving from colon to caecum promoting ileo-caecal motility is true.
D: The arrival of lipid in the duodenum causing a reduction in motility is true.
Stimulation by the sympathetic nervous system will cause which one of the following effects in the inferior esophagus, stomach, small intestine and large intestine?
- A. nothing, because skeletal muscle is found in the walls of these areas
- B. increases peristalsis by stimulation of smooth muscle
- C. decreases peristalsis by inhibition of smooth muscle
- D. decreases peristalsis by stimulation of smooth muscle
Correct Answer: C
Rationale: The correct answer is C: decreases peristalsis by inhibition of smooth muscle. The sympathetic nervous system inhibits gastrointestinal motility by decreasing peristalsis. This is achieved through the release of norepinephrine, which binds to adrenergic receptors on smooth muscle cells, leading to reduced contraction and motility. Choices A and B are incorrect because the sympathetic nervous system can still affect smooth muscle, not just skeletal muscle. Choice D is incorrect because sympathetic stimulation does not directly increase peristalsis.
The nurse monitors the laboratory results of the patient with protein-calorie malnutrition during treatment. Which result is an indication of improvement in the patient's condition?
- A. Decreased lymphocytes
- B. Increased serum transferrin
- C. Increased serum potassium
- D. Decreased serum prealbumin
Correct Answer: B
Rationale: The correct answer is B because an increase in serum transferrin levels indicates improvement in protein-calorie malnutrition as transferrin is a protein that binds and transports iron, which is essential for various body functions. When protein intake increases, transferrin levels also increase to support iron transport.
A: Decreased lymphocytes do not directly reflect improvement in protein-calorie malnutrition.
C: Increased serum potassium is not specific to improvement in protein-calorie malnutrition.
D: Decreased serum prealbumin levels indicate ongoing malnutrition, not improvement.
What occurs during swallowing?
- A. All the processes of Deglutition are under voluntary control.
- B. The vocal folds are relaxed allowing the food to travel down the oesophagus
- C. The swallowing centre located within the medulla oblongata inhibits the medullary respiratory centre
- D. The food bolus travels down the oesophagus due to gravity
Correct Answer: C
Rationale: The correct answer is C because during swallowing, the swallowing center in the medulla oblongata inhibits the medullary respiratory center to prevent aspiration. This coordination ensures that breathing is temporarily halted to prevent food or liquid from entering the airway. Choices A, B, and D are incorrect because not all processes of deglutition are under voluntary control, the vocal folds actually close to protect the airway during swallowing, and the movement of the food bolus down the esophagus is facilitated by peristalsis rather than gravity.