Saliva decreases gingivitis and caries because it contains immunoglobulin A and
- A. lysozymes.
- B. mucus.
- C. salivary amylase.
- D. water.
Correct Answer: A
Rationale: The correct answer is A: lysozymes. Lysozymes in saliva help to break down bacterial cell walls, reducing the risk of gingivitis and caries. Immunoglobulin A helps to fight off harmful bacteria. Salivary amylase aids in digestion, not in preventing gingivitis or caries. Mucus and water in saliva do not directly contribute to the reduction of gingivitis or caries.
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A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective?
- A. The patient uses incontinence briefs to contain loose stools.
- B. The patient uses witch hazel compresses to soothe irritation.
- C. The patient asks for antidiarrheal medication after each stool.
- D. The patient cleans the perianal area with soap after each stool.
Correct Answer: B
Rationale: The correct answer is B: The patient uses witch hazel compresses to soothe irritation. Witch hazel has astringent and anti-inflammatory properties, which can help reduce inflammation and soothe irritated skin. By using witch hazel compresses, the patient is actively taking steps to alleviate discomfort and promote skin healing.
A: The patient using incontinence briefs to contain loose stools does not address the issue of skin integrity maintenance and may lead to prolonged exposure of the skin to stool, exacerbating the problem.
C: Asking for antidiarrheal medication after each stool does not directly address the need for skin integrity maintenance. While it may help reduce stool frequency, it does not specifically target skin healing.
D: Cleaning the perianal area with soap after each stool can be harsh on the already excoriated skin and may further irritate it. Using soap can strip the skin of its natural oils and hinder the healing process.
Priority Decision: A patient returns to the surgical unit with a nasogastric (NG) tube to low intermittent suction, IV fluids, and a Jackson-Pratt drain at the surgical site following an exploratory laparotomy and repair of a bowel perforation. Four hours after admission, the patient experiences nausea and vomiting. What is a priority nursing intervention for the patient?
- A. Assess the abdomen for distention and bowel sounds.
- B. Inspect the surgical site and drainage in the Jackson-Pratt.
- C. Check the amount and character of gastric drainage and the patency of the NG tube.
- D. Administer prescribed prochlorperazine (Compazine) to control the nausea and vomiting.
Correct Answer: C
Rationale: The correct answer is C: Check the amount and character of gastric drainage and the patency of the NG tube. This is the priority nursing intervention because the patient is experiencing nausea and vomiting, which could indicate potential complications related to the NG tube, such as blockage or displacement. By checking the gastric drainage and NG tube patency, the nurse can assess if the patient's symptoms are related to these issues and take appropriate actions to address them.
Choice A is incorrect because assessing the abdomen for distention and bowel sounds is important but not the priority in this situation where the patient is experiencing nausea and vomiting. Choice B is incorrect as inspecting the surgical site and drainage in the Jackson-Pratt drain is also important but not as urgent as checking the NG tube patency in this case. Choice D is incorrect as administering medication should not be the first action taken without first assessing the underlying cause of the symptoms.
Which patient has the highest risk for poor nutritional balance related to decreased ingestion?
- A. Tuberculosis infection
- B. Draining decubitus ulcers
- C. Malabsorption syndrome
- D. Severe anorexia resulting from radiation therapy
Correct Answer: D
Rationale: The correct answer is D: Severe anorexia resulting from radiation therapy. This patient has the highest risk for poor nutritional balance due to the severe anorexia caused by the treatment. Radiation therapy often leads to loss of appetite, making it difficult for the patient to ingest adequate nutrients, resulting in malnutrition.
A: Tuberculosis infection does not necessarily directly cause decreased ingestion, as appetite may vary among patients.
B: Draining decubitus ulcers may lead to protein and fluid loss but not necessarily decreased ingestion.
C: Malabsorption syndrome affects the absorption of nutrients but does not directly relate to decreased ingestion.
Which of these is responsible for the formation of chyme?
- A. bile
- B. mucus
- C. hydrochloric acid
- D. pepsin
Correct Answer: C
Rationale: The correct answer is C: hydrochloric acid. Hydrochloric acid is responsible for creating an acidic environment in the stomach essential for the activation of pepsin and the breakdown of proteins into peptides. This acidic environment also helps in the denaturation of proteins and kills harmful bacteria present in food. Bile (choice A) aids in digestion of fats in the small intestine. Mucus (choice B) helps protect the stomach lining from the acidic environment. Pepsin (choice D) is an enzyme that breaks down proteins but is activated by hydrochloric acid.
Although HAV antigens are not tested in the blood, they stimulate specific immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies. Which antibody indicates there is acute HAV infection?
- A. Anti-HBc IgG
- B. Anti-HBc IgM
- C. Anti-HAV IgG
- D. Anti-HAV IgM
Correct Answer: D
Rationale: The correct answer is D: Anti-HAV IgM. IgM antibodies indicate acute infection as they are the first antibodies produced in response to a new infection. In the case of HAV, the presence of Anti-HAV IgM suggests recent exposure to the virus.
A: Anti-HBc IgG is not relevant to HAV infection. It indicates past or chronic hepatitis B infection.
B: Anti-HBc IgM is specific to hepatitis B infection, not HAV.
C: Anti-HAV IgG indicates past exposure or immunity to HAV, not acute infection.