Nokea
The nurse is caring for a patient receiving chemotherapy. Which of the following signs indicates that the patient is developing a complication from the chemotherapy?
- A. Mild nausea
- B. White blood cell count of 3,000 cells/mm3
- C. Reddened areas on the skin
- D. Small amount of urine output
Correct Answer: B
Rationale: The correct answer is B: White blood cell count of 3,000 cells/mm3. A low white blood cell count is a common side effect of chemotherapy, putting the patient at risk for infections. Monitoring WBC count is crucial to detect complications early.
A: Mild nausea is a common side effect of chemotherapy but does not necessarily indicate a complication.
C: Reddened areas on the skin could be due to various reasons and are not specific to chemotherapy complications.
D: Small amount of urine output could be a concern, but it is not a common sign of chemotherapy complications.
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The stomach produces acids, which denature protein, and popsin that digests protein. The cell membranes of the epithelial cells lining the stomach contain protein. The protein in the epithelial cells are not denatured or digested because
- A. the membranes contain a different type of protein that resists denaturation and digestion.
- B. mucus coats the epithelium.
- C. cell membranes are destroyed but mitotic activity replaces cells with new ones every few hours.
- D. hormones produced by the endocrine cells protect the cell membranes and neutralize the acid pH.
Correct Answer: B
Rationale: The correct answer is B: mucus coats the epithelium. The mucus layer acts as a protective barrier that prevents the acid and pepsin from coming into direct contact with the epithelial cells. This physical barrier helps to shield the cell membranes from denaturation and digestion. Choice A is incorrect because the type of protein in the cell membranes does not determine their resistance to denaturation and digestion. Choice C is incorrect because cell membranes are not destroyed, and mitotic activity does not play a role in protecting the cell membranes. Choice D is incorrect because hormones do not directly protect the cell membranes from acid and pepsin; rather, it is the mucus layer that provides the necessary protection.
The defaecation reflex:
- A. Is initiated by stretching the anal canal
- B. Is integrated in a control center in the lumbar spinal cord
- C. Is integrated in a control center in the sacral spinal cord
- D. Is controlled by the vagus nerve
Correct Answer: C
Rationale: The correct answer is C because the defecation reflex is integrated in a control center in the sacral spinal cord. This is due to the presence of the parasympathetic nerves that control the smooth muscles of the colon and rectum in the sacral region. The sacral spinal cord is responsible for coordinating the reflexive relaxation of the internal anal sphincter and contraction of the rectum during defecation. Choices A and B are incorrect because the initiation and integration of the defecation reflex do not involve the anal canal stretching or the lumbar spinal cord. Choice D is incorrect as the defecation reflex is not controlled by the vagus nerve, which is primarily responsible for the parasympathetic innervation of organs in the thorax and upper abdomen.
A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take?
- A. Assist the patient to cough and deep breath
- C. Palpate the abdomen for rebound tenderness.
- D. Suggest the patient lie on the side, flexing the right leg.
Correct Answer: C
Rationale: The correct answer is C: Palpate the abdomen for rebound tenderness. This action is essential to assess for signs of possible appendicitis, a common cause of right lower quadrant abdominal pain with nausea and vomiting. Rebound tenderness is a classic sign of peritoneal irritation and can indicate an inflamed appendix. The other choices are incorrect because:
A: Assisting the patient to cough and deep breath is not a priority in this situation and does not provide relevant information about the cause of the abdominal pain.
D: Suggesting the patient lie on the side, flexing the right leg, may help alleviate some discomfort but does not provide diagnostic information about the underlying cause of the symptoms.
The carcinoid syndrome is likely to occur with carcinoid tumors:
- A. of the appendix
- B. localized to the ileum
- C. both
- D. neither
Correct Answer: C
Rationale: The correct answer is C because carcinoid syndrome can occur with carcinoid tumors of the appendix and ileum. Carcinoid tumors of the appendix can lead to carcinoid syndrome due to the release of serotonin and other vasoactive substances. Similarly, carcinoid tumors localized to the ileum can also produce these substances, leading to the development of carcinoid syndrome. Choices A and B alone are not comprehensive enough as both sites can give rise to carcinoid syndrome. Choice D is incorrect as carcinoid syndrome can indeed occur with tumors from both sites.
A patient with advanced cirrhosis has a nursing diagnosis of imbalanced nutrition: less than body requirements related to anorexia and inadequate food intake. What would be an appropriate midday snack for the patient?
- A. Peanut butter and salt-free crackers
- B. A fresh tomato sandwich with salt-free butter
- C. Popcorn with salt-free butter and herbal seasoning
- D. Canned chicken noodle soup with low-protein bread
Correct Answer: A
Rationale: Peanut butter and salt-free crackers provide protein and energy, which can help address nutritional deficiencies in a patient with cirrhosis.