The nurse is preparing to administer liquid laxative to a patient in preparation for a colonoscopy. Which action should the nurse take?
- A. Offer a small snack.
- B. Take the patient's temperature.
- C. Mix the laxative with orange juice.
- D. Chill the laxative and pour it over ice.
Correct Answer: D
Rationale: The correct answer is D because chilling the laxative and pouring it over ice can help improve its taste and make it more palatable for the patient. This can encourage the patient to consume the laxative as needed for the colonoscopy preparation. Offering a small snack (choice A) may interfere with the effectiveness of the laxative. Taking the patient's temperature (choice B) is not relevant to administering a laxative. Mixing the laxative with orange juice (choice C) may alter its effectiveness and is not recommended.
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The nervous system or systems that can control peristalsis in the inferior esophagus, stomach, small intestine and large intestine is (are) the
- A. somatic motor nervous system.
- B. sympathetic nervous system.
- C. sympathetic and parasympathetic nervous systems.
- D. autonomic and somatic motor nervous systems.
Correct Answer: C
Rationale: The correct answer is C because peristalsis, the involuntary movement of the digestive tract, is controlled by both sympathetic and parasympathetic nervous systems. The parasympathetic nervous system stimulates peristalsis, while the sympathetic nervous system inhibits it. Choice A is incorrect because the somatic motor nervous system controls voluntary movements, not peristalsis. Choice B is incorrect because the sympathetic nervous system inhibits peristalsis. Choice D is incorrect because the somatic motor nervous system does not control peristalsis in the digestive tract; it controls skeletal muscle movements.
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.
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.
The major secretory product of the colon is
- A. bicarbonate ions.
- B. mucus.
- C. digestive enzymes.
- D. hydrochloric acid.
Correct Answer: B
Rationale: The correct answer is B: mucus. The colon secretes mucus to protect the lining from digestive enzymes and acids, aid in the passage of stool, and maintain proper intestinal function. Bicarbonate ions (A) are secreted in the pancreas to neutralize stomach acid. Digestive enzymes (C) are primarily secreted in the small intestine to break down nutrients. Hydrochloric acid (D) is secreted by the stomach to aid in digestion but not by the colon.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient asks about the best way to prevent respiratory infections. What is the nurse's best response?
- A. "Take a yearly flu shot and avoid crowds during flu season."
- B. "Increase your use of nebulizer treatments to keep your lungs clear."
- C. "Take vitamin C to boost your immune system."
- D. "Use an antibiotic regularly to prevent infections."
Correct Answer: A
Rationale: Step 1: The nurse's response should focus on preventing respiratory infections in a patient with COPD.
Step 2: Yearly flu shots are recommended to prevent influenza, a common trigger for respiratory infections in COPD.
Step 3: Avoiding crowds during flu season reduces exposure to pathogens, further preventing infections.
Step 4: Increasing nebulizer treatments does not directly prevent infections but may help manage COPD symptoms.
Step 5: Vitamin C may have some benefits but is not a primary preventive measure for respiratory infections in COPD.
Step 6: Regular antibiotic use is not recommended to prevent infections due to the risk of antibiotic resistance and potential side effects.
Conclusion: Option A is the best response as it includes evidence-based strategies to prevent respiratory infections in a patient with COPD.
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