Nokea
When assessing a patient with acute pancreatitis, the nurse would expect to find
- A. hyperactive bowel sounds.
- B. hypertension and tachycardia.
- C. a temperature greater than 102°F (38.9°C).
- D. severe midepigastric or left upper quadrant (LUQ) pain.
Correct Answer: D
Rationale: The correct answer is D because severe midepigastric or LUQ pain is a classic symptom of acute pancreatitis due to inflammation of the pancreas. This pain is usually persistent and can radiate to the back.
A: Hyperactive bowel sounds are not typically associated with acute pancreatitis but rather with conditions like gastroenteritis.
B: Hypertension and tachycardia are not specific to acute pancreatitis and can be seen in various medical conditions.
C: While fever can be present in acute pancreatitis, a specific temperature greater than 102°F is not a defining characteristic.
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In which part of the alimentary canal does most digestion occur?
- A. stomach
- B. proximal small intestine
- C. distal small intestine
- D. ascending colon
Correct Answer: B
Rationale: The correct answer is B: proximal small intestine. Most digestion occurs in the proximal small intestine because it is where the majority of enzymes are secreted to break down food. This section also has a large surface area for absorption of nutrients. The stomach primarily breaks down food with acids, while the distal small intestine and ascending colon focus on absorption of nutrients and water, respectively.
What problem should the nurse assess the patient for if the patient was on prolonged antibiotic therapy?
- A. Coagulation problems
- B. Impaired absorption of amino acids
- C. Elevated serum ammonia levels
- D. Increased mucus and bicarbonate secretion
Correct Answer: C
Rationale: The correct answer is C: Elevated serum ammonia levels. Prolonged antibiotic therapy can lead to disruption of normal gut flora, causing overgrowth of ammonia-producing bacteria. Elevated serum ammonia levels can indicate hepatic encephalopathy, a serious condition that requires immediate intervention. Coagulation problems (A) are more commonly associated with liver disease or vitamin deficiencies. Impaired absorption of amino acids (B) is typically seen in conditions like celiac disease or gastrointestinal disorders, not specifically related to prolonged antibiotic use. Increased mucus and bicarbonate secretion (D) are not directly related to prolonged antibiotic therapy, but rather to respiratory or gastrointestinal conditions.
After eating or drinking dairy products like cheese and milk, you have intestinal cramps, bloating and diarrhea. You most likely have
- A. lactose intolerance.
- B. diabetes mellitus, Type I.
- C. heartburn.
- D. peritonitis.
Correct Answer: A
Rationale: The correct answer is A: lactose intolerance. This is due to the inability to digest lactose, the sugar found in dairy products, leading to symptoms like intestinal cramps, bloating, and diarrhea. This is a common condition caused by a deficiency of lactase enzyme.
Choice B: Diabetes mellitus, Type I, is incorrect as it is an autoimmune condition affecting insulin production, not digestion of dairy products.
Choice C: Heartburn is incorrect as it is a symptom of acid reflux, not related to dairy product intolerance.
Choice D: Peritonitis is incorrect as it is an inflammation of the abdominal lining, usually caused by infection or injury, not related to dairy product intolerance.
What is the primary function of the large intestine?
- A. absorbing nutrients
- B. absorbing water and electrolytes
- C. digesting proteins
- D. secreting digestive enzymes
Correct Answer: B
Rationale: The primary function of the large intestine is to absorb water and electrolytes from the indigestible food residue passed from the small intestine. This absorption process helps in forming solid waste (feces) and maintaining body fluid balance. Absorbing nutrients (Option A) primarily occurs in the small intestine. Digesting proteins (Option C) mainly takes place in the stomach and small intestine. The secretion of digestive enzymes (Option D) also primarily occurs in the stomach and small intestine, not in the large intestine. Therefore, the correct answer is B.
The nurse is teaching a patient with diabetes about foot care. Which statement by the patient indicates that further teaching is needed?
- A. "I should wash my feet daily with warm water and mild soap."
- B. "I should inspect my feet daily for blisters, redness, or cuts."
- C. "I can use heating pads to warm my feet if they are cold."
- D. "I should trim my toenails straight across."
Correct Answer: C
Rationale: Correct Answer: C - "I can use heating pads to warm my feet if they are cold."
Rationale:
1. Using heating pads can cause burns or injuries due to reduced sensation in diabetic feet.
2. Patients with diabetes should avoid direct heat on their feet.
3. Optimal foot care for diabetics includes inspecting feet, washing with mild soap, and trimming nails correctly.
Summary:
A: Correct - Washing feet daily is recommended.
B: Correct - Inspecting feet daily is essential for early detection of issues.
C: Incorrect - Using heating pads can be harmful to diabetic feet.
D: Correct - Trimming toenails straight across is an appropriate practice.