Nokea
Which of the following structures is responsible for absorbing water and electrolytes from undigested food residue, forming feces?
- A. Liver
- B. Stomach
- C. Pancreas
- D. Large intestine
Correct Answer: D
Rationale: The large intestine, also known as the colon, is responsible for absorbing water and electrolytes from undigested food residue that passes through the digestive system after it has been processed in the small intestine. As the waste material moves through the colon, water is absorbed, and the remaining material forms feces. The feces are then stored until they are eliminated from the body through the rectum and anus. The liver, stomach, and pancreas play important roles in digestion and nutrient absorption, but the specific function of absorbing water and forming feces is carried out by the large intestine.
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Upon data collection he had been failing three times in his math class and Korino was known for substance dependent for three years. What is the MOST APPROPRIATE nursing diagnosis for him?
- A. Alteration in perception.
- B. Ineffective individual coping.
- C. Alteration in social interaction.
- D. Impaired judgment.
Correct Answer: B
Rationale: The most appropriate nursing diagnosis for the individual described is "Ineffective individual coping." This is because the individual has been facing challenges in both academic (failing math class) and personal (substance dependence) aspects of his life. The repeated failures in his math class and the substance dependence for three years indicate that he might be struggling to cope with stressors and challenges in his life effectively. By identifying this nursing diagnosis, the nurse can focus on helping the individual develop effective coping strategies to manage and overcome these difficulties.
A postpartum client reports severe perineal pain and difficulty passing stools following a vaginal delivery. Which nursing intervention should be implemented?
- A. Administering a stool softener as ordered
- B. Encouraging the client to refrain from defecation until pain subsides
- C. Applying ice packs to the perineum for pain relief
- D. Providing education on proper perineal hygiene
Correct Answer: A
Rationale: Administering a stool softener as ordered is the most appropriate nursing intervention for a postpartum client experiencing severe perineal pain and difficulty passing stools following a vaginal delivery. Stool softeners help to soften the stool, making it easier for the client to pass without straining, which can exacerbate perineal pain. It is important to follow the healthcare provider's orders when administering medications to ensure proper dosing and effectiveness. Encouraging the client to refrain from defecation may lead to constipation and worsen the situation. Applying ice packs to the perineum can provide temporary pain relief, but addressing the underlying issue of constipation with a stool softener is more effective in the long term. Providing education on proper perineal hygiene is important for overall postpartum care, but addressing the immediate issue of constipation with a stool softener takes precedence in this scenario.
A patient presents with fever, headache, myalgia, and a skin lesion resembling a "bull's eye" rash at the site of a tick bite. Which of the following is the most likely causative agent?
- A. Plasmodium falciparum
- B. Trypanosoma cruzi
- C. Borrelia burgdorferi
- D. Leishmania donovani
Correct Answer: C
Rationale: The presentation described in the question, including the skin lesion resembling a "bull's eye" rash at the site of a tick bite, is characteristic of Lyme disease. Lyme disease is caused by the spirochete bacterium Borrelia burgdorferi, which is transmitted to humans through the bite of infected black-legged ticks (Ixodes scapularis). The symptoms of Lyme disease include fever, headache, myalgia, and the erythema migrans rash, which appears as a red circular rash with central clearing resembling a bull's eye.
For this patient who is to undergo surgery (closure of the sac), what would be the PRIORITY nursing diagnosis? It is risk for __________.
- A. Activity intolerance
- B. Infection
- C. Respiration
- D. Altered growth and development
Correct Answer: B
Rationale: The priority nursing diagnosis for a patient undergoing surgery (closure of the sac) would be risk for infection. This is because surgical procedures increase the risk of infection due to the breach in the skin and introduction of microorganisms. Infection can lead to serious complications, delay healing, and prolong recovery time. Therefore, prevention, early detection, and prompt treatment of infections are essential in the perioperative period to ensure the best possible outcomes for the patient.
Which of the following gives cues to the nurse that the patient may be grieving for loss?
- A. Thoughts, feelings , behavior, and physiologic complaints
- B. Hallucination, panic 1evel of anxiety, sense of impending doom
- C. Sad affect, anger anxiety, and sudden change of mood
- D. Complaints of abdominal pain, diarrhea, loss of appetite
Correct Answer: A
Rationale: A grieving individual may show a range of cues across different aspects of their life. Thoughts may include constant preoccupation with the loss, difficulties in concentrating, or intrusive thoughts. Feelings may involve sadness, anger, guilt, confusion, or relief. Behavioral cues may include changes in sleep patterns, appetite, energy levels, social withdrawal, or the use of substances. Physiologic complaints can manifest as headaches, stomach issues, fatigue, or other physical symptoms. Therefore, when a nurse observes cues related to thoughts, feelings, behavior, and physiologic complaints in a patient, it can suggest that the patient is grieving for a loss.