A patient with cholelithiasis asks the nurse why he/she is jaundiced. What is the nurse's best answer?
“Your liver cannot manufacture bile."
"Your pancreas is no longer able to manufacture insulin."
"Your gall bladder is not contracting properly."
"A gallstone can prevent bile from flowing into the Intestines."
The Correct Answer is D
A. "Your liver cannot manufacture bile": The liver can still manufacture bile, but the problem lies in bile flow, not production.
B. "Your pancreas is no longer able to manufacture insulin": This statement refers to diabetes, not cholelithiasis.
C. "Your gall bladder is not contracting properly": While gallbladder dysfunction can cause pain, jaundice specifically occurs due to bile flow obstruction, not just poor contraction.
D. "A gallstone can prevent bile from flowing into the intestines": Gallstones can obstruct the bile ducts, leading to a buildup of bilirubin in the blood, which manifests as jaundice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notify the health care provider: While it may eventually be necessary to notify the healthcare provider, the immediate action should involve confirming the balloon pressure, which is within the scope of respiratory therapy.
B. Call respiratory therapy to obtain the pressure within the balloon: This is the most appropriate action. Respiratory therapists are skilled in managing and measuring the cuff pressure to ensure it is within the correct range (typically 20-30 cm H2O).
C. Add air to the balloon port: Adding air without knowing the current pressure could lead to over inflation, which might cause tracheal injury.
D. Remove air from the balloon port: Similarly, removing air could lead to underinflation, increasing the risk of aspiration or inadequate ventilation.
Correct Answer is D
Explanation
A. Grey-Turner Sign: Grey-Turner Sign refers to bruising along the flanks, often associated with retroperitoneal hemorrhage or acute pancreatitis.
B. Steatorrhea: Steatorrhea refers to fatty stools that are pale, bulky, and foul-smelling, indicating malabsorption, not a physical exam finding on the skin.
C. Asterixis: Asterixis, also known as "liver flap," is a tremor of the hand when the wrist is extended, seen in hepatic encephalopathy, not a skin finding.
D. Cullen's Sign: Cullen's Sign is bruising around the umbilicus, indicating intra-abdominal bleeding, often seen in conditions such as acute pancreatitis or ruptured ectopic pregnancy.
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