You walk into a room and find a patient forcefully expelling stomach contents into a wash basin. When documenting this occurrence, you will use the term:
Retching
Expectorate
Regurgitation
Vomiting
The Correct Answer is D
Choice A reason: Retching is the involuntary attempt to vomit, involving abdominal muscle contractions without expelling stomach contents. The patient is actively expelling contents, which defines vomiting, not just the effort of retching, making this an incorrect term for documentation.
Choice B reason: Expectorate refers to coughing up and spitting out mucus or sputum from the respiratory tract. The patient is expelling stomach contents, not respiratory secretions, making expectorate an incorrect term for this gastrointestinal event.
Choice C reason: Regurgitation is the passive return of undigested food or liquid from the stomach or esophagus, often without force. The forceful expulsion of stomach contents described indicates vomiting, not regurgitation, making this an incorrect documentation term.
Choice D reason: Vomiting is the forceful expulsion of stomach contents through the mouth, driven by coordinated abdominal and diaphragmatic contractions. The patient’s active expulsion into a basin matches this definition, making vomiting the correct term for documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Polycythemia involves an increased erythrocyte count, not a decrease. A low erythrocyte count causes anemia, leading to fatigue or hypoxia, not the neurological symptoms like headaches or dizziness seen in polycythemia, making this an incorrect cause.
Choice B reason: Tissue destruction by macrophages is not a primary feature of polycythemia. It may occur in inflammatory conditions, but polycythemia’s neurological symptoms stem from blood flow changes, not macrophage activity, making this an incorrect cause.
Choice C reason: Increased blood viscosity, due to elevated red blood cell mass in polycythemia, impairs cerebral blood flow, causing neurological symptoms like headaches, dizziness, and confusion. This sluggish circulation directly affects brain perfusion, making it the primary cause of these symptoms.
Choice D reason: Hypoxia occurs in conditions with inadequate oxygen delivery, like anemia or lung disease. Polycythemia increases oxygen-carrying capacity but causes symptoms due to viscous blood flow, not hypoxia, making this an incorrect primary cause.
Correct Answer is B
Explanation
Choice A reason: Weight loss occurs in both DKA and HHNS due to prolonged hyperglycemia and fluid loss. Kussmaul respirations are specific to DKA’s acidosis, so this is incorrect for DKA-only.
Choice B reason: Kussmaul respirations, rapid and deep breathing, are unique to DKA, compensating for metabolic acidosis from ketones. HHNS lacks significant acidosis, making this the correct DKA-specific manifestation.
Choice C reason: Increased serum glucose is common to both DKA and HHNS, as both involve severe hyperglycemia. Kussmaul respirations are DKA-specific, so this is incorrect.
Choice D reason: Fluid loss occurs in both DKA and HHNS due to osmotic diuresis. Kussmaul respirations are exclusive to DKA’s acidotic state, so this is incorrect.
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