A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning

Correct Answer: D

Rationale: The correct answer is D: Breath sounds. In an unconscious stroke patient, airway patency and adequate oxygenation are critical. Assessing breath sounds more frequently than routine helps monitor for respiratory distress, such as aspiration or pneumonia. Apical pulse (B) may be important but not as immediately life-threatening as respiratory status. Bowel sounds (C) may indicate bowel function but are not as urgent as assessing breathing. By prioritizing breath sounds, the nurse can ensure timely intervention in case of respiratory compromise.

Correct Answer: A

Rationale: The correct answer is A: diaphragm. The diaphragm is a dome-shaped muscle that separates the thoracic and abdominal cavities. A hiatal hernia occurs when the stomach pushes through the opening in the diaphragm known as the esophageal hiatus, allowing a portion of the stomach to enter the thoracic cavity. The other choices, B: stomach, C: intestinal, and D: thoracic wall, are incorrect because a hiatal hernia specifically involves a weakness in the diaphragm muscle, not in these other structures. The stomach is the organ affected by the hernia, but the primary issue lies in the diaphragm's weakness. The intestinal and thoracic wall choices are not directly related to the development of a hiatal hernia.

Correct Answer: D

Rationale: The correct answer is D: erythropoiesis. The liver does not have a primary role in the production of red blood cells (erythropoiesis), which is mainly carried out by the bone marrow. A: The liver stores glycogen for energy regulation. B: Detoxification is a crucial function of the liver, breaking down harmful substances. C: The liver synthesizes clotting proteins like fibrinogen. In summary, while the liver is vital for glycogen storage, detoxification, and clotting protein synthesis, it does not play a significant role in erythropoiesis.

Correct Answer: C

Rationale: The correct answer is C: duodenum. The duodenum is the first part of the small intestine where digestion of double sugars, like disaccharides, occurs. Enzymes such as sucrase, lactase, and maltase are secreted in the duodenum to break down double sugars into simple sugars for absorption. The other choices are incorrect because the stomach primarily digests proteins, the jejunum is mainly involved in nutrient absorption, and the pancreas secretes enzymes into the duodenum but does not directly digest double sugars.

Correct Answer: A

Rationale: The correct answer is A because infants' gastric juice contains nuclease, pepsinogen, and lipase. Nuclease helps in breaking down nucleic acids, pepsinogen is the precursor of pepsin which digests proteins, and lipase digests fats. This combination of enzymes is essential for the digestion of various macromolecules in infants. Choice B is incorrect because maltase is an enzyme that breaks down maltose (a sugar), which is not typically found in gastric juice. Rennin is an enzyme that helps in digesting milk protein, which is more common in the stomach of newborn mammals, but not in human infants. Choice C is incorrect because amylase is an enzyme that breaks down carbohydrates and is usually found in saliva, not gastric juice. Rennin and pepsinogen are not typically present in infants' gastric juice. Choice D is incorrect because while pepsinogen and rennin are enzymes found in gastric juice, lip