A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), what should the nurse plan to assess more frequently than is routine?

Correct Answer: C

Rationale: The correct answer is C: Breath sounds. Given the patient's history of GERD, there is an increased risk of aspiration pneumonia due to the reflux of gastric contents into the lungs. Therefore, assessing breath sounds more frequently is crucial to monitor for signs of respiratory distress or pneumonia. A: Apical pulse is important but not directly related to the patient's history of GERD. B: Bowel sounds are relevant for assessing GI function but not specifically impacted by GERD. D: Abdominal girth is more related to abdominal distension or organ enlargement rather than GERD complications.

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

Correct Answer: D

Rationale: The correct answer is D, Hematemesis. This is the priority finding because it indicates upper gastrointestinal bleeding, which can be life-threatening. The nurse should address this immediately to prevent further complications. Epigastric discomfort (A) and dyspepsia (B) are common symptoms of peptic ulcer disease but do not indicate active bleeding. Constipation (C) is not directly related to peptic ulcer disease and does not pose an immediate threat to the client's health.