The patient experienced a blood transfusion reaction. How should the nurse explain to the patient the cause of the hemolytic jaundice that occurred?

Correct Answer: D

Rationale: The correct answer is D. Hemolytic jaundice in a blood transfusion reaction is due to increased breakdown of red blood cells (RBCs) causing elevated serum unconjugated bilirubin. This occurs when the patient's immune system reacts to the transfused blood, leading to destruction of RBCs. The breakdown of these cells releases hemoglobin, which is metabolized into bilirubin. This unconjugated bilirubin then accumulates in the blood, causing jaundice. Choice A is incorrect because hepatocellular disease does not directly cause hemolytic jaundice. Choice B is incorrect as malaria parasite breaking apart RBCs leads to hemolysis, not a blood transfusion reaction. Choice C is incorrect as decreased bile flow through the liver or biliary system typically causes obstructive jaundice, not hemolytic jaundice.

Correct Answer: A

Rationale: The correct answer is A: NPO with NG suction. This treatment prevents further stimulation of the gallbladder by resting the digestive system and reducing the secretion of bile. NPO stands for "nothing by mouth," which reduces gallbladder contractions. NG suction removes stomach contents, preventing bile from reaching the gallbladder. Incisional cholecystectomy is a surgical removal of the gallbladder and not a preventive measure. Antiemetics help control nausea and vomiting but do not directly prevent gallbladder stimulation. Anticholinergics inhibit the parasympathetic nervous system but are not typically used to prevent gallbladder stimulation.

Correct Answer: C

Rationale: The correct answer is C because constant stress triggers the release of excess digestive juices, leading to increased acid production and potentially causing a gastric ulcer. Stress activates the sympathetic nervous system, which in turn stimulates the release of stress hormones that can disrupt the balance of digestive juices. Slowed GI mobility (choice A) typically causes constipation, not directly related to stress. Reversed peristalsis (choice B) leading to projectile vomiting is more commonly associated with conditions such as food poisoning or intestinal blockages. Decreased digestive juices (choice D) would likely result in poor digestion and nutrient absorption, but it is not a common consequence of stress-induced alterations to the GI system.

Correct Answer: D

Rationale: In the mouth, ingestion occurs when food is taken in. Mechanical digestion occurs through chewing and mixing food with saliva. Chemical digestion begins with enzymes in saliva breaking down carbohydrates. Therefore, all processes (ingestion, mechanical digestion, and chemical digestion) occur in the mouth. Other choices are incorrect because they do not encompass all the processes that happen in the mouth.

Correct Answer: D

Rationale: The correct answer is D. Walking barefoot increases the risk of slipping and falling, especially for older adults with balance issues. Wearing shoes indoors provides stability and reduces the risk of falls. Choices A, B, and C all demonstrate good fall prevention strategies by addressing vision, home safety, and orthostatic hypotension respectively.