Which of the following are NOT ways in which the brain can protect itself?

Correct Answer: C

Rationale: The correct answer is C because the formation of tripartite synapses with astrocytes and neurons does not provide direct protection to the brain. Tripartite synapses involve communication between neurons and astrocytes, primarily for synaptic regulation and plasticity. The blood-brain barrier (A) physically protects the brain by restricting the passage of harmful substances. Microglia (B) function as the brain's immune cells, defending against pathogens and removing cellular debris. Therefore, choices A and B contribute to the brain's protection, making them incorrect answers.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) The client reports severe RUQ tenderness. This symptom is indicative of a potential complication following a cholecystectomy, as it could suggest issues such as bile duct injury, bile leakage, or even a retained stone. Reporting severe RUQ tenderness immediately is crucial for timely intervention to prevent further complications. Option A) The client cannot void 4 hours post-operatively is not the most urgent concern in this case, as it could be related to anesthesia effects or fluid balance adjustments post-surgery, which can be monitored and managed over time. Option B) The client reports shoulder pain is a common post-operative symptom due to residual CO2 gas irritating the diaphragm, known as referred pain, and usually resolves spontaneously. It is not typically an immediate concern unless it is severe or persistent. Option D) Output does not equal input for the first few hours is a common occurrence post-operatively due to various factors such as fasting before surgery, fluid shifts, and anesthesia effects. It usually normalizes as the client's bowel function returns, and therefore does not require immediate reporting unless it persists. Educationally, understanding the post-operative complications specific to cholecystectomy is essential for nurses to provide safe and effective care. Recognizing the significance of symptoms like severe RUQ tenderness and knowing when to escalate concerns to the healthcare provider can help prevent adverse outcomes and promote optimal patient recovery.

Correct Answer: D

Rationale: In this scenario, option D, "Discouraging lying down immediately after eating," is the most essential aspect in the intervention plan for the older client who underwent esophageal surgery and experiences gastric distention. This is the correct answer because lying down immediately after eating can contribute to gastric distention by hindering proper digestion and causing stomach contents to reflux back into the esophagus, leading to discomfort and distention. Option A, "Supporting the surgical incision for coughing and deep breathing," though important for postoperative care, is not directly related to addressing gastric distention in this case. Option B, "Avoiding oral nourishment until bowel sounds resume and are active," may be important postoperatively but does not specifically address the issue of gastric distention. Option C, "Turning him to perform deep breathing and coughing every two hours," is important for preventing complications like pneumonia but does not directly address gastric distention. Educationally, it is crucial to understand the physiological impact of lying down immediately after eating on digestion and gastric distention post-esophageal surgery. By providing appropriate education and interventions, nurses can help patients optimize their recovery and manage postoperative complications effectively. Promoting proper positioning and postural habits can significantly improve the client's comfort and aid in their recovery process.

Correct Answer: C

Rationale: In cirrhosis of the liver, the correct physiological change is impaired ability to detoxify chemicals (Option C). This occurs because the liver, which is responsible for detoxifying harmful substances in the body, is damaged and unable to perform this function effectively. As a result, toxins can build up in the body, leading to various complications. Option A, the ability to metabolize hormones, is incorrect because cirrhosis primarily affects the liver's detoxification function, not its ability to metabolize hormones. Option B, absorption of fat-soluble vitamins, is incorrect as cirrhosis typically does not directly impact the absorption of fat-soluble vitamins. Option D, malabsorption of water-soluble vitamins, is also incorrect as cirrhosis primarily affects the liver's detoxification and metabolic functions rather than vitamin absorption. From an educational perspective, understanding the physiological changes in cirrhosis is crucial for healthcare professionals caring for patients with liver disease. It highlights the importance of monitoring and managing complications related to impaired liver function, such as toxin buildup. This knowledge can inform treatment decisions and help prevent further damage to the liver.

Correct Answer: C

Rationale: The correct answer is C) Observation of visible pulsations. When conducting a physical examination of the abdomen, visible pulsations are not a normal finding. This can indicate underlying pathology such as an abdominal aortic aneurysm or other vascular issues. It is important to recognize this abnormal finding as it may warrant further investigation and intervention. A) Auscultation of bruits is not a normal finding but rather suggests a vascular abnormality such as stenosis or aneurysm. It is important to investigate further if bruits are heard during auscultation. B) Percussion of liver dullness in the left midclavicular line is a normal finding indicating the lower border of the liver. This is not an abnormal finding on physical examination. D) Palpation of the spleen 1 to 2 cm below the left costal margin is also a normal finding as the spleen can be palpable in some individuals. However, it is important to note the size and consistency of the spleen as an enlarged spleen can indicate underlying pathology. In an educational context, understanding the normal and abnormal findings on physical examination of the abdomen is crucial for healthcare professionals. This knowledge helps in early detection of potential health issues and guides further diagnostic evaluation and treatment. It is important to emphasize the significance of thorough and accurate physical examination skills in assessing a patient's health status.