Which patient has the highest risk for poor nutritional balance related to decreased ingestion?

Correct Answer: D

Rationale: The correct answer is D: Severe anorexia resulting from radiation therapy. This patient has the highest risk for poor nutritional balance due to the severe anorexia caused by the treatment. Radiation therapy often leads to loss of appetite, making it difficult for the patient to ingest adequate nutrients, resulting in malnutrition. A: Tuberculosis infection does not necessarily directly cause decreased ingestion, as appetite may vary among patients. B: Draining decubitus ulcers may lead to protein and fluid loss but not necessarily decreased ingestion. C: Malabsorption syndrome affects the absorption of nutrients but does not directly relate to decreased ingestion.

Correct Answer: D

Rationale: The correct answer is D because corticosteroids inhibit the synthesis of mucus and prostaglandins, which are important for protecting the stomach lining. Without enough mucus and prostaglandins, the stomach lining becomes more susceptible to damage from stomach acid, leading to the development of peptic ulcers. Choice A is incorrect because the enzyme urease is associated with the development of Helicobacter pylori infection, not peptic ulcers directly. Choice B is incorrect because corticosteroids actually decrease hydrochloric acid secretion. Choice C is incorrect because a decreased rate of mucous cell renewal would lead to decreased mucus production, which could contribute to peptic ulcers, but it is not the primary mechanism associated with corticosteroids.

Correct Answer: C

Rationale: The correct answer is C: Check the amount and character of gastric drainage and the patency of the NG tube. This is the priority nursing intervention because the patient is experiencing nausea and vomiting, which could indicate potential complications related to the NG tube, such as blockage or displacement. By checking the gastric drainage and NG tube patency, the nurse can assess if the patient's symptoms are related to these issues and take appropriate actions to address them. Choice A is incorrect because assessing the abdomen for distention and bowel sounds is important but not the priority in this situation where the patient is experiencing nausea and vomiting. Choice B is incorrect as inspecting the surgical site and drainage in the Jackson-Pratt drain is also important but not as urgent as checking the NG tube patency in this case. Choice D is incorrect as administering medication should not be the first action taken without first assessing the underlying cause of the symptoms.

Correct Answer: C

Rationale: The correct answer is C because 8 hours post colostomy surgery, a purplish stoma that is shiny and moist with mucus indicates adequate blood supply and tissue perfusion, which are signs of a healthy stoma. A is incorrect as hyperactive, high-pitched bowel sounds are not expected immediately post-surgery. B is incorrect as a brick-red, puffy stoma oozing blood could indicate poor perfusion. D is incorrect as liquid fecal drainage is not expected immediately post-surgery; it usually starts a few days later.

Correct Answer: D

Rationale: The correct answer is D: Anti-HAV IgM. IgM antibodies indicate acute infection as they are the first antibodies produced in response to a new infection. In the case of HAV, the presence of Anti-HAV IgM suggests recent exposure to the virus. A: Anti-HBc IgG is not relevant to HAV infection. It indicates past or chronic hepatitis B infection. B: Anti-HBc IgM is specific to hepatitis B infection, not HAV. C: Anti-HAV IgG indicates past exposure or immunity to HAV, not acute infection.