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Health and Illness Concepts I Nursing: N1210 > Gastrointestinal System (Exam One) > Flashcards

Gastrointestinal System (Exam One) Flashcards

1
Q

Where does the absorption of nutrients and digestion take place?

A

Small intestine

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2
Q

Where does the absorption of water and minerals take place?

A

Large intestine

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3
Q

What does the oral cavity consist of?

A
  • Teeth
  • Tongue
  • Salivary glands
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4
Q

Where does digestion begin?

A

In the oral cavity

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5
Q

What is the tongue made of? What nerve does it contain?

A
  • Skeletal muscle

- Hypoglossal nerve

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6
Q

What is the first step in swallowing?

A

Elevation of the tongue

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7
Q

What are the only two digestive enzymes produced in the mouth?

A
  • Amylase

- Linguinal Lipase

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8
Q

Saliva is mostly made up of what?

A

Water

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9
Q

What are the three pairs of salivary glands?

A
  • Parotid
  • Submandibular
  • Sublingual
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10
Q

What is the purpose of the esophagus? How is this done?

A
  • Carries ingested items to the stomach

- Peristalsis propels food to the stomach

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11
Q

What is the purpose of the lower esophageal sphincter (LES)?

A
  • Allows food to enter the stomach

- Prevents backflow of food

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12
Q

The lower esophageal sphincter is also known as what?

A

Cardiac sphincter

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13
Q

List the parts of the stomach.

HINT: the CAR is FUN ‘til the BODY PILES

A
  • Cardia
  • Fundus
  • Body
  • Pylorus
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14
Q

What is the main purpose of the stomach?

A

To store food for digestion

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15
Q

Which cells secrete hydrochloric acid in the stomach?

A

Parietal cells

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16
Q

What does the hydrochloric acid do within the stomach?

A
  • Kills microorganisms
  • Breaks down food
  • Facilitates gastric enzyme activation
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17
Q

When is gastric juice release?

A

At the sight or smell of food

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18
Q

What are rugae?

A
  • Folds on internal surface of stomach
  • Provide extra surface area
  • Allows stomach to stretch
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19
Q

The stomach changes ingested food into what?

A

Chyme

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20
Q

What is the pyloric sphincter responsible for?

A

Regulates the rate of stomach emptying into the small intestine

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21
Q

What are the three portions of the small intestine?

A
  • Duodenum
  • Jejunum
  • Ileum
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22
Q

What ducts are in the duodenum?

A
  • Common bile duct

- Pancreatic duct

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23
Q

What is released by the pancreas release when chyme moves into the small intestine?

A

Bicarbonate

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24
Q

What does bicarbonate do?

A

Protects the small intestine from the acidity of gastric contents

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25
Q

What are villi? What are villi responsible for? Where are they located?

A
  • Small fingerlike projections
  • Located in the small intestine
  • Increase surface area and absorb nutrients
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26
Q

The large intestine is also known as what?

A

Colon

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27
Q

What is the purpose of the large intestine?

A

Forms and stores feces

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28
Q

What does the ileocecal valve do?

A

Prevents backup of fecal matter from the large intestine into the small intestine

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29
Q

What is the liver’s role in digestion?

A

Produces bile

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30
Q

What is bile made of?

A
  • Water

- Bile salts

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31
Q

Bile flows out of the liver through which ducts?

A

Left and right hepatic ducts

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32
Q

What ducts form the common hepatic duct?

A

Left and right hepatic ducts

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33
Q

Which duct is connected to the gallbladder?

A

Cystic duct

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34
Q

Which two ducts form the common bile duct?

A
  • Cystic duct

- Common hepatic duct

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35
Q

What do bile salts do?

A

Break down fats in the small intestine

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36
Q

Explain hepatic portal circulation and how the liver detoxifies blood.

A
  1. Liver receives oxygenated blood from the hepatic artery
  2. Liver receives blood (high in nutrients, low in oxygen) from the abdominal organs and spleen via the hepatic portal vein
  3. Liver filters out by-products from abdominal organs and spleen
  4. By-products are excreted into the bile or the blood
  5. Bile by-products enter the intestine and exit the body via the feces
  6. Blood by-products are filtered out by the kidneys and exit the body via the urine
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37
Q

All blood enters the liver via the what?

A

Hepatic artery

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38
Q

All blood exits the liver via the what?

A

Hepatic portal vein

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39
Q

List the functions of the liver.

A
  • Regulates the blood glucose level
  • Regulates blood levels of non-essential amino acids
  • Forms lipoproteins and cholesterol
  • Produces albumin, clotting factors, and globulins
  • Removes bacteria and foreign substances from the portal blood
  • Forms bilirubin
  • Storage for several vitamins and minerals
  • Detoxification of harmful substances
  • Coverts ammonia to urea
  • Provides the body with active Vitamin D
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40
Q

Which organ is responsible for storing and concentrating bile until it is needed for digestion?

A

Gallbladder

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41
Q

Which hormone secreted when fatty foods need to be digested?

A

Cholecystokinin hormone

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42
Q

What does the hormone cholecystokinin do?

A
  • Signals the gallbladder to contract

- Forces bile into the duodenum

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43
Q

What happens to the GI system of older adults?

A
  • Sense of taste decreases
  • Teeth loss causes difficulty chewing
  • Secretions of GI tract are decreased
  • Peristalsis may decrease causing constipation
  • Frequent indigestion
  • Risk of colon and oral cancer increase
  • Peridontal disease is more common
  • Diverticula may form
  • Hemorrhoids are more common
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44
Q

What is included in the physical exam for a patient with GI issues?

A
  • BMI
  • Dry, cracked lips
  • Foul breath
  • Color of gums
  • Ill fitting dentures
  • Abdomen inspection, auscultation and palpation
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45
Q

A BMI of 30 or higher is considered what?

A

Obese

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46
Q

A BMI of 40 or higher is considered what?

A

Morbidly obese

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47
Q

What will the nurse hear with normal bowel sounds?

A
  • Soft clicks

- Gurgles

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48
Q

What will the nurse hear with abnormal bowel sounds?

A

High-pitched tinkling sounds

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49
Q

What are hyperactive bowel sounds? What causes them?

A
  • Rapid or increased sounds
  • <5 seconds apart
  • Caused by hunger or gastroenteritis
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50
Q

What are absent bowel sounds? What causes them? The nurse knows they should do what if the patients bowel sounds are absent?

A
  • No sound at all for 5 minutes in each quadrant
  • May indicate bowel disease or obstruction
  • Can occur after anesthesia
  • Report to provider!
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51
Q

What are hypoactive bowel sounds? What causes them?

A
  • Infrequent sounds
  • > 15 seconds apart
  • Can occur after abdominal surgery
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52
Q

What is jaundice? What causes jaundice? If a patient is jaundice, what color will their urine and stool be?

A
  • Yellowing of skin and sclera
  • Caused by excess bilirubin
  • Urine will be dark colored
  • Stools may be gray in color
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53
Q

What labs should be assessed in a patient with suspected liver problems?

A
  • CBC
  • Bilirubin
  • Occult blood
  • ALT, AST, ALP
  • Albumin
  • Ammonia
  • Potassium
  • Amylase
  • Lipase
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54
Q

What is a normal bilirubin level?

A

< 1.0 mg/dL

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55
Q

What is the upper GI series (barium swallow) test?

A
  • X-ray of the esophagus, stomach, duodenum, and jejunum

- Patient drinks oral liquid contrast medium (barium) and x-rays are taken at timed intervals

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56
Q

What does the upper GI series detect?

A
  • Strictures
  • Ulcers
  • Tumors
  • Polyps
  • Hiatal hernias
  • Motility issues
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57
Q

What should the nurse monitor the patient for if they have had an upper GI series?

A
  • Ensure patients clears the barium
  • Constipation
  • Chalky white stools
  • Encourage plenty of foods
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58
Q

What education should the nurse provide to the patient before an upper GI series?

A
  • Patient must be NPO for six hours prior to procedure
  • No smoking prior to procedure
  • Encourage plenty of foods
  • Laxatives may be given
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59
Q

What is the a lower GI series (barium enema) test?

A
  • Colon is filled with barium

- X-rays are taken

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60
Q

What does the lower GI series detect?

A
  • Tumors
  • Diverticula
  • Stenosis
  • Obstructions
  • Inflammation
  • Ulcerative colitis
  • Polyps
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61
Q

What education should the nurse provide to the patient before a lower GI series?

A
  • Patient placed on low residue or clear liquid diet several days prior to the procedure
  • Clear liquids 24 hours prior
  • NPO 8 hours before the test
  • Laxatives will be given prior to clear the bowel
  • Encourage liquids
  • Failure to clear the bowel will result in cancellation of test
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62
Q

What patient education should be provided to a patient who has an esophagogastroduodenoscopy ?

A
  • NPO for 8 hours prior to test

- Patient may have a sore throat for a few days

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63
Q

What should the nurse assess and monitor with an esophagogastroduodenoscopy?

A
  • Dentures (think safety!)
  • Assess for gag reflex
  • NPO until gag reflex returns
  • Monitor for perforation
  • Monitor for pain, fever, abnormal vital signs, bleeding
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64
Q

What does the esophagogastroduodenoscopy assess?

A
  • Visualizes the esophagus, stomach, duodenum
  • Used to diagnose ulcers, cancer, bleeding
  • Can obtain specimens via a biopsy
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65
Q

What should the nurse monitor the patient for if they have had an ERCP?

A
  • Gag reflex
  • NPO until gag reflex returns
  • Vital signs
  • Signs of reaction to contrast
  • Assess for contrast dye allergy
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66
Q

What education must be provided for a patient undergoing a colonoscopy?

A
  • Clear liquid diet evening prior to procedure
  • Patient is NPO midnight prior to procedure
  • Bowel must be clear for successful procedure!!
  • Patient may experience gas and abdominal cramping afterwards
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67
Q

What should the nurse monitor for after a colonoscopy?

A

Rectal bleeding

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68
Q

When would a liver biopsy be needed?

A

When other diagnostic tests have not been successful in diagnosing a liver disease

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69
Q

What patient education should be provided prior to a liver biopsy?

A
  • Patient will be on bedrest after procedure
  • Avoid coughing and straining for 1 week
  • Avoid exercise for 1 week
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70
Q

What should the nurse monitor after a liver biopsy?

A
  • Vital signs

- Bleeding

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71
Q

When is gastrointestinal decompression necessary?

A

When the stomach or small intestine becomes filled with air of fluid

72
Q

What can be done to maintain the patency of an NG tube?

A

Irrigation

73
Q

What is enteral nutrition?

A

Provides the patient with hydration and nutrition when oral intake is not possible

74
Q

When is enteral nutrition most commonly used?

A

After GI surgery

75
Q

Do you need an order from a physician for enteral nutrition?

76
Q

How is gravity enteral feeding delivery?

A
  • Place feeding above the level of the stomach

- Feeding delivered by gravity

77
Q

What are intermediate enteral feedings?

A

Feeding administered throughout the day and stopped at night

78
Q

What is continuous enteral feeding?

A

Delivered 24 hours/day by a pump

79
Q

What should the nurse monitor when a patient has enteral feedings?

A
  • Feedings not being absorbed
  • Abdominal distention
  • Patient feels full
  • Nausea
  • Vomiting
80
Q

What should the nurse do if the patient presents with any signs and symptoms of the enteral feeding not being absorbed?

A
  • Stop the feeding

- Contact the provider

81
Q

What nursing management should be provided with enteral feedings?

A
  • HOB at 30-45 degrees
  • Use liquid medications when possible
  • Make sure medications are safe to crush
  • Use normal saline to irrigate
  • Always check placement by x-ray and pH of gastric aspirate
82
Q

How often should the nurse check the pH of gastric aspirate?

A

Every time a feeding is to be administered

83
Q

What is parenteral nutrition?

A

Method of supplying nutrients via an IV route

84
Q

When would parenteral nutrition be used?

A

Used for patients who cannot eat or absorb enough food through tube feeding formula or by mouth

85
Q

What should the nurse check if a patient is receiving parenteral nutrition?

A
  • Blood glucose

- May require insulin

86
Q

Parenteral nutrition has a high concentration of what?

87
Q

The feeling of nausea is _____ to each person.

A

Individualized

88
Q

What interventions may the patient require if they suffer from nausea and vomiting?

A
  • Provide odor free and clean environment
  • Give antiemetic medications
  • Provide oral care
  • Monitor I&Os
  • Daily weights
  • Provide oral or IV fluids
  • NG tube
  • Turn on side to prevent aspiration
89
Q

What should the nurse monitor regarding nausea and vomiting?

A
  • Vital signs
  • I&Os
  • Dehydration
  • Electrolytes
  • Characteristics of vomit
  • Monitor for signs of fluid overload
  • Coffee ground emesis
90
Q

What lab values may be elevated with nausea and vomiting?

A
  • Increased hematocrit
  • Increased sodium
  • Increased pH
  • Decreased potassium
91
Q

What are the causes of anorexia?

A
  • Medications
  • Treatments
  • Stress
  • Emotional problems
  • Infection
92
Q

What are the nursing interventions and considerations regarding anorexia?

A
  • Electrolyte imbalance
  • Accurate documentation of I&O
  • Patient has food available
  • Access to preferred foods
93
Q

Who is most at risk for anorexia nervosa?

A
  • Females 12 to 18 years of age

- Females who have low self esteem

94
Q

What is anorexia nervosa?

A

Eating disorder where patients have a phobia of gaining weight or are afraid to lose control

95
Q

What are the signs and symptoms of anorexia nervosa?

A
  • Poor nutritional health
  • Low BP and HR
  • Heart and kidney failure
  • Osteoporosis
  • Muscle loss
  • Vitamin/electrolyte imbalance
  • Diabetes
  • Constipation
  • Cardiac arrhythmias
96
Q

What is bulimia nervosa?

A
  • Compulsive eating disorder with self induced vomiting
  • Binging and purging
  • Laxatives and exercise used to avoid weight gain
97
Q

What are the signs and symptoms of bulimia nervosa?

A
  • Similar to s/sx of anorexia nervosa
  • Enamel erosion
  • Teeth staining
  • Patient spends large amounts of time in the bathroom
  • Hypokalemia
  • Hypocalcemia
98
Q

What is obesity?

A

Occurs when caloric intake exceeds energy expenditure

99
Q

Patients with obesity are at an increased risk for what?

A
  • Atherosclerosis
  • Gallbladder disease
  • Heart disease
  • Hypertension
  • Sleep apnea
  • Type 2 Diabetes
100
Q

What are the nursing interventions related to obesity?

A
  • Focus on education
  • Healthy diet
  • Exercise
  • Calorie restriction
  • Decrease stress
  • Change concepts about food
  • Join support group
101
Q

Most obese patients have _____ issues.

A

Psychosocial

102
Q

What are the different types of bariatric surgery?

A
  • Laparoscopic adjustable gastric banding
  • Sleeve gastronomy
  • Roux-en-Y
103
Q

What are the complications of bariatric surgery?

A
  • Vomiting due to overeating
  • Bloating
  • Heartburn
  • Staple disruption
  • Obstruction
  • Dumping syndrome
  • Protein, vitamin, mineral deficiencies
  • Compliance issues
  • Band slipping
  • Intestinal leakage
104
Q

What postoperative care should be provided for bariatric surgery patients?

A
  • NG tube
  • HOB elevation
  • Provide support to incision when coughing or sneezing
  • Started on clear liquid diet
  • Only small amounts of fluid at a time
105
Q

What education should be provided to patients who have undergone bariatric surgery?

A
  • Diet is very important
  • Should be able to tolerate regular food 6 weeks post surgery
  • Can not eat and drink at the same time
106
Q

How long should a patient weight to have skin removal surgery after bariatric surgery?

107
Q

Where is oral cancer usually found?

108
Q

What are the signs and symptoms of oral cancer?

A
  • Leukoplakia
  • Painless or tender ulcers
  • Oral sores that wont heal
  • Difficulty chewing, swallowing, or speaking
  • Swollen cervical lymph nodes
109
Q

What are the treatment options for patients with oral cancer?

A
  • Radiation
  • Chemotherapy
  • Surgery
  • Radical or modified neck dissection
110
Q

What is nursing care focused on for patients with oral cancer?

A
  • Nutritional needs
  • Airway management
  • Pain management
  • Education
  • Stridor
  • Avoid alcohol/tobacco use
111
Q

Esophageal cancer is associated with the use of what?

A

Alcohol or tobacco

112
Q

What is Barrett’s esophagus?

A

Precancerous condition associated with esophageal cancer

113
Q

What are the signs and symptoms of esophageal cancer?

A
  • Progressive dysphagia
  • Feeling of fullness
  • Pain in the chest after eating
114
Q

What are treatment options for esophageal cancer?

A
  • Radiation
  • Chemotherapy
  • Surgery (most common)
115
Q

When is esophageal cancer usually detected, late or early?

116
Q

What are the nursing interventions for a patient with esophageal cancer?

A
  • Assess pain and provide pain medication
  • Assess fluid intake
  • Assess swallowing
  • Daily weights
  • Provide fluids
  • Monitor IV nutrition and fluids
  • Monitor vital signs
  • Airway!!!
117
Q

What is a hiatal hernia?

A

Occurs when the stomach slides up through the hiatus of the diaphragm

118
Q

What are the risk factors associated with hiatal hernia?

A
  • Smokers
  • Obese patients
  • Pregnant patients
  • Lifting heavy objects
  • Straining with bowel movement
119
Q

Patients with a hiatal hernia also suffer from what?

120
Q

What are the signs and symptoms of hiatal hernia?

A
  • Pain
  • Heartburn
  • Feeling of fullness
  • Reflux
121
Q

What is the nursing management for patients with a hiatal hernia?

A
  • Lifestyle modifications

- Education patient on eating small meals, raise HOB, no reclining for one hour after meals

122
Q

What is GERD?

A

Occurs when gastric contents reflux into the esophagus

123
Q

What are the signs and symptoms of GERD?

A
  • Heartburn
  • Regurgitation
  • Dysphagia
  • Bleeding
124
Q

What diagnostic tests are used to diagnose GERD?

A
  • Barium swallow
  • Esophagoscopy
  • Esophagus pH
125
Q

What are the complications associated with GERD?

A
  • Esophagitis leading to Barretts esophagus
  • Respiratory complications
  • Asthma
  • Aspiration
  • Pneumonia
  • Bronchospasm
  • Laryngospasm
  • Chronic bronchitis
126
Q

What are the treatment options for GERD?

A
  • Lifestyle changes

- Avoid alcohol, chocolate, fatty foods, caffeinated soda

127
Q

What drugs fall under the class of H2 Receptor Antagonists?

A
  • Zantac
  • Pepcid
  • Tagamet
128
Q

How do H2 Receptor Antagonists work?

A

Compete with histamine for H2 receptors on the stomach’s parietal cells and depress production of hydrochloric acid

129
Q

What drugs fall under the class of Proton Pump Inhibitors?

A
  • Protonix
  • Nexium
  • Prilosec
130
Q

How do Proton Pump Inhibitors work?

A

Irreversibly block the final step of acid production

131
Q

What drugs fall under the class of Antacids?

A
  • Tums
  • Mylanta
  • Maalox
132
Q

How do Antacids work?

A

Neutralize stomach acid

133
Q

What is a common side effect of frequent antacid use?

A

Constipation

134
Q

Using Proton Pump Inhibitors long term can cause what?

135
Q

What is a mallory-weiss tear?

A

Longitudinal tear in the mucous membrane of the esophagus and stomach junction

136
Q

What can cause a mallory-weiss tear?

A
  • Sudden, powerful, prolonged force
  • Vomiting excessively
  • Seizures
  • Coughing
137
Q

What are the signs and symptoms of mallory-weiss tear?

A
  • Result from bleeding
  • Bright red, bloody emesis
  • Bloody tar like stools
138
Q

What should be avoided with mallory-weiss tears?

139
Q

What are esophageal varices? What causes them?

A
  • Dilated blood vessels in esophagus

- Caused by portal hypertension

140
Q

What happens if esophageal varices rupture?

A

Life-threatening, EMERGENCY!

141
Q

What is the priority nursing goal with esophageal varices?

A

Prevent them from bleeding

142
Q

What is gastritis?

A
  • Chronic inflammation of the mucosa of the stomach

- Can be acute, chronic, or stress induced

143
Q

What are signs and symptoms of gastritis?

A
  • Abdominal pain
  • Nausea
  • Anorexia
  • Feeling of fullness
  • Reflux
  • Belching
  • Hematemesis
144
Q

What are the therapeutic measures for gastritis?

A
  • Remove irritating substance
  • Bland diet
  • Eat small, frequent meals
145
Q

What is peptic ulcer disease?

A

Erosion of the lining of the stomach, pylorus, duodenum or esophagus

146
Q

Which portions of the GI tract are most at risk for peptic ulcer disease?

A

Those that are exposed to hydrochloric acid and pepsin

147
Q

Where do peptic ulcers occur most often?

148
Q

What is the main cause of peptic ulcer disease?

A

H. pylori bacteria

149
Q

How is H. pylori transmitted?

A
  • Oral-to-oral

- Oral-to-fecal

150
Q

Who is at an increased risk for peptic ulcer disease?

A
  • People who smoke

- People who frequently use NSAID’s

151
Q

What are signs and symptoms of peptic ulcer disease?

A
  • Different types of pain
  • Anorexia
  • Nausea/vomiting
  • Bleeding may occur (range from large hemorrhage to slow leak)
  • Occult blood
152
Q

What are some complications of peptic ulcer disease?

A
  • Bleeding
  • Perforation of stomach/duodenum wall
  • Obstruction
  • Perforated ulcer (emergency!)
153
Q

What is the treatment for H. pyloric?

A
  • Antibiotics

- Proton Pump Inhibitor

154
Q

Gastroduodenal contents spilling into the abdominal cavity resulting in inflammation is known as what?

A

Peritonitis

155
Q

Peritonitis can lead to what?

A
  • Septicemia

- Hypovolemic shock

156
Q

What nursing care should be provided for a patient with a perforated ulcer?

A
  • IV fluids
  • Insertion of NG tube
  • Monitor VS
  • Be prepared to give blood
  • Manage pain
  • Antibiotics
157
Q

What is the key treatment option for perforated ulcers?

A

Rapid, appropriate surgical intervention

158
Q

What is melena?

A

Black tarry stools containing digested blood

159
Q

What are the signs and symptoms of a severe GI bleed?

A
  • Hypotension
  • Tachycardia
  • Tachypnea
  • Chills
  • Palpitations
  • Weak, thready pulse
  • Hypovolemic shock
160
Q

What are the nursing therapeutic measures for gastric bleeding?

A
  • Patient NPO
  • IV fluids
  • HOB elevation
  • Oxygen therapy
  • Measure I&Os
  • Medications
  • Monitor changes in urine
  • Monitor LOC changes
  • Changes in color or mucous membranes
  • Skin turgor
161
Q

What is the most effective treatment of gastric cancer?

A
  • Surgery (most effective)
  • Chemotherapy
  • Radiation
162
Q

What portion of the stomach is removed in the Billroth I procedure? Where does it attach?

A
  • Distal portion of the stomach removed

- Stomach is attached to duodenum

163
Q

What portion of the stomach is removed in the Billroth II procedure? Where does it attach?

A
  • Greater portion of distal stomach is removed

- Stomach is attached to jejunum

164
Q

What is a total gastrectomy?

A
  • Total removal of the stomach

- Esophagus and jejunum are attached

165
Q

What are the nursing interventions for postoperative gastric surgery?

A
  • Pain management
  • Assessment of incision
  • Monitor vital signs
  • Maintain NG tube
166
Q

What is a complication of gastric surgery?

A
  • Hemorrhage
  • Gastric dumping
  • Life-time supplements
  • Pyloric obstruction
  • Pernicious anemia
  • Steatorrhea
167
Q

What are the symptoms of hemorrhage?

A
  • Restlessness
  • Cold skin
  • Increased pulse
  • Decreased temperature
  • Decreased blood pressure
  • LOC changes
168
Q

What is gastric dumping?

A
  • Food enters jejunum rapidly and mixes with digestive juices improperly
  • Causes fluids to become imbalanced
169
Q

What are the symptoms of gastric dumping?

A
  • Dizziness
  • Tachycardia
  • Fainting
  • Sweating
  • Nausea
  • Diarrhea
  • Abdominal cramping
170
Q

What are the treatment options for gastric dumping? What patient education should be provided?

A
  • Eat small frequent meals
  • High protein, low fat, low sugar, low carb diet
  • Do not drink fluids with meals
  • Limit fluids to one hour prior to meals and two hours after a meal
171
Q

What is pyloric obstruction?

A

Develops as a result of scar tissue or edema

172
Q

Pernicious anemia causes a deficiency of which vitamin?

A

Vitamin B12

173
Q

What will a patient with pernicious anemia require?

A

Lifelong Vitamin B12 injections

174
Q

What is steatorrhea?

A

Presence of fat in stools

175
Q

What are the characteristics of stool with steatorrhea?

A
  • Foul smelling
  • Oily
  • Float
176
Q

Should the esophagus be alkaline or acidic?

Health and Illness Concepts I Nursing: N1210 (12 decks)

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