A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take?
Measure capillary glucose level.
Encourage ambulation in the room.
Monitor for bloody diarrheal stools.
Obtain vital sign measurements.
The Correct Answer is D
Choice A reason: Measuring capillary glucose level is not a priority action for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Corticosteroids can increase blood glucose levels, but this is not an urgent concern in this situation.
Choice B reason: Encouraging ambulation in the room is not appropriate for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Ambulation can worsen the pain and inflammation, and increase the risk of bowel perforation.
Choice C reason: Monitoring for bloody diarrheal stools is important for a client with IBD, but not a priority action for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Bloody stools can be a sign of ulceration or bleeding in the bowel, but they are not specific to peritonitis.
Choice D reason: Obtaining vital sign measurements is the priority action for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Vital signs can reveal signs of infection, inflammation, shock, and organ failure, which can guide the appropriate interventions and treatments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is incorrect because performing a complete mental status exam is not a relevant or appropriate action for the nurse to implement. A mental status exam is used to evaluate the client's cognitive, emotional, and behavioral functioning, but it does not address the client's physical pain or its underlying cause.
Choice B reason: This is incorrect because determining if the client has had a shingles vaccination is not a priority or helpful action for the nurse to implement. A shingles vaccination is recommended for people who are 50 years or older to prevent or reduce the severity of shingles, but it does not affect the occurrence or treatment of postherpetic neuralgia, which is a chronic pain condition that can develop after shingles.
Choice C reason: This is incorrect because teaching the client about phantom pain symptoms is not an accurate or useful action for the nurse to implement. Phantom pain is a type of neuropathic pain that occurs when a person feels pain in a body part that has been amputated or removed. However, this is not the case for the client who has pain in the area where the shingles rash occurred.
Choice D reason: This is correct because completing an assessment of the client's pain is the most important action for the nurse to implement. Pain assessment involves collecting information about the location, intensity, quality, duration, frequency, and aggravating or relieving factors of the pain, as well as its impact on the client's daily activities and quality of life. This can help the nurse identify the cause and severity of the pain, as well as plan and evaluate appropriate interventions.
Correct Answer is B
Explanation
Choice A reason: The humoral immune response is mediated by B cells that produce antibodies against specific antigens. However, this response is not the main problem in AIDS, because B cells are not directly affected by the human immunodeficiency virus (HIV) that causes AIDS. Therefore, this choice is incorrect.
Choice B reason: The cellular immune response is mediated by T lymphocytes that activate other immune cells, such as macrophages, to destroy infected or abnormal cells. This response is the main problem in AIDS, because HIV infects and destroys CD4+ T cells, which are essential for coordinating the cellular immunity. As a result, the client becomes susceptible to opportunistic infections, such as Pneumocystis jiroveci pneumonia. Therefore, this choice is correct.
Choice C reason: Bone marrow suppression of white blood cells can cause immunodeficiency, but it is not the primary cause of AIDS. Bone marrow suppression can occur as a side effect of some drugs or treatments, such as chemotherapy or radiation therapy, but it is not directly caused by HIV. Therefore, this choice is incorrect.
Choice D reason: Exposure to multiple environmental infectious agents can challenge the immune system, but it does not necessarily cause it to fail. The immune system can adapt and respond to different pathogens, unless it is compromised by an underlying condition, such as AIDS. Therefore, this choice is incorrect.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today