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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

a) Denies cramps, weakness, or nausea

This finding indicates that the actions taken were effective in relieving the patient's symptoms of fatigue, weakness, muscle cramps, and nausea. These symptoms may have been caused by electrolyte imbalances, dehydration, or infection related to her ESRD and missed dialysis sessions.

b) BP 116/68 mm Hg, HR 75 bpm

This finding indicates that the actions taken were effective in lowering the patient's blood pressure and heart rate. The patient had a history of HTN and CAD and presented with elevated BP and HR in the ED. The orders for EKG, cardiac monitor, chest X-ray, and echocardiogram may have helped to assess and manage her cardiac status. The patient may have also received antihypertensive medications or fluids as part of her treatment.

c) Potassium level 3.6 mEq/L (3.6 mmol/L)

This finding indicates that the actions taken were effective in normalizing the patient's potassium level. The patient had ESRD and missed dialysis sessions, which could have resulted in hyperkalemia or hypokalemia. The orders for basic metabolic panel and blood cultures may have helped to monitor and correct her electrolyte levels. The patient may have also received potassium supplements or binders as part of her treatment.

d) Verbalizes commitment to dialysis appointments

This finding indicates that the actions taken were effective in educating and motivating the patient to adhere to her dialysis schedule. The patient had ESRD and missed dialysis sessions, which could have worsened her condition and increased her risk of complications. The orders for CT scan of abdomen and echocardiogram may have helped to evaluate her renal function and cardiac function. The patient may have also received counseling or support from the health care team as part of her treatment.

e) Client states that she will need to resume her Lisinopril to control blood pressure

This finding indicates that the actions taken were ineffective in teaching the patient about her medication regimen. The patient had a history of HTN and CAD and was prescribed Lisinopril as an antihypertensive medication. However, Lisinopril is contraindicated in patients with ESRD as it can cause hyperkalemia or worsen renal function. The patient should be informed about the potential risks of taking Lisinopril and advised to consult with her nephrologist or primary care provider before resuming it.

f) Client is eager to add dark green vegetables and potatoes to her diet

This finding indicates that the actions taken were ineffective in educating the patient about her dietary restrictions. The patient had ESRD and required hemodialysis three times a week. She should follow a renal diet that limits the intake of potassium, phosphorus, sodium, and fluid. Dark green vegetables and potatoes are high in potassium and phosphorus and should be avoided or consumed in moderation by patients with ESRD. The patient should be provided with a list of foods that are suitable for her condition and referred to a dietitian for further guidance.

A. The humoral immune response lacks B cells that form antibodies and opportunistic infections result. B. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages. C. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms. D. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.

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.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits For each assessment finding, explain whether the actions taken were effective or ineffective.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

Correct Answer is B

Explanation

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

Exhibits The nurse is reviewing the physician orders. Which of the following physician’s orders requires priority attention from the nurse? Select all that apply.

After initiating a steroid nebulizer treatment for a client with asthma in respiratory distress, which intervention is most important for the nurse to implement?

The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which finding(s) should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply.)

A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?

The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

An older adult client with symptoms of osteoarthritis asks the nurse which form of exercise would be most beneficial. Which is the best response by the nurse?