A family brought their 3-week-old infant to the hospital by ambulance after having a seizure at home.

The baby received phenytoin in the ambulance and arrived at the hospital on 1 L/minute oxygen with a 22-gauge peripheral IV line in the left saphenous vein.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Choice A rationale

Monitoring capillary refill distal to the infusion site is a general nursing intervention during IV therapy. However, it is not specific to the administration of a vesicant chemotherapeutic agent.

Choice B rationale
Applying a topical anesthetic at the infusion site for burning is not a standard intervention during the administration of a vesicant chemotherapeutic agent. The burning sensation is not due to the IV site but due to the vesicant agent itself.

Choice C rationale
Assessing the IV site frequently for signs of extravasation is the most appropriate intervention during the administration of a vesicant chemotherapeutic agent. Extravasation, the leakage of the vesicant into the surrounding tissue, can cause severe local tissue damage. Early detection and intervention are crucial to minimize harm.

Choice D rationale
While it is important to explain potential side effects to the client, explaining that temporary burning at the IV site may occur is not the most crucial intervention. The priority is to monitor for and prevent extravasation.

The correct answer is Choice A

Choice A rationale: Crohn’s disease involves transmural inflammation of the gastrointestinal tract, often leading to hypermotility and increased peristalsis. Activity restriction reduces sympathetic stimulation, thereby minimizing intestinal motility and mechanical stress on inflamed mucosa. This helps prevent exacerbation of symptoms and promotes mucosal rest. By limiting physical exertion, the body can redirect energy toward immune modulation and tissue repair. Normal bowel motility varies, but excessive activity worsens inflammation and nutrient malabsorption in Crohn’s pathology.

Choice B rationale: While diarrhea is a common symptom in Crohn’s disease, activity restriction does not directly modulate stool frequency or water reabsorption. Diarrhea results from mucosal damage, cytokine-mediated secretion, and impaired absorption, not physical activity. Management typically involves anti-inflammatory agents, antidiarrheals, and dietary modifications. Restricting movement may indirectly reduce diarrhea by decreasing intestinal stimulation, but it is not the primary mechanism. Stool water content normally ranges from 60–85%, and inflammation disrupts this balance.

Choice C rationale: Healing in Crohn’s disease is multifactorial, involving immunosuppression, mucosal regeneration, and nutritional support. While rest contributes to systemic recovery, it is not the primary driver of mucosal healing. Healing requires suppression of TNF-alpha, IL-6, and other pro-inflammatory mediators. Activity restriction may support healing indirectly by reducing metabolic demand and stress hormone release, but pharmacologic and nutritional interventions are more central. Normal mucosal turnover occurs every 3–5 days, but inflammation delays this process.

Choice D rationale: Abdominal pain in Crohn’s disease arises from transmural inflammation, bowel distension, and neural sensitization. Although rest may reduce visceral stimulation, pain control is better achieved through anti-inflammatory therapy, bowel rest, and analgesics. Activity restriction does not directly modulate nociceptive pathways or cytokine levels. Pain perception involves complex neuroimmune interactions, and physical rest alone cannot address the underlying pathology. Normal visceral pain thresholds are altered in Crohn’s due to chronic inflammation and fibrosis.