A nurse is attending to a client who has just been admitted due to an acute exacerbation of ulcerative colitis. What should be the nurse’s initial course of action?
Investigate the client’s emotional concerns.
Check the client’s perianal skin integrity.
Obtain a dietary history from the client.
Review the client’s electrolyte values.
The Correct Answer is B
Choice A rationale
While emotional concerns are important to address in a holistic care approach, they are not the initial course of action when a client is admitted due to an acute exacerbation of ulcerative colitis. Emotional concerns are usually addressed once the client’s physical condition is stabilized.
Choice B rationale
Checking the client’s perianal skin integrity is a crucial initial step when a client is admitted due to an acute exacerbation of ulcerative colitis. Ulcerative colitis can cause rectal bleeding and diarrhea, which can lead to skin breakdown in the perianal area. Therefore, assessing for skin integrity helps in early detection and management of potential skin complications.
Choice C rationale
Obtaining a dietary history from the client is important but not the initial course of action in this scenario. Dietary history is usually obtained once the client’s condition is stabilized and when planning for discharge or dietary modifications.
Choice D rationale
Reviewing the client’s electrolyte values is important in managing ulcerative colitis, but it’s not the initial course of action. Electrolyte imbalances can occur due to diarrhea and
malabsorption, which are common in ulcerative colitis. However, this is usually done after initial physical assessments and stabilization of the client.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While heart failure can lead to fluid volume imbalances, a BNP level of 600 pg/mL alone does not indicate a risk for fluid volume deficit.
Choice B rationale
Being NPO since midnight for an endoscopy could potentially lead to fluid volume deficit, but it’s not the most likely choice. Typically, patients are adequately hydrated before and after the procedure.
Choice C rationale
A patient with gastroenteritis and a fever is at high risk for fluid volume deficit. Gastroenteritis can cause significant fluid loss through vomiting and diarrhea, and fever increases insensible water loss.
Choice D rationale
While patients with end-stage renal failure can have fluid volume imbalances, they are more likely to experience fluid volume excess, especially if they are due for dialysis.
Correct Answer is A
Explanation
Choice A rationale
Whole grains are a good source of energy and fiber, which can help regulate bowel movements and maintain a healthy weight. They also contain important nutrients like B vitamins, iron, folate, selenium, potassium, and magnesium, which are beneficial for overall health.
Choice B rationale
While poached eggs are a good source of protein, they do not have a specific benefit for hypothyroidism. It’s important for individuals with hypothyroidism to consume a balanced diet that includes a variety of foods.
Choice C rationale
Baked chicken is a good source of lean protein, but it does not have a specific benefit for hypothyroidism. It’s important for individuals with hypothyroidism to consume a balanced diet that includes a variety of foods.
Choice D rationale
Fresh fruits are a good source of vitamins, minerals, and fiber. They are part of a healthy diet but do not have a specific benefit for hypothyroidism. It’s important for individuals with hypothyroidism to consume a balanced diet that includes a variety of foods.
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