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 A
Explanation
Choice A rationale
Gastroesophageal reflux disease (GERD) is a condition where stomach acid frequently flows back into the esophagus, causing discomfort. Certain lifestyle habits and diet can trigger or worsen GERD symptoms. Alcohol and caffeine are among the substances that can aggravate
GERD123. They can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus. Therefore, reducing or avoiding alcohol and caffeine can help manage GERD symptoms.
Choice B rationale
Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can cause or worsen GERD symptoms. It can irritate the esophagus and stomach lining, leading to heartburn and other GERD symptoms. Therefore, it’s not advisable to take aspirin if you have GERD12.
Choice C rationale
While it’s important to avoid mercury-containing foods due to their potential health risks, there’s no specific link between these foods and GERD12. GERD is primarily triggered by foods that relax the lower esophageal sphincter, cause stomach distension, or irritate the esophagus. Mercury-containing foods do not fall into these categories.
Choice D rationale
Lying down after eating can indeed increase the onset of GERD123. When you lie down, it’s easier for stomach acid to backflow into the esophagus. This is why it’s recommended to wait at least 2-3 hours after eating before lying down.
Correct Answer is A
Explanation
Choice A rationale
Anemia due to excessive blood loss during surgery can lead to a variety of symptoms. One of the most common symptoms is fatigue. This is because anemia results in a decrease in the amount of oxygen that can be delivered to the body’s tissues, leading to a lack of energy and feelings of exhaustion. Therefore, a nurse should expect to find fatigue in a postoperative client who has anemia due to excessive blood loss during surgery.
Choice B rationale
Bradycardia, or a slower than normal heart rate, is not typically associated with anemia. Instead, anemia can actually lead to tachycardia, or a faster than normal heart rate, as the body tries to compensate for the decreased oxygen carrying capacity of the blood.
Choice C rationale
Hypertension, or high blood pressure, is not a typical finding in patients with anemia. In fact, in severe cases, anemia can lead to hypotension, or low blood pressure, due to a decrease in the blood’s ability to carry oxygen.
Choice D rationale
Diarrhea is not a common symptom of anemia. Anemia due to excessive blood loss during surgery is more likely to result in symptoms related to a lack of oxygen in the body’s tissues, such as fatigue, weakness, and shortness of breath.
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