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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Hepatitis A is a highly contagious virus that spreads through person-to-person contact or consuming contaminated food or drink. The virus can contaminate food during growing, harvesting, processing, handling, and even after cooking. Therefore, avoiding serving raw foods can help prevent the spread of the virus.
Choice B rationale
Hepatitis A is not typically spread through sexual intercourse. It is primarily spread through the fecal-oral route, either by person-to-person contact or consumption of contaminated food or water. Therefore, wearing barrier protection during vaginal intercourse is not a primary prevention strategy for Hepatitis A.
Choice C rationale
While it’s possible to contract Hepatitis A from food prepared at any location, including fast food restaurants, the risk is not specifically associated with these establishments. The key is whether the food is contaminated with the virus, which can occur in any setting if food is handled by someone infected with Hepatitis A who doesn’t properly wash their hands after using the toilet.
Choice D rationale
Practicing effective hand hygiene, including thoroughly washing hands after using the bathroom, changing diapers, and before preparing or eating food, is a primary prevention strategy for Hepatitis A1. The virus is spread in part by the fecal-oral route, so good hand hygiene can help prevent ingestion of the virus.
Correct Answer is C
Explanation
Choice A rationale
While performing self-examinations for breast cancer can help in early detection of the disease, it does not provide information about a person’s genetic risk for developing breast cancer.
Choice B rationale
Having a suspicious mammogram could indicate the presence of breast cancer or other abnormalities, but it does not provide information about a person’s genetic risk for developing the disease.
Choice C rationale
Being aware of one’s BRCA (breast cancer gene) status is directly related to understanding their genetic risk for breast cancer. Mutations in the BRCA1 and BRCA2 genes significantly increase the risk of developing breast cancer.
Choice D rationale
Noticing dimpling during a breast self-exam could be a sign of breast cancer, but it does not provide information about a person’s genetic risk for developing the disease.
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