A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?
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 D
A. Investigate the client's emotional concerns:
While addressing emotional concerns is important, assessing electrolyte imbalances and physiological stability takes precedence in managing an acute exacerbation of ulcerative colitis.
B. Check the client's perianal skin integrity:
Assessing perianal skin integrity is crucial, especially in inflammatory bowel disease, but it might not be the immediate priority compared to evaluating electrolyte imbalances.
C. Obtain a dietary history from the client:
Although dietary history is relevant for managing ulcerative colitis, the urgency lies in assessing and managing potential electrolyte imbalances due to the exacerbation of the condition.
D. Review the client's electrolyte values:
This is the correct action. During an acute exacerbation of ulcerative colitis, the client is at risk of electrolyte imbalances due to diarrhea, dehydration, and potential fluid and electrolyte losses. Promptly reviewing the electrolyte values helps identify any imbalances that might require immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Autocratic:
Autocratic leadership involves making decisions without seeking input from others. In this scenario, the charge nurse is eliciting opinions from all group members and organizing a vote, which suggests a more collaborative approach rather than a purely autocratic one.
B. Scientific:
Scientific leadership, often associated with Frederick Taylor's principles of scientific management, involves using data and analysis to make decisions. The scenario does not provide information suggesting a strong emphasis on scientific principles in the decision-making process.
C. Democratic:
Democratic leadership involves including team members in decision-making, seeking their opinions, and often using a voting or consensus-building approach. The charge nurse's approach of eliciting opinions and organizing a vote aligns with democratic leadership.
D. Laizzez-faire:
Laissez-faire leadership involves a hands-off approach, where the leader allows group members considerable freedom to make decisions. In the scenario, the charge nurse is actively seeking input and organizing a vote, which is more indicative of a democratic style rather than laissez-faire.
Correct Answer is C
Explanation
A. Dyspepsia:
Dyspepsia refers to discomfort or pain in the upper abdomen, often described as indigestion. It is a common symptom of peptic ulcer disease but is not as urgent as the manifestation described in option C.
B. Epigastric discomfort:
Epigastric discomfort is a common symptom of peptic ulcer disease, but the priority is to identify more severe complications, such as bleeding.
C. Hematemesis:
This is the correct answer. Hematemesis refers to the vomiting of blood, which is a serious and potentially life-threatening complication of peptic ulcer disease. It indicates active bleeding in the upper gastrointestinal tract and requires prompt medical attention.
D. Epigastric pain:
Epigastric pain is similar to epigastric discomfort and is a common symptom of peptic ulcer disease. However, the priority in the given options is to identify the more severe complication of hematemesis.
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