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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Calcium:
While calcium levels can be affected in pancreatitis, it is more commonly associated with a decrease in calcium levels due to fat necrosis and the formation of calcium soaps. However, the primary electrolyte disturbance is more likely to involve magnesium.
B. Magnesium:
Magnesium levels may be decreased in acute pancreatitis due to factors such as vomiting, malabsorption, and poor oral intake. Hypomagnesemia is a possible consequence, but it's not as specific to pancreatitis as the elevation of amylase.
C. Amylase:
Elevated amylase levels are a hallmark of acute pancreatitis. Amylase is an enzyme released by the pancreas, and its elevation in the blood is a key diagnostic marker for pancreatitis.
D. RBC count:
Acute pancreatitis does not typically result in a significant impact on the red blood cell (RBC) count. The elevation of amylase and lipase levels, along with imaging studies, is more indicative of pancreatitis.
Correct Answer is C
Explanation
A. "Wear compression stockings daily":
Compression stockings are not directly related to preventing the complications of retinopathy and nephropathy in diabetes. They are more commonly recommended for managing conditions like venous insufficiency and preventing blood clots.
B. "Have an eye examination once per year":
While regular eye examinations are important for monitoring and early detection of diabetic retinopathy, maintaining stable blood glucose levels is more directly related to preventing the progression of retinopathy.
C. "Maintain stable blood glucose levels":
This is the correct instruction. Stable blood glucose levels are crucial in preventing and minimizing the long-term complications of diabetes, including retinopathy (damage to the retina) and nephropathy (kidney damage). Consistent blood glucose control is key to reducing the risk of complications.
D. "Examine your feet carefully every day":
Daily foot examinations are essential for preventing diabetic foot complications, including ulcers and infections. While important for overall diabetes management, foot care is not specifically directed at preventing retinopathy and nephropathy.
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