A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority?

Provide emotional support.

Evaluate ﬂuid and electrolyte levels.

Promote physical mobility.

Review stress factors that can cause disease exacerbation

Answer and Explanation

The Correct Answer is B

Choice A reason: Providing emotional support is important for a client who has ulcerative colitis, as the condition can aﬀect their quality of life and mental health. However, this is not the priority action for a nurse who is caring for a client who is experiencing an acute exacerbation of ulcerative colitis, as it does not address the immediate physical needs of the client.

Choice B reason: Evaluating ﬂuid and electrolyte levels is the priority action for a nurse who is caring for a client who is experiencing an acute exacerbation of ulcerative colitis, as the client is at risk of dehydration, hypovolemia, and electrolyte imbalances due to diarrhea, vomiting, and poor oral intake. The nurse should monitor the client’s vital signs, urine output, weight, skin turgor, mucous membranes, and laboratory values such as serum sodium, potassium, chloride, bicarbonate, blood urea nitrogen (BUN), and creatinine.

Choice C reason: Promoting physical mobility is beneficial for a client who has ulcerative colitis, as it can help prevent complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), and pressure ulcers. However, this is not the priority action for a nurse who is caring for a client who is experiencing an acute exacerbation of ulcerative colitis, as the client may have abdominal pain, fatigue, and weakness that limit their mobility. The nurse should encourage rest and provide comfort measures such as positioning, heat therapy, and analgesics.

Choice D reason: Reviewing stress factors that can cause disease exacerbation is helpful for a client who has ulcerative colitis, as stress can trigger or worsen inﬂammation in the bowel. However, this is not the priority action for a nurse who is caring for a client who is experiencing an acute exacerbation of ulcerative colitis, as it does not address the immediate physical needs of the client. The nurse should teach the client about stress management techniques and refer them to appropriate resources such as counseling or support groups.

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Correct Answer is D

Explanation

Choice A: Both illnesses result in malabsorption of nutrients. This is incorrect because malabsorption of nutrients is more common in Crohn’s disease than in ulcerative colitis. Crohn’s disease can aﬀect any part of the gastrointestinal tract, including the small intestine, where most of the nutrient absorption occurs. Ulcerative colitis mainly aﬀects the colon and rectum, which are responsible for water and electrolyte absorption.

Choice B: Both illnesses begin in the rectum. This is incorrect because ulcerative colitis usually begins in the rectum and spreads proximally to the colon, while Crohn’s disease can begin anywhere in the gastrointestinal tract, from the mouth to the anus.

Choice C: Both illnesses manifest fistula formation. This is incorrect because fistula formation is more common in Crohn’s disease than in ulcerative colitis. Fistulas are abnormal connections between diﬀerent parts of the gastrointestinal tract or other organs, such as the bladder, vagina, or skin. They are caused by inﬂammation, ulceration, and infection that penetrate through the bowel wall.

Choice D: Both illnesses are inﬂammatory in nature. This is correct because both ulcerative colitis and Crohn’s disease are types of inﬂammatory bowel disease (IBD), which are chronic conditions that cause inﬂammation and damage to the gastrointestinal tract. The exact cause of IBD is unknown, but it may involve genetic, immune, environmental, and microbial factors.

A. Negative Chvostek’s sign B. Flaccid muscles C. Numbness of the hands D. Hypercalcemia

Correct Answer is C

Explanation

Choice A: Negative Chvostek’s sign is the absence of facial twitching when the facial nerve is tapped. This is a normal finding and does not indicate hypoparathyroidism. A positive Chvostek’s sign is a sign of hypocalcemia, which can occur in hypoparathyroidism.

Choice B: Flaccid muscles are weak and limp muscles that lack tone and resistance. This is not a typical finding of hypoparathyroidism, as low levels of parathyroid hormone can cause muscle spasms, cramps, and tetany.

Choice C: Numbness of the hands is a common finding of hypoparathyroidism, as low levels of parathyroid hormone can cause hypocalcemia, which aﬀects the nerve function and sensation. Numbness can also occur in the feet, lips, and tongue.

Choice D: Hypercalcemia is a high level of calcium in the blood. This is not a finding of hypoparathyroidism, as low levels of parathyroid hormone can cause hypocalcemia, which is a low level of calcium in the blood. Hypercalcemia can be a sign of hyperparathyroidism, which is the opposite condition of hypoparathyroidism.

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A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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