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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Phosphate 5.7 mg/dL is an elevated value, as the normal range is 2.5 to 4.5 mg/dL. Hypoparathyroidism causes low levels of parathyroid hormone (PTH), which regulates calcium and phosphorus balance in the body. Low PTH leads to low calcium and high phosphorus levels in the blood.
Choice B reason: Vitamin D 25 ng/mL is a normal value, as the normal range is 20 to 50 ng/mL. Hypoparathyroidism does not directly affect vitamin D levels, but vitamin D supplements may be given to help increase calcium absorption and lower phosphorus levels in the blood.
Choice C reason: Calcium 9.8 mg/dL is a normal value, as the normal range is 8.6 to 10.2 mg/dL. Hypoparathyroidism causes low levels of parathyroid hormone (PTH), which regulates calcium and phosphorus balance in the body. Low PTH leads to low calcium and high phosphorus levels in the blood. However, calcium levels may be normal or near- normal in some cases of hypoparathyroidism, especially if the condition is mild or well-controlled with treatment.
Choice D reason: Magnesium 1.8 mEq/L is a normal value, as the normal range is 1.5 to 2.5 mEq/L. Hypoparathyroidism does not directly affect magnesium levels, but magnesium deficiency can cause or worsen hypoparathyroidism, as magnesium is needed for PTH secretion and action. Magnesium supplements may be given to correct magnesium deficiency and improve PTH function.
Correct Answer is B
Explanation
Choice A: Sensitivity to cold. This is incorrect because sensitivity to cold is a manifestation of hypothyroidism, not hyperthyroidism. Clients with hyperthyroidism have increased metabolism and heat production, which makes them more sensitive to heat.
Choice B: Frequent mood changes. This is correct because frequent mood changes are a manifestation of hyperthyroidism. Clients with hyperthyroidism have increased levels of thyroid hormones, which can affect their nervous system and cause irritability, anxiety, nervousness, or emotional instability.
Choice C: Weight gain. This is incorrect because weight gain is a manifestation of hypothyroidism, not hyperthyroidism. Clients with hyperthyroidism have increased metabolism and appetite, which makes them lose weight or have difficulty gaining weight.
Choice D: Constipation. This is incorrect because constipation is a manifestation of hypothyroidism, not hyperthyroidism. Clients with hyperthyroidism have increased bowel motility and peristalsis, which makes them more prone to diarrhea or frequent stools.
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