A nurse is preparing a client who has advanced cirrhosis for an abdominal paracentesis. Which of the following actions should the nurse take?

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.

Choice A: “I will feel shaky.” This is a correct statement, as shakiness is a common manifestation of hypoglycemia, which is a low blood glucose level. Hypoglycemia can cause the sympathetic nervous system to release adrenaline, which can cause tremors, nervousness, and anxiety.

Choice B: “My skin will be warm and moist.” This is an incorrect statement, as warm and moist skin is not a typical manifestation of hypoglycemia. Warm and moist skin can be a sign of hyperglycemia, which is a high blood glucose level. Hyperglycemia can cause dehydration, which can lead to sweating and flushing.

Choice C: “I will be more thirsty than usual.” This is an incorrect statement, as thirst is not a typical manifestation of hypoglycemia. Thirst can be a sign of hyperglycemia, which can cause dehydration, as the body tries to flush out excess glucose through urine.

Choice D: “My appetite will be decreased.” This is an incorrect statement, as decreased appetite is not a typical manifestation of hypoglycemia. Decreased appetite can be a sign of other conditions, such as nausea, infection, or depression. Hypoglycemia can cause increased hunger, as the body needs more glucose to function properly.