Á 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?

Obtain a dietary history from the client.

Review the client's electrolyte values.

Investigate the client's emotional concerns.

Check the client's perianal skin integrity.

Answer and Explanation

The Correct Answer is B

A. Obtaining a dietary history is relevant for ongoing management but is not the initial priority.

B. Reviewing electrolyte values is essential because exacerbations of ulcerative colitis can lead to severe fluid and electrolyte imbalances, which need prompt correction.

C. Investigating emotional concerns is important but does not take precedence over addressing potential electrolyte imbalances that can be life-threatening.

D. Checking perianal skin integrity is relevant for comfort but is not the priority in stabilizing the client during an acute exacerbation.

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Correct Answer is C

Explanation

A. Checking for fecal impaction can help relieve the cause of autonomic dysreflexia but should be done after positioning the client.

B. Skin breakdown can trigger autonomic dysreflexia, but the immediate priority is to lower blood pressure by sitting the client up.

C. Placing the client in a sitting position helps lower blood pressure, which is the immediate concern in autonomic dysreflexia.

D. Checking for bladder distention is essential to find the trigger, but positioning comes first to manage the acute blood pressure elevation.

A. Poor impulse control B. Deficits in the right visual field C. Unable to discriminate words and letters D. Motor retardation

Correct Answer is A

Explanation

A. The right hemisphere controls judgment, reasoning, and impulse control, so clients may exhibit impulsive behaviors after a right-sided stroke.

B. Deficits in the right visual field would occur with a left hemisphere stroke, not a right hemisphere stroke.

C. Difficulty discriminating words and letters is typically associated with left hemisphere damage.

D. Motor retardation is not a specific finding associated with right hemisphere strokes; these often involve impulsive behavior and left-sided neglect.

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Á 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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