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. A score of 6 indicates a severe impairment in consciousness, not alertness and orientation.

B. A score of 6 does not indicate a stable neurologic status but rather severe brain injury or impairment.

C.Because a score of 6 indicates the client is likely unresponsive or has very limited responses to stimuli, they cannot perform activities of daily living or protect their own airway. They require comprehensive, total nursing care.

D. While a GCS of 3 indicates deep coma, a score of 6 reflects severe impairment, though not necessarily a deep coma.

A. Dispose all linen in trash after use B. Don a mask, gloves, and gown C. Restrict visitors who have active infections D. Instruct the client to eat cooked foods only E. Limit the client from bathing daily

Correct Answer is ["B","C","D"]

Explanation

A. Used linens do not need to be disposed of in the trash but should be laundered to prevent contamination.

B. Wearing a mask, gloves, and gown helps protect immunosuppressed clients from potential infections.

C. Restricting visitors who have active infections prevents the spread of infections to the client.

D. Instructing the client to eat only cooked foods reduces the risk of foodborne infections.

E. Limiting bathing is not necessary; in fact, good hygiene practices are essential to prevent infections.

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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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