In the context of caring for a patient diagnosed with Crohn’s disease, which nursing assessment should be prioritized?
Altered mucus membranes
Fluid volume deficit
Nutrition
Skin integrity .
The Correct Answer is C
Choice A rationale
While altered mucus membranes can occur in patients with Crohn’s disease, it is not typically the primary nursing assessment.
Choice B rationale
Fluid volume deficit can occur in patients with Crohn’s disease due to diarrhea, a common symptom of the disease. However, it is not typically the primary nursing assessment.
Choice C rationale
Nutrition should be prioritized in the nursing assessment for a patient diagnosed with Crohn’s disease. Malnutrition can occur due to decreased appetite, malabsorption of nutrients, and increased nutritional needs due to inflammation.
Choice D rationale
While skin integrity can be a concern in patients with Crohn’s disease, particularly those with fistulas, it is not typically the primary nursing assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Cheyne-Stokes breathing, characterized by a cycle of increasing and decreasing respiratory rate and depth, is not a typical symptom of diabetic ketoacidosis (DKA). DKA is more commonly associated with Kussmaul breathing, which is rapid, deep, and labored.
Choice B rationale
An acetone odor to the breath is a classic symptom of DKA. This is due to the body breaking down fat for energy, which produces ketones. These ketones can cause the breath to smell fruity or like nail polish remover.
Choice C rationale
A blood glucose level below 40 mg/dL is not a symptom of DKA. In fact, DKA is characterized by high blood glucose levels, typically above 250 mg/dL111213.
Choice D rationale
Malignant hypertension is not a typical symptom of DKA. While DKA can cause dehydration and electrolyte imbalances that may affect blood pressure, it does not typically cause malignant hypertension.
Correct Answer is A
Explanation
Choice A rationale
If a client reports feeling “down” and sad, having no energy, and wanting to cry, these could be signs of postpartum depression. It’s crucial to assess whether the client has considered harming her newborn, as this could indicate a severe form of postpartum depression that requires immediate intervention.
Choice B rationale
While anticipating a prescription for an antidepressant might be part of the treatment plan for postpartum depression, it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.
Choice C rationale
Assisting the family to identify prior use of positive coping skills in family crises could be helpful, but it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.
Choice D rationale
Reinforcing postpartum and newborn care discharge teaching is important, but it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.
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