The nurse is caring for a client who was admitted for an acute exacerbation of Crohn's Disease with severe diarrhea for the last two days. The nurse knows that which of the following is the priority risk for this client?
Impaired perineal skin integrity
Protein-calorie malnutrition
Pain related to abdominal cramping
Fluid and electrolyte imbalance
The Correct Answer is D
A. While impaired perineal skin integrity is a concern due to frequent diarrhea, it is not the priority because it does not pose an immediate threat to the client’s overall health or survival.
B. Protein-calorie malnutrition is a long-term risk associated with Crohn’s disease but is less critical during an acute exacerbation compared to immediate risks like fluid and electrolyte imbalance.
C. Although pain related to abdominal cramping is a significant concern, addressing pain does not take precedence over life-threatening risks such as dehydration or electrolyte disturbances.
D. Fluid and electrolyte imbalance is the priority because severe diarrhea can rapidly lead to dehydration, hypovolemia, and electrolyte imbalances, which can cause life-threatening complications such as cardiac arrhythmias or shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
· Total volume: 250 mL
· Infusion time: 2 hours
· Calculation: 250 mL / 2 hours = 125 mL/hour
Correct Answer is B
Explanation
A. Furosemide (Lasix) is a loop diuretic that typically causes the loss of potassium through the urine, thus putting clients at risk for hypokalemia, not hyperkalemia.
B. Spironolactone (Aldactone) is a potassium-sparing diuretic, meaning it helps the body retain potassium. As a result, it can lead to hyperkalemia, especially in patients with kidney dysfunction or when used with other medications that increase potassium levels.
C. Sodium polystyrene sulfate (Kayexalate) is used to treat hyperkalemia by exchanging sodium for potassium in the intestines, thus lowering potassium levels. It does not contribute to hyperkalemia.
D. Insulin does not directly cause hyperkalemia; in fact, insulin administration can lower potassium levels by driving potassium into cells.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.