The nurse is writing a care plan for a client who was diagnosed with Crohn's disease a year ago and is now hospitalized with a fourth acute exacerbation. Which client problem should receive the highest priority?
Fluid overload
Altered body image
Imbalanced nutrition - less than body requirements
Social isolation
The Correct Answer is C
C. Crohn's disease exacerbation often leads to malnutrition due to decreased oral intake, malabsorption, and increased nutrient losses through diarrhea. Addressing imbalanced nutrition is crucial to replenish depleted nutrient stores, support healing, and prevent further complications.
A. While fluid overload can be a concern in certain situations, such as when administering intravenous fluids or in clients with renal impairment, it is not typically a primary concern in clients hospitalized with Crohn's disease exacerbation. Crohn's disease is more commonly associated with dehydration due to diarrhea and malabsorption rather than fluid overload.
B. In the acute phase of Crohn's disease exacerbation, addressing immediate physiological needs and stabilizing the client's condition typically take precedence over psychosocial concerns.
D. Social isolation can be a concern for clients with chronic illnesses, including Crohn's disease, as it may impact their quality of life and emotional well-being. However, in the acute phase of exacerbation, addressing physiological needs and stabilizing the client's condition typically takes precedence over psychosocial concerns such as social isolation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. The expected effect of TPN is to maintain or promote weight gain in clients who are unable to meet their nutritional needs orally. TPN provides essential nutrients directly into the bloodstream, allowing for adequate caloric intake to support energy needs and promote tissue repair and growth.
A. A serum white blood cell count of 16,000/mm3 indicates leukocytosis, which may suggest infection or inflammation rather than a direct effect of TPN.
B. Pre-albumin is a marker of nutritional status, and levels below 10 mg/dl typically indicate malnutrition rather than a positive response to TPN.
D. Negative nitrogen balance occurs when the body loses more nitrogen than it gains, typically due to inadequate protein intake or increased protein breakdown. TPN provides amino acids, which are the building blocks of protein, and aims to promote a positive nitrogen balance to support tissue repair and growth.
Correct Answer is D
Explanation
D. Pregnancy is a known risk factor for gallstone formation and cholecystitis. Hormonal changes during pregnancy, particularly increased levels of estrogen, can lead to increased cholesterol saturation in bile, decreased gallbladder emptying, and increased risk of gallstone formation.
A. Fiber helps to regulate bowel movements and may decrease cholesterol levels in bile, thereby reducing the likelihood of gallstone formation.
B. Pregnancy itself can predispose individuals to gallstone formation due to hormonal changes that increase cholesterol saturation in bile. However, normal weight gain reduces the risk of cholecystitis.
C. Certain ethnicities, including individuals of Native American, Hispanic, and African-American ancestry, have a higher prevalence of gallstones compared to other populations. However, ethnicity alone may not be a direct cause of acute cholecystitis.
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