A 25-year-old patient calls the clinic complaining of diarrhea for 24 hours.
Which of the following should be the nurse's first response?
Inform the patient that laboratory testing of blood and stools will be necessary.
Ask the patient to describe the character of the stools and any associated symptoms.
Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility.
Suggest that the patient drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte.
The Correct Answer is B
Choice A rationale
While laboratory testing may eventually be necessary to identify the cause of diarrhea, the immediate priority is to gather more information about the patient's condition. Jumping directly to testing without understanding the symptoms could delay appropriate initial interventions and fail to address immediate needs.
Choice B rationale
Assessing the characteristics of the stools, such as frequency, consistency, color, and any associated symptoms like abdominal pain, nausea, vomiting, or fever, is crucial for determining the potential cause and severity of the diarrhea. This information guides subsequent interventions and helps differentiate between self-limiting conditions and those requiring further investigation.
Choice C rationale
Advising the use of loperamide without a proper assessment could mask underlying issues, potentially delaying appropriate treatment if the diarrhea is due to an infection or other serious condition. Antidiarrheal medications are not always indicated and should be used cautiously.
Choice D rationale
While maintaining hydration and electrolyte balance is important, especially with diarrhea, it is not the first action a nurse should take before understanding the nature of the patient's symptoms. The initial step should be to gather more information to guide appropriate advice and interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Herpes simplex virus type 2 (HSV-2) is highly contagious through direct contact with the virus, which can be present on towels and other personal items. Sharing towels, even with family members, can facilitate the transmission of the virus, especially during active outbreaks.
Choice B rationale
Prior to the development of visible blisters, many individuals with HSV-2 experience prodromal symptoms such as itching, tingling, or burning at the site where the lesions will eventually appear. This indicates an understanding of the early signs of a recurrent outbreak.
Choice C rationale
Daily antiviral medication for HSV-2 is suppressive therapy, which helps to reduce the frequency, duration, and severity of outbreaks, as well as the risk of transmission. However, it does not entirely prevent the occurrence of sores in all individuals.
Choice D rationale
Even after the blisters rupture and begin to heal, the herpes simplex virus can still be present in the secretions and can potentially be transmitted to others through direct contact until the lesions are completely healed and the skin is intact.
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Blood pressure is a critical indicator of hemodynamic stability, which can be severely compromised in a patient with ulcerative colitis and severe diarrhea due to significant fluid and electrolyte loss. Hypovolemia resulting from dehydration can lead to decreased blood pressure and inadequate tissue perfusion, making this a high priority assessment. Normal blood pressure is typically around 120/80 mmHg.
Choice B rationale
Skin integrity is important to assess in patients with diarrhea due to the increased risk of skin breakdown in the perianal area from frequent bowel movements and irritation. While important for preventing complications, it is not the highest priority compared to assessing hemodynamic stability in the context of severe diarrhea.
Choice C rationale
Abdominal percussion is part of the abdominal assessment and can provide information about bowel sounds and distension, which might be relevant in ulcerative colitis. However, in the immediate context of severe diarrhea, assessing the patient's fluid balance and cardiovascular status takes precedence.
Choice D rationale
Heart rate and rhythm are crucial indicators of cardiovascular status and can be significantly affected by fluid and electrolyte imbalances resulting from severe diarrhea in ulcerative colitis. Tachycardia (increased heart rate) and arrhythmias can occur due to dehydration and electrolyte shifts, making this a high-priority assessment. Normal resting heart rate for adults is typically between 60 and 100 beats per minute.
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