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 C
Explanation
Choice A rationale
The scalp is generally not a primary site for the recurrence of herpes simplex virus type 1 (HSV-1) lesions. HSV-1 typically affects the oral and facial areas, innervated by the trigeminal nerve.
Choice B rationale
The extremities are not the typical location for recurrent HSV-1 infections. While herpes simplex virus type 2 (HSV-2) is more commonly associated with genital lesions, HSV-1 primarily affects areas innervated by the trigeminal nerve.
Choice C rationale
Viral rhinitis can trigger the recurrence of herpes simplex virus type 1 (HSV-1) lesions because both conditions can involve inflammation and potential stress on the body. HSV-1 typically lies dormant in the trigeminal ganglion and can reactivate, leading to lesions around the mouth, such as cold sores or fever blisters.
Choice D rationale
The genitalia are the primary site for herpes simplex virus type 2 (HSV-2) infections. While HSV-1 can occasionally cause genital herpes, recurrence in this area is less common than around the mouth in individuals with a history of HSV-1.
Correct Answer is C
Explanation
Choice A rationale
Dry, scaly patches on the elbows are more characteristic of psoriasis, a chronic autoimmune skin disorder. Psoriasis typically presents with well-defined, erythematous plaques covered with silvery scales, commonly found on extensor surfaces like elbows and knees.
Choice B rationale
Different pigmented patches in the genital area could suggest various dermatological conditions, such as tinea cruris or post-inflammatory hyperpigmentation, but are not typical findings associated with herpes zoster. Herpes zoster lesions follow a dermatomal distribution.
Choice C rationale
Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus. It characteristically presents with a painful, vesicular rash that follows the distribution of a sensory nerve pathway or dermatome. The pain often precedes the appearance of the rash.
Choice D rationale
Excessive hair growth, or hirsutism, is not a typical finding associated with herpes zoster. Hirsutism is usually related to hormonal imbalances or certain medications affecting androgen levels.
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