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 D
Explanation
Choice A rationale
Pantothenic acid (vitamin B5) is involved in fatty acid metabolism and coenzyme A synthesis, while vitamin B6 (pyridoxine) is crucial for amino acid metabolism and neurotransmitter synthesis. Prednisone does not typically lead to deficiencies in these vitamins.
Choice B rationale
Biotin (vitamin B7) plays a role in carbohydrate, fat, and protein metabolism, and vitamin B2 (riboflavin) is essential for cellular respiration and energy production. Prednisone therapy is not directly linked to a need for these supplements.
Choice C rationale
Folic acid (vitamin B9) is necessary for DNA synthesis and cell division, and vitamin C (ascorbic acid) is an antioxidant involved in collagen synthesis and immune function. Prednisone's effects do not primarily target these metabolic pathways to cause deficiencies.
Choice D rationale
Long-term prednisone therapy can lead to bone demineralization by increasing osteoclast activity and decreasing calcium absorption in the gut, thus increasing the risk of osteoporosis. Vitamin D is essential for calcium absorption and bone health. Supplementation with calcium and vitamin D helps to mitigate these adverse effects of prednisone. Normal serum calcium levels range from 8.5 to 10.5 mg/dL, and normal vitamin D levels are generally considered to be between 20 to 50 ng/mL, although optimal levels may vary.
Correct Answer is D
Explanation
Choice A rationale
Providing mittens might prevent scratching and subsequent skin damage, but it does not address the underlying cause of the pruritus, which is likely residual irritation from the scabies treatment or the scabies mites themselves. While preventing secondary infection from scratching is important, alleviating the itch is the priority for client comfort.
Choice B rationale
Encouraging the client to gently rub the affected area can actually worsen the pruritus. Rubbing can stimulate nerve endings in the skin, further intensifying the sensation of itching and potentially leading to skin irritation and excoriation. Gentle patting or cool compresses are generally more soothing for itchy skin.
Choice C rationale
Applying additional scabicide after the initial treatment is usually not indicated for pruritus following scabies treatment, unless there is evidence of ongoing infestation. Pruritus can persist for several weeks after successful treatment due to the inflammatory response of the skin to the dead mites and their products. Overuse of scabicides can cause further skin irritation.
Choice D rationale
Assisting the client to take a cool shower can help to relieve pruritus by causing vasoconstriction of the superficial blood vessels and reducing the release of histamine and other inflammatory mediators in the skin. The cool temperature can also have a soothing effect on the nerve endings, temporarily alleviating the sensation of itching.
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