A nurse is attending to a client who has just been admitted due to an acute exacerbation of ulcerative colitis. What should be the nurse’s initial course of action?
Investigate the client’s emotional concerns.
Check the client’s perianal skin integrity.
Obtain a dietary history from the client.
Review the client’s electrolyte values.
The Correct Answer is B
Choice A rationale
While emotional concerns are important to address in a holistic care approach, they are not the initial course of action when a client is admitted due to an acute exacerbation of ulcerative colitis. Emotional concerns are usually addressed once the client’s physical condition is stabilized.
Choice B rationale
Checking the client’s perianal skin integrity is a crucial initial step when a client is admitted due to an acute exacerbation of ulcerative colitis. Ulcerative colitis can cause rectal bleeding and diarrhea, which can lead to skin breakdown in the perianal area. Therefore, assessing for skin integrity helps in early detection and management of potential skin complications.
Choice C rationale
Obtaining a dietary history from the client is important but not the initial course of action in this scenario. Dietary history is usually obtained once the client’s condition is stabilized and when planning for discharge or dietary modifications.
Choice D rationale
Reviewing the client’s electrolyte values is important in managing ulcerative colitis, but it’s not the initial course of action. Electrolyte imbalances can occur due to diarrhea and
malabsorption, which are common in ulcerative colitis. However, this is usually done after initial physical assessments and stabilization of the client.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Monitoring for changes in the color of urine to maroon or red is not typically associated with peptic ulcers. This could be a sign of other conditions such as urinary tract infections, kidney stones, or certain medications.
Choice B rationale
Unintentional weight gain is not a common symptom of peptic ulcers. In fact, some people with peptic ulcers may experience weight loss due to discomfort while eating or a decrease in appetite.
Choice C rationale
The appearance of ecchymosis (bruising) on the sides of the abdomen or pelvic areas is not a typical symptom or concern with peptic ulcers. This could be a sign of trauma, certain medications, or other medical conditions.
Choice D rationale
One of the symptoms of a peptic ulcer can be changes in the color of the stool, particularly if it becomes dark or black. This can be a sign of bleeding in the gastrointestinal tract, which can occur with peptic ulcers. Therefore, patients should be advised to monitor for this symptom and seek medical attention if it occurs.
Correct Answer is D
Explanation
Choice A rationale
While a 25-year-old planning to lose 20 pounds after childbirth may have increased nutritional needs, they would not typically be considered at higher risk for malnutrition unless there were other factors such as inadequate diet or certain health conditions.
Choice B rationale
A 65-year-old who recently underwent hernia surgery might have temporary changes in diet or appetite related to the surgery, but would not typically be at high risk for malnutrition unless there were other ongoing issues such as poor diet, difficulty eating, or a chronic health condition.
Choice C rationale
A 70-year-old who has been fasting since midnight in preparation for a colonoscopy would not typically be at risk for malnutrition from this short-term fast. However, if they had ongoing issues with diet, appetite, or a chronic health condition, they could potentially be at risk.
Choice D rationale
A 55-year-old who has been consuming alcohol for 35 years is at higher risk for malnutrition. Alcohol can interfere with the body’s ability to absorb and use nutrients, and individuals with long-term heavy alcohol use may also have other lifestyle factors that increase their risk for malnutrition.
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