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 A
Explanation
Choice A rationale
Increasing daily protein intake is often recommended for clients with chronic pancreatitis. Protein is needed for healing and repairing tissues, and people with chronic pancreatitis may have increased protein needs.
Choice B rationale
Decreasing caloric intake when abdominal pain is present is not typically recommended for clients with chronic pancreatitis. Adequate nutrition, including sufficient calories, is important for managing this condition.
Choice C rationale
Increasing fat intake when experiencing loose stools is not typically recommended for clients with chronic pancreatitis. Fat can be difficult to digest for these clients and can contribute to loose stools.
Choice D rationale
Limiting alcohol intake to 2-3 drinks per week is not typically recommended for clients with chronic pancreatitis. Alcohol can exacerbate pancreatitis and should be avoided.
Correct Answer is D
Explanation
Choice A rationale
While assessing the client’s skin for a rash could be part of the overall assessment of the client’s condition, it is not the priority action when a client is experiencing chills and back pain during a blood transfusion.
Choice B rationale
Notifying the provider is an important step when a client is experiencing a reaction to a blood transfusion, but it is not the first action that should be taken.
Choice C rationale
Covering the client with a blanket may provide comfort to the client, but it does not address the underlying issue of a potential transfusion reaction.
Choice D rationale
The priority action when a client is experiencing chills and back pain during a blood transfusion is to stop the transfusion. This is because these symptoms could indicate a transfusion reaction, which can be serious.
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