A nurse is caring for a client diagnosed with gastrointestinal bleeding.
Which of the following actions should the nurse take first?

Explain the procedure for an upper gastrointestinal series

Administer pain medication

Assess orthostatic blood pressure

Test the client’s emesis for blood .

Answer and Explanation

The Correct Answer is C

Choice A rationale

Explaining the procedure for an upper gastrointestinal series is important for a client diagnosed with gastrointestinal bleeding. However, it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

Choice B rationale

Administering pain medication is important for a client’s comfort, but it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

Choice C rationale

Assessing orthostatic blood pressure is the first action a nurse should take when caring for a client diagnosed with gastrointestinal bleeding. Orthostatic hypotension (a drop in blood pressure when standing up from a sitting or lying position) can be a sign of significant blood loss. This assessment helps determine the severity of the bleeding and guides further interventions.

Choice D rationale

Testing the client’s emesis for blood is an important part of diagnosing and managing gastrointestinal bleeding. However, it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

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Correct Answer is C

Explanation

Choice A rationale

While altered mucus membranes can occur in patients with Crohn’s disease, it is not typically the primary nursing assessment.

Choice B rationale

Fluid volume deficit can occur in patients with Crohn’s disease due to diarrhea, a common symptom of the disease. However, it is not typically the primary nursing assessment.

Choice C rationale

Nutrition should be prioritized in the nursing assessment for a patient diagnosed with Crohn’s disease. Malnutrition can occur due to decreased appetite, malabsorption of nutrients, and increased nutritional needs due to inflammation.

Choice D rationale

While skin integrity can be a concern in patients with Crohn’s disease, particularly those with fistulas, it is not typically the primary nursing assessment.

A. Recent history of stressful, positive life events. B. Being male and over the age of 80. C. Being an only child. D. Having elevated levels of serotonin.

Correct Answer is B

Explanation

Choice A rationale

A recent history of stressful, positive life events is not a primary risk factor for depression. While any significant life change can trigger stress and potentially contribute to depression, it is typically negative or traumatic events that are most strongly associated with an increased risk of depression.

Choice B rationale

Being male and over the age of 80 is a primary risk factor for depression. Older adults, particularly those with chronic medical conditions, are at an increased risk of depression. Additionally, while women are more likely than men to experience depression at younger ages, the gender gap narrows with age.

Choice C rationale

Being an only child is not a primary risk factor for depression. While family history can play a role in depression risk, it is typically a history of depression in first-degree relatives that is most strongly associated with an increased risk.

Choice D rationale

Having elevated levels of serotonin is not a primary risk factor for depression. In fact, it is typically low levels of serotonin that are associated with an increased risk of depression. Informed consent Explore

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A nurse is caring for a client diagnosed with gastrointestinal bleeding.Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In the context of caring for a patient diagnosed with Crohn’s disease, which nursing assessment should be prioritized?

Correct Answer is C

Explanation

A nurse is providing teaching for a client diagnosed with depression.Which of the following should the nurse identify as a primary risk factor for this disorder?

Correct Answer is B

Explanation

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A nurse is caring for a client diagnosed with gastrointestinal bleeding.
Which of the following actions should the nurse take first?