A nurse is caring for a patient who is being admitted for an acute exacerbation of ulcerative colitis.
Which of the following actions should the nurse take first?
Obtain a dietary history from the patient.
Review the patient's electrolyte values.
Check the patient's perianal skin integrity.
Investigate the patient's emotional concerns.
The Correct Answer is B
Choice A rationale
Obtaining a dietary history is important in managing ulcerative colitis, as certain foods can exacerbate symptoms. However, in an acute exacerbation, the immediate priority is to address physiological instability, which electrolyte imbalances can significantly contribute to.
Choice B rationale
During an acute exacerbation of ulcerative colitis, patients can experience significant fluid and electrolyte losses due to frequent and bloody diarrhea. Reviewing electrolyte values, such as potassium, sodium, and magnesium, is the priority to identify and promptly correct any imbalances that could lead to cardiac arrhythmias or other complications. Normal ranges for serum electrolytes are: Sodium: 135-145 mEq/L, Potassium: 3.5-5.0 mEq/L, Chloride: 98-106 mEq/L, Bicarbonate: 22-26 mEq/L, Calcium: 8.5-10.5 mg/dL, Magnesium: 1.5-2.5 mEq/L.
Choice C rationale
Checking perianal skin integrity is important because frequent diarrhea can lead to skin breakdown. However, this assessment is secondary to addressing potential life-threatening electrolyte imbalances that can occur during an acute flare-up.
Choice D rationale
Addressing the patient's emotional concerns is a crucial aspect of holistic care for patients with chronic conditions like ulcerative colitis. However, in the context of an acute exacerbation, the immediate physiological needs, such as identifying and correcting electrolyte imbalances, take precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Peripheral edema can occur in systemic lupus erythematosus (SLE) due to various factors like kidney involvement or heart issues. While it should be monitored, it is not typically the highest priority finding compared to signs of acute organ involvement.
Choice B rationale
Joint pain is a common symptom of SLE due to inflammation in the joints. While it affects the patient's quality of life, it is usually a chronic manifestation rather than an acute, life-threatening concern.
Choice C rationale
A dry, raised rash on the face, particularly a butterfly-shaped rash across the cheeks and bridge of the nose, is a classic and specific sign of an SLE flare. This rash can indicate active disease and potential systemic involvement, making it a high priority for the provider to assess and manage.
Choice D rationale
Feelings of depression are common in patients with chronic illnesses like SLE and should be addressed for the patient's mental well-being. However, a new or worsening physical symptom indicative of active disease, such as the characteristic rash, takes higher priority in terms of immediate medical assessment and intervention. .
Correct Answer is B
Explanation
Choice A rationale
Pediculosis refers to an infestation of lice, which typically presents with intense itching and the presence of nits (lice eggs) attached to hair shafts. While there may be redness and irritation from scratching, oozing lesions are not a primary characteristic of pediculosis.
Choice B rationale
Contact dermatitis is an inflammatory skin condition caused by direct contact with an allergen or irritant. It often manifests as pruritus (itching), redness (erythema), and oozing lesions (vesiculation and weeping) at the site of contact. The client's report of pruritus and reddened, oozing lesions on her lower leg is consistent with contact dermatitis.
Choice C rationale
Alopecia refers to hair loss, which can be localized or widespread. It does not typically involve pruritus or oozing lesions on the skin.
Choice D rationale
Tinea pedis, also known as athlete's foot, is a fungal infection of the feet. It commonly presents with scaling, itching, redness, and sometimes blistering, but oozing lesions are less typical unless there is a secondary bacterial infection. The location on the lower leg is also less common for tinea pedis, which primarily affects the feet. .
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