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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Echinacea is an herb often used to support the immune system, particularly for colds and flu. There is no strong scientific evidence to support its effectiveness in managing the joint pain associated with osteoarthritis, which is a degenerative joint disease.
Choice B rationale
Applying ice to a joint before exercising can decrease pain and inflammation, but it can also stiffen the joint and potentially limit range of motion during activity. Heat application is generally recommended before exercise in osteoarthritis to warm up the muscles and tissues.
Choice C rationale
Purines are compounds that break down into uric acid. Reducing purine intake is important for managing gout, a type of inflammatory arthritis caused by the deposition of uric acid crystals in the joints, not osteoarthritis, which is characterized by cartilage breakdown.
Choice D rationale
Maintaining a recommended body weight is crucial for managing osteoarthritis. Excess weight puts additional stress on weight-bearing joints like the hips and knees, accelerating cartilage breakdown and increasing pain. Weight loss can significantly reduce these stresses and alleviate symptoms.
Correct Answer is D
Explanation
Choice A rationale
Increasing protein intake is important for tissue repair and overall healing in patients with osteomyelitis. However, addressing the acute bacterial infection is the immediate priority to prevent further bone destruction and systemic spread of the infection.
Choice B rationale
Teaching relaxation breathing can help manage the pain associated with osteomyelitis. While pain management is crucial for patient comfort, it does not address the underlying bacterial infection that is causing the acute illness and bone damage.
Choice C rationale
Antipyretic therapy, such as acetaminophen or ibuprofen, can help reduce fever, which is a common systemic manifestation of acute osteomyelitis. However, lowering the fever does not treat the underlying infection and its potential complications.
Choice D rationale
Acute osteomyelitis is a bone infection, and the priority intervention is the prompt administration of antibiotics. Antibiotics target and eradicate the causative bacteria, preventing further bone destruction, reducing the risk of sepsis, and promoting healing. Delaying antibiotic administration can lead to severe and potentially life-threatening complications.
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