A nurse is caring for an adolescent in the emergency department (ED).
Complete the diagram by dragging from the choices below to specity what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
• Crohn's disease: The client’s presentation of hematochezia, abdominal pain, fever, anorexia, elevated CRP, hypoalbuminemia, anemia, and positive stool leukocytes points toward Crohn’s, an inflammatory bowel disease with systemic and intestinal involvement.
• Encourage a high-protein diet: Chronic inflammation and malabsorption in Crohn’s disease contribute to weight loss and muscle wasting, so a high-protein diet supports tissue repair and nutritional repletion.
• Record dietary intake: Careful documentation helps identify food triggers, ensures adequate caloric and protein intake, and provides a baseline for evaluating nutritional support interventions.
• Hemoglobin level: Clients with Crohn’s are prone to gastrointestinal blood loss, putting them at risk for anemia; trending hemoglobin values helps track disease activity and bleeding severity.
• Albumin level: Hypoalbuminemia in Crohn’s reflects both malnutrition and protein-losing enteropathy; monitoring this value provides insight into nutritional status and disease progression.
Rationale for Incorrect Choices
• Appendicitis: Appendicitis usually presents with localized right lower quadrant pain, rebound tenderness, and leukocytosis without chronic systemic signs like anemia or hypoalbuminemia, which are more consistent with Crohn’s disease.
• Peptic ulcer disease: Ulcers typically cause epigastric pain and possible melena, but they do not explain systemic inflammation, positive stool leukocytes, or low albumin seen in this case.
• Celiac disease: Celiac often presents with diarrhea, bloating, and steatorrhea, but this client’s hematochezia, fever, and elevated CRP are more consistent with inflammatory bowel disease.
• Administer an enema: This intervention is contraindicated in clients with bowel inflammation due to risk of worsening irritation or triggering perforation.
• Provide a gluten-free diet: While effective in celiac disease, it does not address the inflammation and malabsorption specific to Crohn’s disease.
• Prepare for surgery: Surgery is not the first-line intervention in Crohn’s unless complications like obstruction or perforation occur; conservative management is prioritized initially.
• Abrupt decrease in pain level: This is concerning for ruptured appendix and peritonitis, which are not primary features of Crohn’s disease progression.
• Abdominal rigidity: This is a sign of peritonitis, usually from perforation, which is not the presenting concern for this client with Crohn’s disease.
• Presence of steatorrhea: Steatorrhea is more typical of celiac disease or pancreatic insufficiency rather than Crohn’s, which more commonly presents with bloody stools.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A","dropdown-group-3":"B"}
Explanation
Rationale for Correct Choices
• Give iron with vitamin C to increase absorption: Vitamin C enhances the solubility and bioavailability of iron, which is especially important for a child on a vegetarian diet where non-heme iron predominates. Taking iron with citrus juice or ascorbic acid reduces the risk of poor absorption and supports correction of anemia.
• Give iron through a straw to prevent staining of teeth: Liquid iron supplements can cause temporary discoloration of tooth enamel. Using a straw minimizes direct contact of iron with the teeth, helping to preserve dental appearance while ensuring the child still receives the full dose.
• Increase intake of iron-rich foods such as beans, leafy greens, and fortified cereals: A vegetarian child should be encouraged to consume a variety of non-heme iron foods. Combining these with vitamin C sources improves absorption and supports bone marrow production of healthy red blood cells.
Rationale for Incorrect Choices
• Give iron with milk to reduce stomach upset: Milk contains calcium and casein, both of which inhibit iron absorption, reducing the effectiveness of therapy.
• Administer iron on an empty stomach with no fluids: Iron is best absorbed on an empty stomach, but giving it without fluids increases gastric irritation and may cause poor adherence in children.
• Encourage brushing with baking soda after iron administration: Baking soda is abrasive and not recommended for children, as it may damage developing enamel while not significantly reducing iron staining.
• Mix iron with milk to reduce metallic taste: Mixing with milk impairs absorption, worsening anemia, and undermines the therapeutic purpose of supplementation.
• Restrict protein sources to avoid overworking bone marrow: Protein is essential for hemoglobin synthesis and red blood cell production; restricting it would worsen the child’s anemic state.
• Reduce iron-containing foods until medication is completed: Limiting dietary iron would prevent recovery from anemia and contradicts the goal of maximizing iron intake during supplementation.
Correct Answer is B
Explanation
A. "I will monitor my child's blood glucose levels every 8 hours.": During illness, blood glucose can fluctuate rapidly due to stress hormones and changes in intake. Monitoring every 8 hours is not frequent enough; checks should be done every 3–4 hours or as recommended.
B. "I will increase the amount of fluids I offer my child.": Illness increases the risk of dehydration and ketoacidosis in children with diabetes. Encouraging extra fluids helps prevent dehydration and assists in flushing out ketones, making this an appropriate action.
C. "I will offer my child 20 grams of carbohydrates every 2 hours.": While carbohydrate intake is important when sick, strict scheduled dosing like this is not necessary unless blood glucose is low. Nutrition should be tailored to blood sugar levels and the child’s tolerance.
D. "I will withhold my child's dose of insulin when his appetite is poor.": Insulin should not be withheld during illness, even if the child eats less. The body may require the same or increased insulin due to stress hormones, and skipping doses raises the risk of hyperglycemia.
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