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":"C"}
Explanation
Rationale for correct choices:
• Seizures: Clients with meningitis are at risk for seizures due to meningeal irritation, high fever, and increased intracranial pressure. Neurological complications arise as the infection spreads within the central nervous system, disrupting electrical activity in the brain.
• Level of consciousness: The adolescent is lethargic, drowsy, and irritable when aroused, which reflects altered neurological status. This finding indicates cerebral involvement, which increases the likelihood of seizure activity as the illness progresses.
Rationale for incorrect choices:
• Lyme disease: This condition is caused by tick bites and typically presents with erythema migrans rash, arthralgia, and fatigue, not acute fever, photophobia, or purpuric rash as seen here.
• Pneumonia: Respiratory involvement would present with abnormal breath sounds, cough, or hypoxemia, but this client has clear lung sounds and normal oxygen saturation, making pneumonia unlikely.
• Mononucleosis: This condition usually causes fever, pharyngitis, and lymphadenopathy, but the client’s cervical nodes are normal and their presentation aligns more with meningitis.
• Constipation: Gastrointestinal complications such as constipation are not relevant here since bowel sounds are active, the abdomen is soft, and there are no reports of decreased stooling.
• Abdominal findings: The abdomen is soft, flat, and with normal bowel sounds, which provides no evidence of an abdominal complication linked to meningitis risk.
• Rash: While the purpuric rash supports the diagnosis of meningococcal meningitis, it is not the primary indicator of seizure risk. Neurological status is a stronger predictor of seizure development.
• Cervical lymph nodes: These are normal without edema or tenderness, ruling out lymphatic involvement as a significant concern in this scenario.
• Breath sounds: Breath sounds are clear and equal bilaterally, which excludes a respiratory complication such as pneumonia as the risk factor linked to seizures.
Correct Answer is ["A","B","E","F","G","H","I"]
Explanation
Rationale for Correct Choices
- Toddler is irritable: Irritability in a young child is a red flag for worsening systemic illness, dehydration, or early hypoxia, and requires close observation and intervention.
- Oral mucosa dry: This is a classic clinical sign of dehydration. It indicates that the toddler's body is losing more fluids than it's taking in, leading to a fluid volume deficit.
- Temperature 39.6° C (103.2° F): A persistent high fever in a toddler increases the risk of dehydration and febrile seizures. It requires prompt intervention with antipyretics and fluids to prevent further complications.
- Blood pressure 88/42 mm Hg: This is hypotension for a 2-year-old, suggesting compromised perfusion. Immediate action is needed as this can indicate progressing dehydration or early septic shock.
- Heart rate 150/min: Tachycardia in toddlers may indicate dehydration, fever, or compensatory response to low blood pressure. If unaddressed, it can progress to cardiovascular instability.
- Capillary refill 3 seconds: Prolonged refill indicates poor peripheral perfusion, which often accompanies dehydration or hypovolemia. This is a red flag for impaired circulation and worsening shock.
- Weight loss from 12 kg to 11.3–11.4 kg: A loss of nearly 6% body weight in a short period is clinically significant dehydration in a toddler. This requires prompt fluid replacement to avoid further decline.
Rationale for Incorrect Choices
- Respiratory rate 28/min: This rate is within the normal range for a 2-year-old (20–30 breaths/min). Without distress, retractions, or desaturation, it does not require immediate follow-up.
- Oxygen saturation 96% on room air: This is an acceptable oxygen level in a toddler. There are no signs of hypoxemia or respiratory compromise requiring intervention.
- Apical heart rate regular, no murmur: A regular rhythm without abnormal sounds indicates stable cardiac function. No immediate follow-up is required here.
- Lung sounds clear in all fields: The absence of wheezing, crackles, or diminished sounds rules out acute respiratory distress, so no intervention is immediately required.
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