A nurse is caring for an adolescent in the emergency department (ED).

Complete the diagram by dragging from the choices below to specify 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.

Answer and Explanation

The Correct Answer is []

Condition Most Likely Experiencing: Crohn's disease

Actions to Take:

Record dietary intake
Provide a gluten-free diet.

Parameters to Monitor:

Albumin level.
Hemoglobin level.

Rationale:

Crohn’s Disease- Positive stool occult blood and positive leukocytes suggest intestinal inflammation and bleeding, which are characteristic of Crohn’s disease. Elevated C-reactive protein (CRP) (3.2 mg/dL) and WBC count (13,000/mm³) indicate inflammation and infection, common in Crohn’s disease flare-ups. Low albumin (3.4 g/dL) suggests malabsorption and protein loss, which occurs in Crohn’s disease due to chronic inflammation and poor nutrient absorption.

Appendicitis – Usually presents with localized right lower quadrant (RLQ) pain, fever, nausea, vomiting, and abdominal rigidity. The patient does not have classic signs of appendicitis.

Peptic Ulcer Disease (PUD) – Typically associated with H. pylori infection (negative in this case) and does not usually cause elevated CRP and WBC.

Celiac Disease – Would not cause elevated inflammatory markers (CRP, WBC) or stool occult blood.·

Record dietary intake.Nutritional deficiencies (e.g., low albumin) are common in Crohn’s disease. Keeping a food diary helps identify trigger foods that exacerbate symptoms.

Provide a gluten-free diet. While gluten-free diets are primarily for celiac disease, some Crohn’s disease patients may benefit from avoiding gluten and other inflammatory foods. Low-residue, high-protein diets are often recommended to reduce intestinal irritation and promote healing.

Administer an enema. Contraindicated in Crohn’s disease, as enemas can worsen inflammation and irritate the bowel.

Prepare for surgery. Surgery is not the first-line treatment for Crohn’s disease. It is only considered for severe complications (e.g., strictures, fistulas, or perforation).

Albumin level. Low albumin suggests malabsorption and protein loss, which should be monitored to assess nutritional status.

Hemoglobin level. Anemia (Hgb 11 g/dL, Hct 33%) suggests chronic blood loss from inflammation. Monitoring hemoglobin helps assess disease progression and response to treatment.

Abrupt decrease in pain level. This would be a concern for bowel perforation rather than an indicator of improvement in Crohn’s disease.

Abdominal rigidity. Not a typical assessment parameter for Crohn’s disease, but more relevant for appendicitis or peritonitis

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. "Apply firm pressure to the wound base while removing the gauze dressing." Applying firm pressure can cause pain and damage the wound bed, delaying healing and increasing the risk of bleeding.

B. "Irrigate the wound with half-strength hydrogen peroxide while removing the gauze dressing." Hydrogen peroxide can damage healthy tissue and delay wound healing. It is not recommended for routine wound care.

C. "Continue to remove the gauze dressing by pulling it parallel to the skin." Removing a dry gauze dressing without moistening it can cause trauma to the wound bed, increasing pain and impeding healing.

D. "Saturate the gauze dressing with sterile saline solution prior to removing it." Moistening the dressing with sterile saline reduces trauma to the wound, prevents tissue damage, and minimizes pain. This method is preferred for atraumatic dressing removal.

A. Attach the bag first to the perineum, then to the skin above the urethra. B. Remove the bag 1 hr after the infant voids. C. Place absorbent cotton balls inside the bag. D. Apply petroleum jelly to the perineum before applying the bag.

Correct Answer is A

Explanation

A. "Attach the bag first to the perineum, then to the skin above the urethra." Proper technique involves first securing the collection bag to the perineum to ensure a snug fit, then pressing it firmly to the surrounding skin to prevent leaks.

B. "Remove the bag 1 hr after the infant voids." The bag should be removed as soon as sufficient urine is collected to avoid contamination or leakage.

C. "Place absorbent cotton balls inside the bag." Absorbent materials would absorb the urine, making it difficult to retrieve an adequate sample for testing.

D. "Apply petroleum jelly to the perineum before applying the bag." Petroleum jelly could prevent the bag from adhering properly, leading to leakage or contamination.

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Rationale:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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