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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","G"]
Explanation
A. Apply pressure to the puncture site following the procedure. Applying pressure helps prevent cerebrospinal fluid (CSF) leakage and reduces the risk of complications.
B. Limit the child's fluid intake following the procedure. Fluids should be encouraged to help replenish lost CSF and reduce the risk of post-lumbar puncture headache.
C. Position the child in a prone position during the procedure. The correct positioning for a lumbar puncture is the side-lying fetal position or sitting with the back curved forward to widen the space between the vertebrae.
D. Ensure the guardian has signed the consent form prior to the procedure. A lumbar puncture is an invasive procedure, so informed consent is required before proceeding.
E. Ensure the child voids prior to the procedure. Having the child empty their bladder before the procedure helps prevent discomfort and reduces the risk of bladder distention during positioning.
F. Insert an indwelling urinary catheter during the procedure. A urinary catheter is not necessary for a lumbar puncture unless there is another medical indication.
G. Monitor for paresthesia and tingling in extremities following the procedure. Paresthesia or tingling could indicate nerve irritation or injury, which requires prompt assessment and intervention.
Correct Answer is A
Explanation
A. "Monitor blood pressure every 4 hr." Acute glomerulonephritis can cause hypertension due to fluid retention and impaired kidney function. Regular monitoring is essential to detect and manage hypertension early.
B. "Increase fluid consumption." Fluid intake is often restricted to prevent fluid overload, especially if there is hypertension, edema, or decreased urine output.
C. "Implement a protein-restricted diet." A protein-restricted diet is not necessary unless the child has severe renal impairment. In most cases, moderate protein intake is recommended.
D. "Collect and strain all urine for sediment." While hematuria (blood in urine) is common in acute glomerulonephritis, straining urine for sediment is not a standard intervention for this condition.
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