A nurse is caring for an adult client on the medical-surgical unit.
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 []
Rationale for correct condition
The client developed profuse watery diarrhea after antibiotic therapy, consistent with C. difficile colitis. Antibiotics disrupt normal gut flora, allowing C. difficile overgrowth. Hyperactive bowel sounds, abdominal cramping, and hypotension support this diagnosis. CT scan ruled out appendicitis.
The client’s diarrhea began after cefazolin administration, a known risk factor for C. difficile. The frequency of stools every 30 minutes indicates severe colitis. Hypotension suggests fluid loss. Hyperactive bowel sounds confirm increased motility. CT imaging excluded surgical pathology.
Rationale for correct actions
Contact precautions prevent transmission of C. difficile spores, which survive on surfaces. IV fluids restore intravascular volume lost through diarrhea. Both actions directly address infection control and physiological stability.
Placing the client on contact precautions is essential because C. difficile spores resist alcohol-based sanitizers and require soap and water hand hygiene. Gown and glove use prevents nosocomial spread. Isolation reduces risk to other patients.
IV fluids are necessary because diarrhea causes hypovolemia and electrolyte imbalance. Normal blood pressure ranges 90–120/60–80 mm Hg, and the client’s drop to 105/68 indicates fluid depletion. IV fluids restore perfusion, prevent shock, and maintain renal function.
Rationale for correct parameters
Serum potassium must be monitored because diarrhea causes potassium loss. Blood pressure must be tracked to assess hydration status. Both parameters reflect complications of fluid and electrolyte imbalance.
Serum potassium normal range is 3.5–5.0 mEq/L. Diarrhea leads to hypokalemia, which can cause arrhythmias, muscle weakness, and ileus. Monitoring ensures timely replacement and prevention of cardiac complications.
Blood pressure reflects intravascular volume. The client’s decline from 149/87 to 105/68 shows significant fluid loss. Hypotension increases risk of shock. Monitoring ensures IV fluid therapy effectiveness and guides titration to maintain perfusion.
Rationale for incorrect conditions
Celiac disease involves gluten sensitivity, not acute antibiotic-associated diarrhea. Crohn’s disease is chronic, not sudden onset. Appendicitis presents with localized right lower quadrant pain and CT abnormalities, absent here.
Celiac disease causes malabsorption and steatorrhea, not profuse watery diarrhea after antibiotics. Gluten-free diet is the intervention, not isolation.
Crohn’s disease is a chronic inflammatory bowel disease with bloody stools and weight loss. It does not present acutely after antibiotic therapy.
Appendicitis causes rebound tenderness, guarding, and CT abnormalities. The client’s CT was normal, ruling out appendicitis.
Rationale for incorrect actions
Barium swallow study is for esophageal disorders, not colitis. Gluten-free diet is for celiac disease. Emergent surgery is for appendicitis, not antibiotic-associated diarrhea.
Barium swallow evaluates swallowing dysfunction, not infectious diarrhea. It is irrelevant here.
Gluten-free diet treats celiac disease by reducing immune-mediated villous damage. It does not address C. difficile.
Emergent surgery is indicated for appendicitis or perforation. CT scan excluded surgical pathology.
Rationale for incorrect parameters
Surgical incision monitoring applies to postoperative patients. Hemoglobin and hematocrit assess bleeding, not diarrhea. Steatorrhea is linked to malabsorption in celiac disease, not C. difficile colitis.
Surgical incision infection monitoring is relevant only after surgery, absent here.
Hemoglobin (normal 12–16 g/dL) and hematocrit (normal 36–48%) assess anemia or bleeding, not fluid loss.
Steatorrhea indicates fat malabsorption in celiac disease, not infectious colitis.
Test-taking strategy
- Identify key clinical clues
- Profuse watery diarrhea after antibiotics → C. difficile colitis
- Hypotension and hyperactive bowel sounds → fluid loss and increased motility
- Rule out incorrect conditions
- Celiac disease → chronic, gluten-related
- Crohn’s disease → chronic inflammatory, not acute
- Appendicitis → localized pain, abnormal CT
- Match actions to condition
- Contact precautions → infection control for C. difficile spores
- IV fluids → restore hydration and electrolytes
- Select parameters linked to complications
- Serum potassium → diarrhea causes hypokalemia
- Blood pressure → hypotension from fluid loss
- Eliminate distractors
- Barium swallow → esophageal disorders
- Gluten-free diet → celiac disease
- Surgery → appendicitis
- Steatorrhea → malabsorption
Take home points
- C. difficile colitis is strongly associated with antibiotic use and presents with profuse watery diarrhea.
- Contact precautions are critical to prevent nosocomial spread of spores.
- Electrolyte monitoring, especially potassium, is essential in severe diarrhea.
- Differentiate C. difficile from celiac disease, Crohn’s disease, and appendicitis using onset, cause, and diagnostic findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Placing the client in a prone position for 20 to 30 minutes several times a day is essential to prevent hip flexion contractures. After an above-the-knee amputation, the flexor muscles often become stronger than the extensors, leading to a permanent shortening of the hip joint. The prone position stretches the hip flexors and promotes neutral alignment. This is critical for future mobility and successful gait training with a prosthetic limb in the rehabilitation phase.
Choice B rationale
Elevating the foot of the bed might assist with initial edema, but doing so after the first 24 to 48 hours increases the risk of hip flexion contractures. Continuous elevation keeps the hip in a flexed state, which is counterproductive to the goal of maintaining full joint range of motion. By day three, the focus shifts from acute swelling management to preventing long-term orthopedic complications. Nurses must prioritize muscle length over minor dependent edema at this stage.
Choice C rationale
Elevating the stump on a pillow is generally discouraged after the first 24 hours postoperatively. Continuous elevation on a soft surface promotes flexion at the hip joint, which can lead to a contracture. Once a contracture occurs, the client may never be able to walk properly with a prosthesis because the limb cannot extend fully. Modern nursing care emphasizes keeping the residual limb flat on the bed to ensure the hip joint remains extended as much as possible.
Choice D rationale
Encouraging the client to sit up as much as possible is contraindicated for a client with a recent above-the-knee amputation. Prolonged sitting keeps the hip in a constant state of flexion, which significantly increases the likelihood of a permanent contracture. The nurse should instead encourage short periods of sitting followed by periods of extension or prone positioning. Maintaining the flexibility of the hip joint is the most important factor for achieving a normal walking pattern later.
Correct Answer is C
Explanation
Choice A rationale
Pulmonary artery pressure monitoring via a Swan Ganz catheter provides detailed information about left ventricular function and pulmonary vascular resistance. While useful in complex critical care cases, it is an invasive procedure with significant risks like dysrhythmias or pulmonary infarction. For a standard burn patient with 75 percent coverage, central venous pressure is usually the initial preferred method to guide the massive fluid resuscitation required during the first 24 to 48 hours.
Choice B rationale
Auscultating blood pressure using a cuff is often inaccurate or impossible in patients with 75 percent full thickness burns. The presence of significant edema, or the fact that the burns may cover all four extremities, prevents the effective use of a standard sphygmomanometer. Even if a site is available, the massive fluid shifts and decreased peripheral perfusion during burn shock make non invasive cuff pressures unreliable for guiding life saving titration.
Choice C rationale
Obtaining a central venous pressure is the most effective way to monitor fluid volume status in a severely burned patient. Full thickness burns over 75 percent of the body cause massive capillary leak and hypovolemia. CVP monitoring allows the healthcare team to assess the pressure in the right atrium and vena cava, providing a direct measurement of preload. This ensures that fluid resuscitation is sufficient to maintain organ perfusion without causing fluid overload.
Choice D rationale
Palpating pulse pressure provides a general sense of stroke volume and arterial tone, but it is purely subjective and lacks the precision needed for a patient in critical condition. In a patient with extensive burns, peripheral pulses may be difficult to palpate due to edema or eschar formation. Relying on manual palpation is insufficient for the minute to minute hemodynamic monitoring required to manage the complex fluid requirements of major burn injuries. .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.