A nurse reviews the electronic health record of a client who has Crohn disease and a draining fistula. What data requires immediate intervention?

White blood cell count of 8200/mm3 (8.2 x 109/L)

Client ate 20% of breakfast meal

Client's weight decreased by 3 lb (1.4 kg)

Serum potassium of 2.6 mEq/L (2.6 mmol/L)

Answer and Explanation

The Correct Answer is D

Crohn disease is a transmural inflammatory condition that often leads to fistula formation. Draining fistulas cause the loss of nutrient-rich fluids and electrolytes through abnormal tracts. Potassium is the primary intracellular cation, and its depletion can lead to fatal myocardial irritability and paralysis of the respiratory muscles, requiring emergent pharmacological replacement and monitoring.

Rationale:

A. A white blood cell count of 8200/mm3 is within the normal reference range of 5000 to 10000/mm3. While patients with fistulas are at risk for infection, this specific value does not indicate an acute inflammatory process or sepsis. Therefore, this data point is stable and does not necessitate an immediate or emergent nursing intervention.

B. Eating only 20% of a meal is concerning for a patient with a chronic inflammatory condition, but it is not an acute emergency. Poor oral intake is common in Crohn disease due to abdominal pain and anorexia. While nutritional support is necessary, it is a long-term management goal rather than an immediate life-saving priority.

C. A weight decrease of 3 lb is significant and indicates a negative fluid or nutritional balance. In a patient with a draining fistula, this weight loss likely reflects fluid loss or malabsorption. However, compared to the immediate risk of cardiac arrest from electrolyte imbalance, weight changes are addressed over a longer clinical timeframe.

D. A serum potassium of 2.6 mEq/L requires immediate intervention because it represents severe hypokalemia. The normal range is 3.5 to 5.0 mEq/L; levels below 2.5 to 3.0 mEq/L are associated with life-threatening ventricular dysrhythmias and cardiac arrest. The nurse must notify the provider immediately to begin intravenous potassium replacement under continuous cardiac monitoring.

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Correct Answer is D

Explanation

Pernicious anemiais a megaloblastic anemia caused by an autoimmune-mediated deficiency of intrinsic factor. This glycoprotein is secreted by gastric parietal cells and is essential for the absorption of cobalaminin the terminal ileum. Without intrinsic factor, dietary vitamin B12 cannot be utilized, leading to impaired DNA synthesis in erythrocytes and progressive, irreversible neurological degeneration.

Rationale:

A.Limiting citrus fruits is an incorrect dietary strategy for any form of anemia. Vitamin C found in citrus actually enhances the absorption of non-heme iron. While pernicious anemia is specifically a B12 issue rather than an iron issue, restricting these fruits provides no therapeutic benefit and could potentially impair general nutritional health.

B.Avoiding green leafy vegetables is inappropriate because these foods are rich in folate. Folate is another essential B vitamin required for red blood cell maturation. While folate cannot correct the vitamin B12 deficiency of pernicious anemia, it is a vital component of a balanced diet for hematologic health and should not be restricted.

C.Increasing fats and carbohydrates does not address the underlying pathophysiology of pernicious anemia. This condition is not a calorie-deficiency disorder but a specific micronutrient absorption failure. Promoting a high-fat or high-carbohydrate diet could lead to metabolic issues without improving the megaloblastic red blood cell production or the patient's neurological symptoms.

D.Increasing animal proteins like fish and meat indicates an understanding that vitamin B12is exclusively found in animal-derived foods. While patients with true pernicious anemia usually require lifelong parenteral injectionsbecause they cannot absorb oral B12, maximizing dietary intake is still taught as a supportive nutritional measure to ensure all available metabolic pathways are utilized.

A. Esophagogastroduodenoscopy (EGD) B. Magnetic resonance imaging (MRI) C. Nuclear medicine scan D. Abdominal arteriogram

Correct Answer is A

Explanation

Esophagogastroduodenoscopy(EGD) is the gold standard diagnostic tool for evaluating the upper gastrointestinal tract. This endoscopic procedure allows for direct visualization of the esophageal, gastric, and duodenal mucosa to identify ulcers, tumors, or inflammation. It is superior to imaging because it facilitates the collection of biopsy specimensto test for Helicobacter pylorior malignancy.

Rationale:

A.Esophagogastroduodenoscopy (EGD) is the expected procedure for investigating gastric pain and dyspepsia. It allows the clinician to directly visualize the interior of the stomach and duodenum to identify the cause of the pain, such as peptic ulcer disease or gastritis. During the EGD, the provider can also perform therapeutic interventions or take biopsies, which is essential for a definitive diagnosis.

B.Magnetic resonance imaging (MRI) provides detailed cross-sectional images of internal organs but is not the first-line choice for mucosal evaluation. While MRI is useful for identifying solid organ tumors or complex anatomical issues, it cannot visualize the surface of the gastric lining with the clarity of an endoscope. It also lacks the ability to take tissue samples, making it less diagnostic for dyspepsia.

C.A nuclear medicine scan, such as a gastric emptying study, is used to assess the motility of the stomach rather than its structural integrity. This test is helpful for diagnosing gastroparesis but is not the standard initial test for undiagnosed gastric pain. It involves the ingestion of radioactive isotopes, which is unnecessary when direct visualization via endoscopy is indicated first.

D.An abdominal arteriogram is an invasive procedure used to visualize the blood vessels of the abdomen, typically to identify blockages or hemorrhages. It is not used to evaluate dyspepsia or routine gastric pain unless a severe vascular issue like mesenteric ischemia is suspected. For mucosal inflammation and common epigastric pain, the EGD remains the most appropriate and direct diagnostic tool.

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A nurse reviews the electronic health record of a client who has Crohn disease and a draining fistula. What data requires immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client who has pernicious anemia about necessary dietary changes. Which statement by the client indicates understanding about those changes?

Correct Answer is D

Explanation

The nurse is caring for a client who has frequent gastric pain and dyspepsia. Which procedure would the nurse expect to teach the client about?

Correct Answer is A

Explanation

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