The nurse is caring for a client with ulcerative colitis. Which findings does the nurse determine is consistent with this diagnosis? (Select all that apply)
Hypercalcemia.
Hypernatremia.
Frothy, fatty stools.
Bloody stool.
10 to 20 liquid stools daily.
Complains of pain at right lower abdominal quadrant.
Complains of pain at left lower abdominal quadrant.
Correct Answer : D,E,G
Choice A reason: Hypercalcemia is not associated with ulcerative colitis, which affects the colon and causes diarrhea. Bloody stools are typical, making this incorrect, as it’s unrelated to the nurse’s expected findings in a client with ulcerative colitis during assessment.
Choice B reason: Hypernatremia may occur with dehydration but isn’t specific to ulcerative colitis. Frequent bloody stools are hallmark signs, making this incorrect, as it’s not a primary finding compared to the nurse’s expected manifestations in ulcerative colitis diagnosis.
Choice C reason: Frothy, fatty stools indicate malabsorption, typical in Crohn’s or pancreatic issues, not ulcerative colitis. Bloody stools are correct, making this incorrect, as it doesn’t align with the nurse’s anticipated findings in a client with ulcerative colitis.
Choice D reason: Bloody stool is a classic finding in ulcerative colitis due to mucosal inflammation and ulceration. This aligns with gastrointestinal assessment, making it a correct finding the nurse would determine is consistent with the client’s ulcerative colitis diagnosis.
Choice E reason: 10 to 20 liquid stools daily reflect severe diarrhea, a key feature of ulcerative colitis exacerbations. This aligns with clinical manifestations, making it a correct finding the nurse would identify in a client diagnosed with ulcerative colitis during assessment.
Choice F reason: Right lower quadrant pain is more typical of Crohn’s or appendicitis, not ulcerative colitis, which affects the left colon. Left quadrant pain is correct, making this incorrect, as it doesn’t support the nurse’s findings for ulcerative colitis diagnosis.
Choice G reason: Left lower quadrant pain is consistent with ulcerative colitis, as inflammation often affects the sigmoid colon. This aligns with abdominal assessment, making it a correct finding the nurse would expect in a client with ulcerative colitis during evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A reason: Bilateral pedal pulses at 88 beats/min indicate restored circulation post-fasciotomy, preventing compartment syndrome. This aligns with vascular assessment post-burn and fracture, making it a correct finding showing the nurse’s actions were effective in maintaining perfusion in the leg.
Choice B reason: No swelling in lower extremities post-fasciotomy indicates reduced pressure and effective decompression, preventing tissue damage. This aligns with post-surgical burn care, making it a correct finding demonstrating the nurse’s actions were successful in managing the client’s leg injury.
Choice C reason: Spontaneous respirations are expected with intubation but unrelated to fasciotomy effectiveness for leg burn and fracture. Pulse presence is more relevant, making this incorrect, as it does not reflect the outcome of the nurse’s actions on the leg injury.
Choice D reason: Pulse oximetry of 93% reflects respiratory status, not fasciotomy effectiveness for leg perfusion. No swelling is a direct outcome, making this incorrect, as it’s unrelated to the nurse’s actions addressing the burn and fracture in the client’s leg.
Choice E reason: Pain reduced to 5/10 from 10 post-fasciotomy indicates effective decompression and pain management. This aligns with post-surgical burn care outcomes, making it a correct finding showing the nurse’s actions improved the client’s comfort and leg injury status.
Choice F reason: Normal temperature of 98.6°F is expected but doesn’t directly indicate fasciotomy effectiveness for leg perfusion. Pedal pulses are more specific, making this incorrect, as it’s not a primary outcome of the nurse’s actions for the client’s leg injury.
Correct Answer is B
Explanation
Choice A reason: Tongue furrows indicate dehydration but don’t assess ambulation safety, which requires hemodynamic stability. Orthostatic blood pressure changes are key, making this incorrect, as it’s less relevant than the nurse’s priority to evaluate fall risk in a dehydrated client.
Choice B reason: Comparing blood pressure in lying, sitting, and standing positions detects orthostatic hypotension, a fall risk in dehydrated older clients. This aligns with mobility safety assessment, making it the correct action to determine if the client is safe for independent ambulation.
Choice C reason: Serum potassium above 3.5 mEq/L ensures cardiac stability but doesn’t directly assess ambulation safety. Orthostatic changes are more relevant, making this incorrect, as it’s not the nurse’s primary focus for evaluating mobility in a dehydrated client.
Choice D reason: Radial and apical pulse consistency checks pacemaker function, not ambulation safety in dehydration. Blood pressure changes are critical, making this incorrect, as it’s unrelated to the nurse’s assessment of safe independent ambulation in the dehydrated older client.
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