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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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Administering an intramuscular injection is within the LPN’s scope of practice, ensuring safe delegation. This aligns with nursing delegation guidelines, making it the correct example of appropriate task assignment for the nurse to delegate to the LPN on a busy unit.

Choice B reason: Assessing a wound for infection requires RN judgment, exceeding the LPN’s scope. Administering an injection is appropriate, making this incorrect, as it’s an improper delegation compared to the nurse’s choice of a task within the LPN’s role.

Choice C reason: MAs cannot discuss test results, as this requires clinical judgment beyond their scope. LPN injection administration is correct, making this incorrect, as it’s an inappropriate task for the MA compared to the nurse’s proper delegation choice.

Choice D reason: Inserting a nasogastric tube is an RN task, not within the MA’s scope. LPN injection administration is appropriate, making this incorrect, as it’s unsafe delegation compared to the nurse’s selection of a task suitable for the LPN.

A. Apply supplemental oxygen via nasal cannula. B. Administer intravenous morphine for pain. C. Keep the hard collar in place until cleared. D. Administer intravenous methylprednisolone (Solu-Medrol) as prescribed.

Correct Answer is C

Explanation

Choice A reason: Supplemental oxygen is unnecessary with a normal respiratory rate (16) and stable vitals. Maintaining the collar prevents spinal injury, making this incorrect, as it’s not indicated compared to the nurse’s priority of ensuring spinal stability in a client with a fall history.

Choice B reason: Morphine for pain is premature without confirming spinal stability, as it may mask symptoms. Keeping the collar in place is critical, making this incorrect, as it risks missing neurological changes in the nurse’s care of a potential spinal injury client.

Choice C reason: Keeping the hard collar in place until cleared by imaging prevents worsening of potential spinal injury after a trampoline fall. This aligns with trauma care protocols, making it the correct action for the nurse to take to ensure the client’s safety and stability.

Choice D reason: Methylprednisolone is used for confirmed spinal cord injury, not suspected cases without imaging. Maintaining the collar is the priority, making this incorrect, as it’s premature compared to the nurse’s focus on spinal precautions in a client with numbness and tingling.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You are working on a busy unit and need to delegate tasks to the LPN and M

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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