The nurse is caring for a patient with ulcerative colitis and severe diarrhea.
Which nursing assessment is the highest priority?

Choice A rationale

Avoiding snacking between meals can actually worsen GERD symptoms for some individuals by allowing the stomach to become completely empty, which can then lead to increased acid production when the next meal is consumed. Smaller, more frequent meals are often recommended to maintain a more consistent level of gastric contents and reduce acid reflux.

Choice B rationale

Limiting foods high in fiber is generally not recommended for managing GERD. Fiber helps with gastric emptying and can prevent constipation, which can indirectly increase intra-abdominal pressure and potentially worsen reflux. A balanced diet with adequate fiber is usually encouraged.

Choice C rationale

Elevating the head of the bed by 6 to 8 inches, not 18 inches, is a recommended strategy to manage GERD. Gravity helps to keep stomach acid down in the stomach. An elevation of 18 inches might be too steep and uncomfortable for sleeping, potentially leading to other issues.

Choice D rationale

Avoiding eating 2 to 3 hours before bedtime is a crucial recommendation for managing GERD. Lying down shortly after eating can facilitate the backflow of stomach acid into the esophagus because gravity no longer assists in keeping the acid in the stomach. Allowing time for some gastric emptying before lying down can significantly reduce nighttime reflux symptoms. .

Choice A rationale

Decreased right knee range of motion is a common finding in older adults due to age-related degenerative changes like osteoarthritis. While it warrants assessment, it does not necessarily indicate an acute issue requiring immediate intervention unless accompanied by pain, swelling, or functional limitations.

Choice B rationale

Report of left hip aching when jogging could be related to musculoskeletal issues like arthritis or muscle strain, which are not uncommon in older adults. Further assessment is needed to determine the cause and appropriate management, but it does not immediately signal a critical issue requiring urgent intervention.

Choice C rationale

A history of recent loss of balance and a fall in a 77-year-old patient is a significant finding that requires further nursing assessment and intervention. Falls in older adults can lead to serious injuries such as fractures, and a recent history suggests an underlying issue affecting stability and safety. This necessitates investigation into potential causes and implementation of fall prevention strategies.

Choice D rationale

Occasional mild constipation is a common complaint among older adults due to factors like decreased physical activity, dietary changes, and medication side effects. While it should be addressed with appropriate interventions like increased fiber and fluids, it does not typically require immediate or urgent nursing intervention unless it is severe or accompanied by other concerning symptoms. .