Explanation:
"Check the client's glucose level" is a valid intervention, as monitoring glucose levels is essential when a client is receiving total parenteral nutrition (TPN). TPN solutions contain glucose, which can affect blood sugar levels, so regular monitoring helps prevent complications such as hyperglycemia or hypoglycemia.
Explanation:
Smoking cigarettes is a major risk factor for the development of IBD and should be the behavior on which the nurse focuses. Dietary changes, such as a low-fat diet or eliminating alcohol, are not associated with decreasing the risk of IBD. Increasing regular exercise does not reduce the risk of developing IBD.
Explanation:
Option 2, "Rest the client's bowels," is the most appropriate intervention during an acute exacerbation of ulcerative colitis. This allows the colon to heal by reducing inflammation. Options 1, 3, and 4 may be relevant in other contexts but are not specifically targeted at managing an acute exacerbation of this condition.
Explanation: A child with severe UC is having frequent diarrhea and most likely has a fluid volume deficit. The priority goal for this child is to maintain adequate hydration to support fluid, electrolyte, and acid-base balance. Healthy coping skills are important, but physiological needs should be addressed first. The child may be too young to self-administer medication. There is no indication that the child is having difficulty sleeping.
Explanation:
Aphthoid lesions are small, inflammatory ulcers with a white base and elevated margin. They have a similar appearance to a canker sore, but they are not cankers. A crypt abscess is found in the beginning stages of ulcerative colitis, not Crohn’s disease. Fistulas appear as Crohn’s disease progresses, not in the early stages.
Explanation:
Sulfasalazine is a medication commonly used to treat inflammatory bowel disease (IBD) because it releases 5-aminosalicylic acid (5-ASA), which acts topically on the colon mucosa to reduce inflammation. Option 1 is incorrect because sulfasalazine is typically administered orally. Option 2 is inaccurate because sulfasalazine does not directly affect gastrointestinal motility. Option 3 is incorrect because sulfasalazine does not primarily function as an antibiotic.
Explanation:
During an acute exacerbation of inflammatory bowel disease (IBD), the priority intervention for the nurse is to closely monitor the client's gastrointestinal symptoms, particularly the frequency, amount, and color of stools. This assessment helps evaluate disease severity and guide treatment decisions.
Explanation:
Option 3 demonstrates therapeutic communication by acknowledging the client's distress, offering support, and initiating a conversation. It validates the client's feelings and provides an opportunity for the client to express concerns.
Explanation:
Ulcerative colitis typically presents with symptoms such as bloody diarrhea, abdominal pain, and urgency to defecate. The presence of frequent bloody stools, as described in option 1, is a hallmark symptom of ulcerative colitis. Options 2, 3, and 4 are not typically associated with ulcerative colitis.
Explanation:
Option 2, "Assess the client for muscle weakness," is the priority because a low serum potassium level can cause muscle weakness. Assessing for this symptom helps the nurse understand the severity of the condition and guides further actions. Options 1, 3, and 4 may be necessary, but assessing for muscle weakness is the immediate priority to address the potential impact of low potassium levels on the client's health.
Explanation:
A low-residue diet typically consists of foods that are low in fiber, such as white rice and plain custard. Foods like roast pork and white rice are easily digestible and unlikely to aggravate symptoms associated with ulcerative colitis.
