Difficulty: Medium
Average Score: 73%
Simulated
Passage / Scenario
Vital Signs 1405: Temperature 38° C (100.4° F), Heart rate 96/min, Respiratory rate 18/min, Blood pressure 104/72 mm Hg, Oxygen saturation 98% on room air; Laboratory Results 1430: C-reactive protein 3.2 mg/dL (<1.0 mg/dL), Albumin 3.4 g/dL (3.5 to 5.0 g/dL), Hemoglobin 11 g/dL (10 to 15.5 g/dL), Hematocrit 33% (32% to 44%), RBC count 4.0 x 10°/μL (4.0 to 5.5 x 10/μL), WBC count 13,000/mm3 (5,000 to 10,000/mm3), Platelets 275,000/mm3 (150,000 to 400,000/mm3), Potassium 3.5 mEq/L (3.4 to 4.7 mEq/L), Magnesium 1.4 mEq/L (1.4 to 1.7 mEq/L), Total calcium 9.0 mg/dL (8.8 to 10.8 mg/dL); Stool: Positive for occult blood (negative), Positive for leukocytes 4/high-power field (<2/high-power field), Negative for helicobacter pylori (negative)A nurse is caring for an adolescent in the emergency department (ED). Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct answer
D
Rationale
Action to Take: Gluten-free diet, Record intake; Potential Condition: Crohn's disease; Parameter to Monitor: Albumin, Hemoglobin. Crohn's disease is a chronic inflammatory condition affecting the gastrointestinal tract, requiring a gluten-free diet and careful monitoring of nutrient intake to manage symptoms and prevent malnutrition. Monitoring albumin and hemoglobin levels helps assess the client's nutritional status and response to treatment. The other choices are incorrect because they do not align with the characteristic features of Crohn's disease, such as gluten sensitivity and the need for meticulous dietary management. The actions and parameters in the correct answer are specific to Crohn's disease, making it the most appropriate choice for the scenario presented.