A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?
Explain that the need to restrict fluids is the primary limitation.
Advise the client to limit foods that are high in calcium and iron.
Describe the use of an elimination diet to find trigger foods.
Instruct the client to avoid foods with gluten, such as wheat bread.
The Correct Answer is C
Rationale:
A. While some clients may need to manage fluid intake based on their symptoms, it is not the primary dietary restriction for Crohn's disease.
B. Clients with Crohn's disease often need to focus on nutrient-rich foods; limiting calcium and iron is not generally advised unless specific deficiencies are present.
C. An elimination diet can help identify trigger foods that exacerbate symptoms, making this response appropriate and beneficial for managing Crohn's disease.
D. Avoiding gluten is specifically related to celiac disease rather than Crohn's disease, as not all individuals with Crohn's need to eliminate gluten unless they have an associated gluten sensitivity.
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Correct Answer is A
Explanation
Rationale:
A. Culturing for sensitive organisms is essential in identifying the causative agent of the infection indicated by the purulent drainage, guiding appropriate antibiotic therapy.
B. Blood pH level is not directly relevant to assessing wound drainage or infection status.
C. C-reactive protein (CRP) can indicate inflammation but is not specific enough to provide immediate information regarding the infection at the wound site.
D. Serum blood glucose level is more relevant for assessing the client's overall metabolic status and risk for infections rather than directly correlating with the purulent drainage observed.
Correct Answer is A
Explanation
Rationale:
A. The priority nursing problem is the risk for aspiration related to difficulty swallowing (dysphagia). This condition poses an immediate risk to the client's safety as they may inhale food or liquids into the lungs, leading to aspiration pneumonia, which can be life-threatening.
B. While chronic pain is significant, addressing the risk of aspiration is more urgent in this context, especially considering the client's current symptoms.
C. Imbalanced nutrition is a concern, but it is secondary to the immediate risk posed by dysphagia and aspiration.
D. Although anxiety and grieving are important to address, they do not present an immediate threat to the client’s safety compared to the risk of aspiration.