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 D
Explanation
Rationale:
A. While assessing body temperature is important, it is not the most critical action prior to administering vancomycin.
B. Auscultating bowel sounds can provide information about gastrointestinal function but is not specifically required before administering vancomycin.
C. Measuring oxygen saturation is important in assessing respiratory status but is not related to the administration of vancomycin.
D. Checking serum creatinine is essential because vancomycin can affect renal function, and assessing kidney function is critical before administration to prevent potential toxicity, especially in patients with a history of renal impairment.
Correct Answer is D
Explanation
Rationale:
A. Uncontrollable shaking can be a side effect of albuterol, but it is not as critical as other potential cardiovascular concerns.
B. Increased anxiety is common with respiratory distress but is not immediately life-threatening.
C. Throat irritation may occur but is generally not a severe concern compared to cardiovascular effects.
D. An irregular rapid heart rate is a significant sign of potential adverse effects from albuterol, indicating possible toxicity or worsening of the client’s condition, which requires immediate intervention.