A 47-year-old web designer has a 14-year history of ulcerative colitis. He recently moved to your area and presents to your office for continued management of his ulcerative colitis. He has been asymptomatic for the past two years and off all medications for one year with no rectal bleeding, diarrhea, abdominal pain, tenesmus, or fever. Before that he had very active colitis requiring steroids and immunosuppressants. He brings records from his previous physician that include his last three colonoscopy and pathology reports. The reports from 6 and 12 years ago documented active colitis with friable mucosa from the mid-transverse colon to the rectum, superficial ulcerations, crypt abscesses and crypt distortion, and acute and chronic inflammation. The most recent report, from almost three years ago, was fairly unremarkable endoscopically. Numerous random biopsies had been obtained. They showed mucosal changes on histology also consistent with a history of ulcerative colitis, but there was no evidence of active disease. What do you recommend?

Correct Answer: D

Rationale: The correct answer is D: Do not start steroids; if stools are heme-occult positive, then refer for colonoscopy. In this scenario, the patient is asymptomatic for the past two years and off all medications for one year with no signs of active disease. Initiation of steroids is not indicated as the patient is currently in remission. However, given the history of ulcerative colitis and the risk of disease flare-ups, it is important to monitor for any signs of disease recurrence. Checking for heme-occult positive stools can be an early indicator of active disease. Referring for colonoscopy if stools are heme-occult positive allows for a more thorough evaluation of disease activity without unnecessary initiation of steroids. This approach balances the need for monitoring with avoiding unnecessary treatment. Other choices are incorrect as they either recommend starting steroids in a patient in remission (A, C) or do not incorporate monitoring for disease activity (B).

Correct Answer: C

Rationale: The correct answer is C because the patient should be transferred to a transplant center immediately due to the severity of her condition, not only if she does not awaken with lactulose therapy. The patient's rapidly progressing encephalopathy, significant liver enzyme elevations, high INR, and metabolic acidosis indicate severe hepatotoxicity from acetaminophen overdose. Prompt evaluation by a transplant center is essential for potential liver transplant candidacy. Choices A, B, and D are incorrect because: A - She may indeed need a liver transplant due to the severity of her liver injury. B - Intubation and hyperventilation may be necessary for respiratory support in severe cases of acetaminophen overdose. D - N-acetylcysteine is the standard treatment for acetaminophen overdose to prevent liver damage.

Correct Answer: C

Rationale: The primary symptom of a peptic ulcer is abdominal pain. Peptic ulcers are sores that develop on the lining of the stomach, small intestine, or esophagus, causing a dull or burning pain in the stomach area. This pain typically occurs when the stomach is empty and can be relieved by eating or taking antacids. Nausea (choice A) and vomiting (choice D) can occur but are not typically the primary symptoms of a peptic ulcer. Heartburn (choice B) is more commonly associated with gastroesophageal reflux disease (GERD) rather than peptic ulcers.

Correct Answer: A

Rationale: The correct answer is A: Avoid spicy foods. Spicy foods can irritate the stomach lining and exacerbate symptoms of peptic ulcer disease (PUD). By avoiding spicy foods, the patient can reduce the risk of worsening their condition. B: Increasing caffeine intake can stimulate acid production in the stomach, which can aggravate PUD symptoms. C: Limiting fluid intake is not recommended as staying hydrated is important for overall health and can help with digestion. D: Eating three large meals per day can put a strain on the stomach and increase acid production, potentially worsening PUD symptoms. It is better to eat smaller, more frequent meals to help manage PUD.

Correct Answer: B

Rationale: The primary goal of nursing care for a patient with a bleeding peptic ulcer is to manage and prevent shock (Choice B). This is because bleeding from the ulcer can lead to hypovolemic shock, a life-threatening condition. Nursing interventions focus on stabilizing the patient's condition by monitoring vital signs, administering IV fluids, and preparing for potential blood transfusions. Decreasing pain (Choice A) is important but not the primary goal in this emergency situation. Similarly, reducing anxiety (Choice C) and educating about dietary restrictions (Choice D) are important aspects of care but are not the immediate priority when the patient is at risk of shock.