A Jewish client has been diagnosed with ulcerative colitis. A nursing diagnosis appropriate for a client who has ulcerative colitis is:

Correct Answer: A

Rationale: Among the given choices, the nursing diagnosis appropriate for a client with ulcerative colitis is "abdominal pain related to decreased peristalsis." Ulcerative colitis is a chronic inflammatory bowel disease that directly affects the lining of the colon and rectum, leading to symptoms such as abdominal pain, diarrhea, and bloody stool. Decreased peristalsis occurs in patients with ulcerative colitis, resulting in abdominal pain due to inflammation and irritation of the intestines. This pain is a common symptom experienced by individuals with ulcerative colitis and can significantly impact their quality of life. Therefore, addressing the client's abdominal pain is crucial in providing effective nursing care for someone diagnosed with ulcerative colitis.

Correct Answer: C

Rationale: During the surgical procedure, the circulating nurse, scrub nurse, and nurse first assistant are responsible for keeping track of all instruments, needles, and sponges used. As the surgical incision is being closed, the circulating nurse and the scrub nurse/nurse first assistant conduct a final count of all needles, sponges, and instruments to ensure that nothing is accidentally left inside the patient's body. This is a critical step in preventing retained surgical items (RSI), which can lead to serious complications for the patient. It is part of the standard protocol in the operating room to have these specific personnel take charge of counting and verifying all items before the procedure is concluded.

Correct Answer: B

Rationale: Carbamazepine is a known enzyme inducer, and it can increase the metabolism of other drugs, such as phenytoin (Dilantin). This can lead to lower levels of phenytoin in the blood and potentially reduce its effectiveness. Therefore, patients taking carbamazepine should be monitored for elevated levels of phenytoin to ensure optimal seizure control. Diplopia (double vision), leukocytosis, and adult respiratory distress syndrome are not typically associated with carbamazepine use.

Correct Answer: D

Rationale: During the first 24 hours after a client is diagnosed with Addisonian crisis, it is crucial for the nurse to frequently assess the client's vital signs. Addisonian crisis is a life-threatening condition resulting from acute adrenal insufficiency. Monitoring vital signs such as blood pressure, heart rate, respiratory rate, and temperature can provide valuable information about the client's condition and response to treatment. Changes in vital signs may indicate worsening or improvement in the client's health status, helping the nurse to make timely interventions and adjustments in the client's care plan. Regular assessment of vital signs is essential in managing the client's stability and preventing complications during this critical period.

Correct Answer: C

Rationale: The signs and symptoms of headache, sweating, tremor, pallor, and nervousness described in the client suggest hypoglycemia, which is caused by low blood sugar levels. Insulin is a medication used to lower blood sugar levels in individuals with diabetes. In this case, the client has taken a combination of regular insulin and NPH insulin before breakfast, which could have led to a rapid drop in blood sugar levels by the afternoon causing the symptoms described. It is important to treat hypoglycemia promptly by giving the client a fast-acting carbohydrate source, such as glucose tablets or juice, to raise their blood sugar back to a safe level.