A 65-year-old client with a history of Crohn's disease prese… | 마이메르시 MyMerci
Adult Health
문제

A 65-year-old client with a history of Crohn's disease presents to the clinic with complaints of fatigue and diarrhea. Which laboratory finding should the nurse anticipate as most characteristic of the expected nutritional deficiency?

해설
Vitamin B12 deficiency causes megaloblastic anemia with pale conjunctiva and glossitis (smooth, red tongue). Other options are associated with iron deficiency (brittle nails), vitamin A deficiency (dry skin), and calcium/vitamin D deficiency (muscle cramps).

심화 해설

Core Nursing Explanation Key Concept Analysis: This question assesses the nurse's ability to link a specific chronic gastrointestinal disease, Crohn's disease, to its most common and characteristic nutritional complication. Crohn's disease is an inflammatory bowel disease (IBD) that primarily affects the terminal ileum. The terminal ileum is the primary site for the absorption of Vitamin B12 and the reabsorption of bile salts. Chronic inflammation and surgical resection in this area lead to malabsorption.

Answer Rationale: Key Point! The most characteristic and anticipated deficiency in Crohn's disease, especially when the ileum is involved, is Vitamin B12 deficiency. Vitamin B12 is essential for DNA synthesis in red blood cells. Its deficiency leads to megaloblastic anemia. The classic clinical signs of this anemia are pallor (pale conjunctiva) and glossitis (a smooth, beefy-red tongue). Fatigue is a direct symptom of anemia, and diarrhea is a hallmark of the underlying Crohn's disease. Therefore, option ② perfectly describes the expected findings.

Distractor Analysis:
  • Option ① (Brittle nails and hair loss): These are classic signs of Watch out for confusion! Iron deficiency anemia, which can also occur in Crohn's due to chronic blood loss but is not the *most characteristic* ileal-related deficiency.
  • Option ③ (Dry, scaly skin and night blindness): These point to a deficiency in Vitamin A, which is a fat-soluble vitamin. While fat malabsorption can occur, it is less specific to Crohn's than B12 deficiency and night blindness is a more advanced sign.
  • Option ④ (Muscle cramps and bone pain): These suggest deficiencies in Calcium and Vitamin D, also fat-soluble vitamins. Malabsorption and steroid therapy (common in Crohn's) can lead to osteoporosis, but again, this is not the primary, most direct deficiency from ileal involvement.
Related Concepts: Understanding "site-specific" complications is crucial. For NCLEX, know that problems in the terminal ileum = think B12 and bile salts. Problems in the duodenum/jejunum = think iron, folate, and general nutrient absorption.

Concept Summary
DeficiencyKey Signs/SymptomsPrimary Site of Absorption Affected in Crohn's
Vitamin B12Fatigue, pallor, glossitis (smooth red tongue), paresthesias, megaloblastic anemiaTerminal Ileum
IronFatigue, pallor, brittle nails, hair loss, pica (microcytic hypochromic anemia)Duodenum
Vitamin ANight blindness, dry skin (xerosis), Bitot's spotsRequires fat absorption (generalized)
Calcium/Vitamin DMuscle cramps, bone pain, osteoporosis, tetany, positive Chvostek's/Trousseau's signDuodenum (Ca), requires fat absorption (Vit D)

Side-by-Side Comparison!
ConditionCharacteristic Nutritional DeficiencyWhy?Key NCLEX Clue
Crohn's Disease (Ileitis)Vitamin B12Inflammation/resection of terminal ileum"Terminal ileum involvement" = Think B12
Ulcerative ColitisIronChronic blood loss from colonic ulcers"Bloody diarrhea" = Think Iron loss
Celiac DiseaseMultiple (Iron, Folate, Fat-soluble vitamins)Villous atrophy in duodenum/jejunum"Gluten sensitivity", generalized malabsorption

Anatomy, Physiology & Pharmacology Points
  • Anatomy: The Terminal Ileum is the last part of the small intestine, connecting to the cecum. It contains specialized receptors for absorbing the Intrinsic Factor-Vitamin B12 complex.
  • Physiology: B12 absorption requires intrinsic factor from gastric parietal cells. The complex is absorbed in the ileum. Without the ileum, even with intrinsic factor, B12 cannot be absorbed.
  • Pharmacology: Patients with ileal resection or severe Crohn's ileitis will require lifelong Vitamin B12 supplementation, typically via intramuscular (IM) injections or high-dose sublingual/oral forms, as oral absorption is impaired.

Memory Tips
  • Mnemonic: "B12 is in the ILEUM" or "I (Ileum) need my B12."
  • Visual Association: Picture the small intestine. The very end (terminal) is like the "B12 station." If that station is closed (inflamed/resected), the B12 train can't stop.
  • Glossitis: Remember, a smooth, red, beefy tongue is a hallmark of B12 (and folate) deficiency—it looks "angry" because the epithelial cells can't regenerate properly.

High-Frequency NCLEX Topics NCLEX loves to test the connection between disease location and specific complications. Crohn's disease and its associated deficiencies (B12, but also fistulas, strictures) are high-yield. Be ready to distinguish the anemia types: megaloblastic (B12/Folate) vs. microcytic hypochromic (Iron).

Watch Out for Question Variations!
  • Shift from Symptom to Lab: Instead of asking for signs, it might ask: "The nurse reviews the lab results for a client with Crohn's disease. Which result requires immediate follow-up?" Correct answer: Low serum Vitamin B12 level.
  • Shift to Intervention: "A client with Crohn's disease and a history of ileal resection reports tingling in their hands and feet. Which prescription should the nurse anticipate?" Correct answer: Schedule for monthly Vitamin B12 intramuscular injections.
  • Shift to Patient Education: "When teaching a client with Crohn's disease about long-term management, the nurse should emphasize the importance of which action?" Correct answer: Adhering to scheduled Vitamin B12 supplementation.

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are a nurse in a gastroenterology clinic. Mr. Johnson, a 65-year-old with a 20-year history of Crohn's disease (with known ileal involvement), comes for a follow-up. He says, "I'm just so tired all the time, no matter how much I sleep. And my diarrhea has been acting up again."

Nursing Intervention Strategy:
  1. Assessment: Perform a focused assessment. Check vital signs (tachycardia? hypotension?). Inspect his conjunctiva and oral mucosa for pallor and glossitis. Ask about paresthesias (tingling/numbness), which are neurological signs of B12 deficiency. Review his medication list (is he on B12 supplements?).
  2. Nursing Diagnosis: Risk for imbalanced nutrition: less than body requirements related to malabsorption secondary to Crohn's disease.
  3. Planning & Implementation:
    • Collaborate with the provider to order labs: Complete Blood Count (CBC) (looking for macrocytic anemia), Serum Vitamin B12 level, and possibly methylmalonic acid (MMA) and homocysteine levels (more sensitive markers).
    • Provide education on the connection between his disease and B12 deficiency.
    • If B12 deficient, administer prescribed B12 injection (e.g., cyanocobalamin 1000 mcg IM) and teach about the lifelong need for supplementation.
    • Discuss dietary modifications for diarrhea management (low-residue, low-fat diet during flares) while ensuring adequate calorie and protein intake.
Patient Safety and Precautions:
  • Key Point! Neurological damage from prolonged B12 deficiency can be irreversible. Early recognition and treatment are critical.
  • Monitor for signs of hypokalemia and fluid volume deficit due to persistent diarrhea.
  • Assess for signs of infection at injection sites if on regular B12 injections.

Nursing Procedure & Medication Flow Vitamin B12 (Cyanocobalamin) Intramuscular Injection:
  • Site: Typically ventrogluteal or vastus lateralis (deep IM).
  • Dose: Often 1000 mcg monthly for maintenance after a loading dose.
  • Patient Education: Explain that this is a replacement therapy, not a cure. It must be continued for life if the ileum is non-functional. Teach signs of deficiency recurrence (fatigue, tingling).

A Word from Your Senior Nurse "In the real world, patients with chronic illnesses like Crohn's often become experts on their own bodies, but they might not connect 'tiredness' to a specific vitamin deficiency. Your role is to be that detective! When you see 'Crohn's + fatigue,' let a little alarm bell ring for 'B12.' It's a simple connection that can dramatically improve a patient's quality of life. On the NCLEX, they're testing if you can make these fundamental pathophysiological links—so always ask yourself, 'What is the core problem in this disease, and what does that break in the system lead to?' That's the heart of nursing knowledge."

핵심 개념

  • Crohn's Disease — A chronic, transmural inflammatory bowel disease that can affect any part of the GI tract from mouth to anus, but most commonly the terminal ileum and colon. It causes skip lesions, strictures, and fistulas.
  • Terminal Ileum — The final section of the small intestine, crucial for the absorption of Vitamin B12 and bile salts. Its inflammation or resection in Crohn's leads to specific deficiencies.
  • Vitamin B12 Deficiency — A condition resulting from inadequate intake or malabsorption of vitamin B12, leading to megaloblastic anemia and neurological symptoms like paresthesias. A hallmark complication of ileal Crohn's disease.
  • Megaloblastic Anemia — A type of anemia characterized by large, immature red blood cells (megaloblasts), caused by impaired DNA synthesis. Most commonly due to deficiencies in Vitamin B12 or folate.
  • Glossitis — Inflammation of the tongue, often appearing smooth, red, and beefy. A classic clinical sign of nutritional deficiencies, particularly Vitamin B12, folate, and niacin (B3).

마이메르시로 국가고시 완벽 대비

기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요.

무료로 시작하기
App Store Google Play

학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.