A client diagnosed with cholecystitis reports right upper quadrant pain that radiates to the right shoulder. Which of the following interventions is the priority for the nurse to implement?
Administer IV ketorolac.
Report findings to healthcare provider.
Offer a high-calorie, high-fat meal.
Assess the pain level.
The Correct Answer is D
Choice A reason: This is incorrect because administering IV ketorolac is not a priority intervention for a client with cholecystitis. Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal bleeding and kidney damage, which are contraindicated in cholecystitis. The nurse should administer analgesics as prescribed, but only after assessing the pain level and severity.
Choice B reason: This is incorrect because reporting findings to healthcare provider is not a priority intervention for a client with cholecystitis. The nurse should communicate with the healthcare provider about the client's condition and treatment plan, but only after assessing the pain level and other vital signs.
Choice C reason: This is incorrect because offering a high-calorie, high-fat meal is not an intervention for a client with cholecystitis, but a potential trigger. High-fat foods can stimulate the gallbladder to contract and cause more pain and inflammation. The nurse should advise the client to avoid fatty foods and follow a low-fat diet.
Choice D reason: This is the correct answer because assessing the pain level is a priority intervention for a client with cholecystitis. Pain is the most common symptom of cholecystitis and can indicate the severity and complications of the condition. The nurse should assess the pain level using a numeric or descriptive scale, and monitor for changes in location, intensity, and duration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Reporting itching if it becomes bothersome is part of client teaching, as it may indicate inflammation or infection of the ear canal. External otitis is also known as swimmer's ear, as it can be caused by water trapped in the ear after swimming or bathing.
Choice B Reason: Using earplugs when swimming is part of client teaching, as it can prevent water from entering and irritating the ear canal. External otitis can be prevented by keeping the ear dry and avoiding trauma or foreign objects.
Choice C Reason: This is the correct choice. Inserting a cotton-tip applicator to remove excess wax is not part of client teaching, as it can damage or scratch the ear canal and increase the risk of infection. Wax helps protect and lubricate the ear canal and should not be removed unless it causes hearing impairment or discomfort.
Choice D Reason: Using a hairdryer set to low, 6 inches away from ear is part of client teaching, as it can help dry the ear canal after swimming or bathing. External otitis can be treated by applying warm compresses, using topical antibiotics or antifungals, and taking pain relievers or anti-inflammatory drugs.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because acute hemorrhagic stroke is not consistent with these observations. Acute hemorrhagic stroke is a sudden bleeding in the brain that can cause severe neurological deficits, such as paralysis, aphasia, or coma. It does not cause tremors, slowness, or mask-like facial expressions.
Choice B reason: This is incorrect because Alzheimer's disease is not consistent with these observations. Alzheimer's disease is a progressive degeneration of the brain that causes cognitive impairment, memory loss, and behavioral changes. It does not cause tremors, slowness, or mask-like facial expressions.
Choice C reason: This is the correct answer because Parkinson's disease is consistent with these observations. Parkinson's disease is a chronic disorder of the brain that affects movement and coordination. It causes tremors, slowness, rigidity, and postural instability, as well as mask-like facial expressions due to reduced facial muscle activity.
Choice D reason: This is incorrect because traumatic brain injury is not consistent with these observations. Traumatic brain injury is damage to the brain caused by external force, such as a blow, fall, or penetration. It can cause various neurological symptoms depending on the location and severity of the injury, but it does not typically cause tremors, slowness, or mask-like facial expressions.
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