A nurse in a mental health facility is caring for a client.

Exhibits

For each potential nursing action, click to specify if the potential action is anticipated, nonessential, or contraindicated for the client.

A. The gallbladder has become inflamed due to the cholesterol in the gallstones. While cholesterol is a common component of gallstones, the problem is not just inflammation due to cholesterol itself. Gallstones can cause inflammation (cholecystitis) when they block the bile ducts, leading to pain and potential infection, not just due to cholesterol buildup alone.
B. The gallbladder became infected by a virus and needs to be removed. This statement is not accurate because gallstones typically cause inflammation (cholecystitis) when they obstruct bile flow, not due to a viral infection. The infection typically results from the obstruction of bile flow by the stones, leading to bacterial growth, not a viral cause.
C. The gallbladder has become blocked by a tumor and is no longer working. While tumors in the bile ducts can cause similar symptoms, the most common cause for gallbladder removal (cholecystectomy) is the presence of gallstones, not a tumor. Gallstones can block bile flow, causing inflammation and requiring surgical removal.
D. The gallbladder has become inflamed due to a build-up of gallstones that are blocking the common bile duct. This is the correct explanation. Gallstones can form in the gallbladder and, when they block the common bile duct, they can cause inflammation (cholecystitis), pain, and sometimes infection. This blockage can impair bile flow, leading to symptoms like nausea, vomiting, and jaundice. This is the typical reason for needing a cholecystectomy.

A. Peritonitis is an infection of the peritoneum, typically associated with peritoneal dialysis, not hemodialysis. Symptoms would usually include fever, abdominal pain, and cloudy dialysate rather than headache, nausea, and restlessness.
B. Air embolism is a rare but serious complication of hemodialysis caused by air entering the bloodstream. Symptoms would include chest pain, hypotension, and shortness of breath, not headache, nausea, and restlessness.
C. Dialysis disequilibrium is the correct answer. This complication occurs when there is a rapid change in blood chemistry during hemodialysis, particularly in those with acute kidney injury or chronic kidney disease. The symptoms—headache, nausea, restlessness, confusion, and even seizures—are a result of the rapid reduction in blood urea levels and the shift of fluid and electrolytes in the body.
D. Septicemia refers to a blood infection and is associated with symptoms like fever, chills, hypotension, and tachycardia. While it is a potential complication of dialysis, the described symptoms of headache, nausea, and restlessness are more consistent with dialysis disequilibrium.