A nurse is caring for a client with cholecystitis who is experiencing severe abdominal pain. Which of the following actions should the nurse take first?
Administer pain medication as prescribed.
Assess the client's vital signs and pain level.
Place the client in a semi-Fowler's position.
Offer the client a cup of herbal tea for relaxation.
The Correct Answer is B
Choice A reason:
Administering pain medication is important, but assessing the client's vital signs and pain level takes priority to determine the severity of the pain and the appropriate intervention.
Choice B reason:
This statement is correct. Assessing the client's vital signs and pain level is the first action the nurse should take to evaluate the client's condition and determine the appropriate intervention.
Choice C reason:
Placing the client in a semi-Fowler's position may provide some comfort, but it does not address the underlying pain or assist in determining the severity of the situation.
Choice D reason:
Offering herbal tea for relaxation is a non-pharmacological intervention that can be helpful, but it is not the first action the nurse should take when the client is experiencing severe abdominal pain.
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Correct Answer is C
Explanation
Choice A reason:
While cholecystectomy is a common procedure, minimizing the client's fear and anxiety by downplaying the risks is not appropriate. It is essential to acknowledge the client's concerns and address them appropriately.
Choice B reason:
Avoiding thinking about the surgery may not be helpful for the client. It is essential to encourage open communication and support the client in expressing their fears and concerns.
Choice C reason:
This statement is correct. Encouraging the client to express their fears and concerns allows the nurse to address them appropriately and provide the necessary support and information to reduce anxiety.
Choice D reason:
While sharing personal experiences can sometimes be helpful, it is essential to focus on the client's feelings and needs rather than diverting attention to the nurse's experience.
Correct Answer is C
Explanation
Choice A reason:
Age below 30 years is not a risk factor for developing cholecystitis. Cholecystitis is more commonly seen in individuals over the age of 40, especially in those with additional risk factors such as obesity or a high-fat diet.
Choice B reason:
Regular physical exercise is not considered a risk factor for cholecystitis. In fact, staying physically active is generally beneficial for overall health and may help reduce the risk of gallstone formation.
Choice C reason:
This statement is correct. Family history of gallstones is a significant risk factor for developing cholecystitis. Genetics can play a role in the composition of bile and the propensity to form gallstones.
Choice D reason:
Consuming a low-fat diet is not a risk factor for cholecystitis. On the contrary, a high-fat diet is associated with an increased risk of gallstone formation and subsequent cholecystitis.
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