A nurse is collecting data from a client who has acute cholecystitis. Which of the following findings should the nurse expect?
Pain in the right upper abdomen
Discomfort with urination
Pain radiating to the jaw
Increased abdominal discomfort prior to meals
The Correct Answer is A
A. Pain in the right upper abdomen is correct. Acute cholecystitis is the inflammation of the gallbladder, typically caused by gallstones blocking bile flow. This condition leads to severe right upper quadrant (RUQ) pain, often triggered by fatty meals and sometimes accompanied by nausea, vomiting, and fever.
B. Discomfort with urination is incorrect. Urinary discomfort is not associated with cholecystitis. This symptom is more indicative of urinary tract infections (UTIs) or kidney stones.
C. Pain radiating to the jaw is incorrect. Jaw pain is more characteristic of cardiac conditions, such as myocardial infarction (MI), rather than gallbladder inflammation.
D. Increased abdominal discomfort prior to meals is incorrect. Clients with cholecystitis typically experience more pain after meals, especially fatty foods, due to gallbladder contractions attempting to release bile.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I'm going to contact your family so they can be with you.": While involving family is important, the nurse should first provide emotional support to the client. It may feel abrupt to the client if the nurse immediately redirects the focus to others without acknowledging the client's current emotional state.
B. "I will stay with you for a while.": This is correct. Offering presence and emotional support by staying with the client is an appropriate response. It shows empathy and provides the client with comfort in a time of emotional distress.
C. "I'm sorry you have to deal with this.": This is less supportive. While it acknowledges the difficulty of the situation, it could unintentionally invalidate the client’s feelings by focusing on the nurse’s perspective rather than the client's experience.
D. "When you feel better, we'll talk about your treatment options.": This is not an appropriate response. It minimizes the client’s current emotional needs and may make the client feel that their feelings are not being prioritized. The focus should be on emotional support first.
Correct Answer is A
Explanation
A. Heart rhythm: This is correct. Hypothermia, indicated by a body temperature of 32.5°C (90.5°F), can affect the cardiovascular system, potentially causing arrhythmias or even cardiac arrest. Monitoring heart rhythm is critical because of the risk of life-threatening cardiac complications associated with severe hypothermia.
B. Urinary output: While urinary output may decrease in hypothermic conditions due to vasoconstriction, it is not the priority. Cardiac function takes precedence, as severe hypothermia can lead to fatal arrhythmias.
C. Pain sensation: Although decreased pain sensation can occur in hypothermia, it is less urgent to monitor compared to the potential for life-threatening arrhythmias or cardiac arrest.
D. Muscle strength: While hypothermia can impair muscle strength, it is not the priority compared to monitoring for cardiac irregularities, which can be fatal if left unchecked.
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