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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Erythema is a sign of infection or irritation, not fluid infiltration. Fluid infiltration typically does not cause redness or inflammation.

B. Edema is correct. Fluid infiltration occurs when the IV catheter becomes displaced and the fluid leaks into the surrounding tissue, causing swelling (edema. at the insertion site.

C. Blood would suggest either an accidental dislodging of the catheter or a complication such as hematoma formation, but it is not a sign of fluid infiltration.

D. Pruritus (itching) is typically associated with an allergic reaction, not fluid infiltration.

A. Encourage the toddler to flush the toilet while still seated. B. Have the toddler remain on the toilet for a minimum of 20 min. C. Wake the toddler every 2 hr. in the night to prevent bed-wetting. D. Give the toddler a sticker after each successful toileting attempt.

Correct Answer is D

Explanation

A. Encouraging the toddler to flush the toilet while still seated is incorrect. Some children may be startled by the flushing sound, which can create fear and resistance to toilet training. It is better to allow the child to stand before flushing if they show hesitation.

B. Having the toddler remain on the toilet for a minimum of 20 minutes is incorrect. Extended sitting can lead to discomfort and frustration, making the experience negative. Shorter, 5- to 10-minute sessions are more effective and developmentally appropriate.

C. Waking the toddler every 2 hours in the night to prevent bed-wetting is incorrect. Nighttime bladder control develops gradually, and disrupting sleep can be counterproductive. Instead, using protective bedding and encouraging toileting before bedtime is recommended.

D. Giving the toddler a sticker after each successful toileting attempt is correct. Positive reinforcement, such as stickers or praise, encourages consistency and motivation, which is particularly beneficial for children with cognitive impairments.

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A nurse is collecting data from a client who has acute cholecystitis. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect at the insertion site?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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