A nurse is collecting data from a client who has obstruction and inflammation of the common bile duct due to cholelithiasis. Which of the following findings is expected for this condition?

Ecchymosis of the extremities

Tenderness in the left upper abdomen

Straw-colored urine

Fatty stools

Answer and Explanation

The Correct Answer is D

A. Ecchymosis of the extremities: Ecchymosis refers to the medical term for a bruise. It's characterized by a discoloration of the skin resulting from bleeding underneath, typically caused by trauma to the blood vessels. This is not directly related to cholelithiasis.

B. Tenderness in the left upper abdomen: Tenderness in the left upper abdomen might be associated with conditions such as pancreatitis or splenic issues, not directly with obstruction and inflammation of the common bile duct due to cholelithiasis.

C. Straw-colored urine: Straw-colored urine is normal and healthy. Dark-colored or cloudy urine might indicate underlying issues, but straw-colored urine is generally a sign of proper hydration.

D. Fatty stools: When the common bile duct is obstructed due to cholelithiasis, proper digestion of fats doesn't occur, leading to the passage of fatty stools. This is due to the inability to properly digest and absorb fats, leading to their presence in the stool.

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Correct Answer is C

Explanation

A. Assume position with legs and rectum lower than the stomach.

Explanation: This position helps gas move through the intestines more effectively, relieving abdominal distension and promoting the passage of flatus. It's a commonly recommended position for patients experiencing discomfort due to abdominal gas.
B. Drink cold liquids.

Explanation: Drinking cold liquids might not directly help with abdominal distension and flatus. Warm liquids, on the other hand, can sometimes promote digestion and relieve gas discomfort.
C. Ambulate several times a day.

Explanation: Ambulation or walking encourages movement in the intestines, aiding in the passage of gas. It also promotes overall bowel function and can help prevent postoperative complications like atelectasis and deep vein thrombosis.
D. Use a straw.

Explanation: Using a straw doesn't have a direct impact on relieving abdominal distension or flatus. It's more relevant for patients who might have difficulty drinking directly from a glass due to medical conditions or after certain types of surgeries

A. Percuss B. Auscultate. C. Palpate. D. Inspect

Correct Answer is D

Explanation

A. Percuss:
Percussion involves tapping the abdomen with the fingers to assess for areas of dullness or resonance. Dullness might indicate organ enlargement or mass, while resonance is the typical sound over air-filled structures. This step helps identify the borders and size of organs.

B. Auscultate:
Auscultation involves listening to the abdomen using a stethoscope. The nurse listens for bowel sounds, which are the noises made by the movement of the intestines. Absence or abnormal bowel sounds can indicate intestinal obstruction or other gastrointestinal issues.

C. Palpate:
Palpation involves gently pressing the abdomen to assess for tenderness, masses, or areas of discomfort. This step helps identify areas of pain or tenderness, guarding, or rigidity, which might indicate inflammation, infection, or other abdominal issues.

D. Inspect:
Inspection involves visually assessing the abdomen for any visible abnormalities such as scars, distention, pulsations, or visible masses. It's the first step in the abdominal assessment process as it provides initial information about the overall condition of the abdomen before physical contact.

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A nurse is collecting data from a client who has obstruction and inflammation of the common bile duct due to cholelithiasis. Which of the following findings is expected for this condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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