A nurse is collecting data from a patient who is African American and has cholecystitis.
Which of the following areas should the nurse inspect to monitor for the presence of jaundice?
The sclera
Nail beds
Periumbilical area
Webbed areas of the fingers .
The Correct Answer is A
Choice A rationale
Jaundice, a common symptom of cholecystitis, is a yellow discoloration of the skin and whites of the eyes (sclera) caused by an excess of bilirubin in the blood. The sclera is often the first place where jaundice is noticeable because the high amount of elastin in the sclera binds to bilirubin, causing a yellowish discoloration.
Choice B rationale
While nail beds can sometimes show signs of certain health issues, they are not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.
Choice C rationale
The periumbilical area (around the belly button) is not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.
Choice D rationale
The webbed areas of the fingers are not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Assuring the patient that the problem is temporary may not be accurate. Postoperative dysphagia could indicate a complication from the surgery, such as the stomach fundus being wrapped too tight around the esophagus, causing food obstruction. It’s important to not dismiss the patient’s concerns without proper assessment.
Choice B rationale
Cutting the food into small pieces might help the patient swallow easier, but it does not address the underlying issue. The patient’s difficulty in swallowing could be a sign of a serious problem that needs medical attention.
Choice C rationale
Reporting the observation to the healthcare provider (HCP) is the correct action. After the repair of a paraesophageal hernia, dysphagia should be reported to the HCP. The corrective fundoplication surgery may have the stomach fundus wrapped too tight around the esophagus, causing food obstruction.
Choice D rationale
Offering the patient liquids instead might alleviate the symptom temporarily, but it does not solve the potential problem. The healthcare provider needs to be informed about the dysphagia to assess and treat the possible complication.
Correct Answer is C
Explanation
Choice A rationale
Condition A is not typically associated with a risk for vitamin deficiency. Vitamin deficiencies are usually caused by inadequate intake, poor absorption, or increased demand for vitamins.
Choice B rationale
Condition B is not typically associated with a risk for vitamin deficiency. Vitamin deficiencies are usually caused by inadequate intake, poor absorption, or increased demand for vitamins.
Choice C rationale
Condition C, also known as pernicious anemia, is associated with a risk for vitamin B12 deficiency. This condition impairs the body’s ability to absorb vitamin B12 from the gastrointestinal tract.
Choice D rationale
Condition D is not typically associated with a risk for vitamin deficiency. Vitamin deficiencies are usually caused by inadequate intake, poor absorption, or increased demand for vitamins
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