After reviewing the client’s medical record. The nurse suspects a diagnosis of
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale for correct choices:
• Cholelithiasis: The client’s presentation of right upper quadrant abdominal pain radiating to the back, nausea and vomiting, and history of recent rapid weight loss strongly suggests gallstone formation. The CT scan confirming gallstones provides definitive evidence of cholelithiasis, making this the most likely diagnosis.
• CT scan results: Imaging is the gold standard for diagnosing cholelithiasis. The presence of gallstones on the CT scan directly correlates with the client’s symptoms and confirms the etiology of right upper quadrant pain, nausea, and vomiting. This objective finding supports the nurse’s suspected diagnosis.
Rationale for incorrect choices:
• Peptic ulcer disease: Although the client reports epigastric discomfort and burning sensation, peptic ulcer disease is less likely because the pain is localized primarily to the right upper quadrant and radiates to the back, and the CT scan shows gallstones rather than ulceration.
• Acute pancreatitis: Acute pancreatitis can present with upper abdominal pain radiating to the back and nausea; however, laboratory findings do not indicate markedly elevated amylase or lipase levels, and imaging reveals gallstones rather than pancreatic inflammation.
• Epigastric pain: While epigastric pain is present, the primary complaint is right upper quadrant pain radiating to the back, making this finding nonspecific for the definitive diagnosis. Epigastric pain alone does not confirm cholelithiasis.
• Regurgitation: Regurgitation or burning in the chest may suggest gastroesophageal reflux, but this symptom is secondary and does not explain the radiologic finding of gallstones or the severe right upper quadrant pain, making it an inappropriate basis for diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Tell me why you hurt yourself.": Asking for reasons at admission can feel interrogative and may increase defensiveness or distress. Understanding triggers is important later, but immediate priorities focus on safety and risk assessment rather than detailed exploration of behavior. Timing matters in therapeutic communication.
B. "Who can we call to support you?": Identifying supports is valuable once immediate safety is established. Without first assessing suicidal ideation, the nurse may miss an urgent risk requiring heightened observation or intervention. Support planning follows, not precedes, safety screening.
C. "Do you have thoughts of suicide?": Directly assessing suicidal ideation is essential when self-inflicted injury is present. This question determines immediate risk, level of observation, and need for urgent interventions. Clear, direct inquiry is evidence-based and does not increase self-harm risk.
D. "What coping methods help you when you feel bad?": Exploring coping strategies supports long-term management and recovery. However, it does not establish current lethality risk or intent, which is the priority during admission with active self-injury. Safety assessment must come first.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
Rationale:
• Weigh the adolescent each morning after voiding and before any intake: Daily weight monitoring is a standard intervention in inpatient treatment for anorexia nervosa. Weighing after voiding and before eating ensures accurate, consistent measurement of body weight trends, which is critical for assessing treatment progress and detecting rapid weight loss or gain.
• Monitor the adolescent for 1 hr after each meal: Post-meal monitoring is essential in anorexia nervosa care to prevent purging behaviors, such as vomiting or laxative use. Observation ensures the adolescent consumes the prescribed meals and supports safe refeeding, which is a core component of inpatient treatment protocols.
• Allow the adolescent to exercise for up to 1 hr per day: Exercise is generally restricted in the early phase of treatment for anorexia nervosa to prevent further energy depletion and cardiovascular strain. Permitting exercise could exacerbate malnutrition, weight loss, and electrolyte imbalance.
• Obtain an electrocardiogram: The adolescent exhibits bradycardia (heart rate 48/min), hypotension (80/50 mm Hg), and irregular heart rhythm, which increases the risk of cardiac complications. ECG monitoring is a routine intervention to assess cardiac status and detect arrhythmias associated with severe malnutrition.
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