The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis?

Right upper quadrant pain

Right lower leg pain

Positive Babinski sign

Yawning at mass

Answer and Explanation

The Correct Answer is A

Choice A reason: Right upper quadrant pain is a common clinical manifestation of cholecystitis, which is inflammation of the gallbladder. The pain is often severe and can radiate to the back or shoulder. It is usually triggered by the intake of fatty foods and may be accompanied by other symptoms such as nausea and vomiting.

Choice B reason: Right lower leg pain is not associated with cholecystitis. This type of pain could indicate other conditions such as deep vein thrombosis or musculoskeletal issues.

Choice C reason: A positive Babinski sign indicates central nervous system dysfunction and is not related to cholecystitis. It involves dorsiflexion of the big toe and fanning of the other toes when the sole of the foot is stimulated.

Choice D reason: Yawning at mass is irrelevant to the diagnosis of cholecystitis. It could indicate tiredness or boredom but has no clinical significance related to gallbladder inflammation.

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Correct Answer is B

Explanation

Choice A reason: Decreased central venous pressure is not typically associated with glomerulonephritis. This condition often leads to fluid retention and increased pressure within the blood vessels.

Choice B reason: Hypertension is a common manifestation of glomerulonephritis due to fluid retention and impaired kidney function. The kidneys are unable to excrete excess fluid, leading to increased blood pressure.

Choice C reason: Bradycardia is not typically associated with glomerulonephritis. The condition primarily affects kidney function and fluid balance, rather than heart rate.

Choice D reason: Decreased cardiac output can occur in severe cases of acute kidney injury, but it is not a primary manifestation of glomerulonephritis. Monitoring blood pressure and fluid status is more critical in these patients.

A. Administer the prescribed antipyretic and notify the primary health care provider. B. Assess the color and content of the urine specimen for urinalysis. C. Note the consistency of respiratory secretions and obtain a specimen for culture. D. Compare all prior vital signs and continue to monitor every hour.

Correct Answer is A

Explanation

Choice A reason: Administering an antipyretic to reduce the fever and notifying the primary health care provider are the priority actions. A rapid rise in temperature in a client with multiple myeloma receiving chemotherapy could indicate a serious infection, which requires prompt medical attention.

Choice B reason: Assessing the color and content of the urine specimen for urinalysis is important but is not the immediate priority. The rapid rise in temperature is a more urgent concern.

Choice C reason: Noting the consistency of respiratory secretions and obtaining a specimen for culture is important but not the immediate priority. The primary concern is addressing the fever and notifying the healthcare provider.

Choice D reason: Comparing prior vital signs and continuing to monitor every hour is necessary but not the immediate priority. Immediate action is required to address the fever and potential infection.

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The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis?

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Naxlex Comprehensive Predictor Exams

A client diagnosed with glomerulonephritis is at risk for developing acute kidney injury. Which of the clinical manifestations should the nurse monitor for?

Correct Answer is B

Explanation

A client with multiple myeloma receiving chemotherapy has a temperature of 102.2 degrees Fahrenheit. The temperature was 99.2 degrees Fahrenheit six hours ago. The PRIORITY nursing intervention is to:

Correct Answer is A

Explanation

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