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: The statement "Because of the dysrhythmia, blood backs up in the legs and puts you at risk for blood clots" is incorrect. Atrial fibrillation primarily causes blood to pool in the atria, not the legs.

Choice B reason: The statement "Because the atria are quivering, blood flows sluggishly through them, and clots can form along the heart wall, which then could loosen and travel to the lungs or brain" accurately explains the risk of clot formation in atrial fibrillation and the importance of anticoagulant therapy to prevent strokes and other complications.

Choice C reason: The statement "The medications that you are taking cause blood clots as a side effect so you need this medication to prevent them" is incorrect. Anticoagulant therapy in atrial fibrillation is used to prevent clot formation due to the arrhythmia itself, not as a counteraction to the side effects of other medications.

A. High purine diet B. High protein diet C. Not exercising enough D. Taking too much of the prescribed medication

Correct Answer is D

Explanation

Choice A reason: A high purine diet is more commonly associated with gout and hyperuricemia, not cholinergic crisis.

Choice B reason: A high protein diet is not directly related to cholinergic crisis. The crisis is related to medication levels rather than dietary factors.

Choice C reason: Not exercising enough is not a direct cause of cholinergic crisis. Physical activity levels do not impact the balance of acetylcholine in the body in this context.

Choice D reason: A cholinergic crisis occurs due to excessive accumulation of acetylcholine, often from taking too much of prescribed anticholinesterase medications. This can lead to overstimulation of the neuromuscular junction and symptoms such as muscle weakness and respiratory distress.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client with atrial fibrillation about the need to begin long-term anticoagulant therapy. Which explanation should the nurse use to best describe the reasoning for this therapy?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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