Which assessment findings will the nurse anticipate in the client with cholelithiasis?

Coffee ground emesis, nausea/vomiting

Right lower quadrant abdominal pain, constipation.

Absent bowel sounds, abdominal pain

Right upper quadrant abdominal pain, nausea/vomiting

Answer and Explanation

The Correct Answer is D

Cholelithiasis refers to the presence of gallstones in the gallbladder or bile ducts. The most common symptom is right upper quadrant abdominal pain, which may be colicky or steady. Nausea and vomiting are also commonly associated with cholelithiasis.

Coffee ground emesis and constipation are not typical findings associated with cholelithiasis. Absent bowel sounds may be a sign of bowel obstruction but are not specific to cholelithiasis.

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Correct Answer is D

Explanation

These symptoms suggest the possibility of deep vein thrombosis (DVT), which is a potentially serious complication following surgery. DVT occurs when a blood clot forms in a deep vein, commonly in the lower extremities. The symptoms of a swollen, warm, and painful calf can indicate the presence of a DVT.

DVT is a medical emergency that requires immediate attention and intervention to prevent further complications such as a pulmonary embolism (where the blood clot travels to the lungs). Prompt evaluation and treatment, such as anticoagulant therapy, are necessary to prevent complications

A. Notify the healthcare provider that the client's pain is not well-managed B. Reassure the client that the pain and stress of the fracture will soon get better. C. Order a chest CT Computerized Tomography) to rule out a pulmonary embolus (PE). D. Notify the healthcare provider that the client may have a fat embolism

Correct Answer is D

Explanation

Fat embolism syndrome can occur when fat globules enter the bloodstream after a long bone fracture, such as a femur fracture. The fat globules can travel to the lungs and cause respiratory distress and decreased oxygen saturation. The symptoms observed in the client, including tachypnea (labored breathing), decreased oxygen saturation (88%), and the presence of petechiae (small red or purple spots) on the neck and anterior chest, are consistent with fat embolism syndrome.

Fat embolism syndrome is a serious condition that requires immediate medical attention. Notifying the healthcare provider allows for prompt evaluation, confirmation of the diagnosis, and initiation of appropriate treatment. This may involve further diagnostic tests such as a chest CT scan, as mentioned in one of the options, to rule out other potential causes or complications.

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Which assessment findings will the nurse anticipate in the client with cholelithiasis?

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