A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?

Bile-stained emesis.

Clay-colored stool.

Distended, hard, and rigid abdomen.

Radiating, sharp pain in the right shoulder.

Answer and Explanation

The Correct Answer is C

Choice A reason: Bile-stained emesis indicates an obstruction, but it is not as immediately critical as a distended, hard, and rigid abdomen.

Choice B reason: Clay-colored stool is a sign of bile duct obstruction but is not as urgent as the abdomen findings.

Choice C reason:

The correct answer is c) because a distended, hard, and rigid abdomen suggests peritonitis or a perforated organ, which requires immediate medical intervention.

Choice D reason: Radiating, sharp pain in the right shoulder is common in gallbladder issues but is not as immediately life-threatening as a distended, hard, and rigid abdomen.

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Correct Answer is C

Explanation

Choice A reason: While chicken and rice are healthy, they do not specifically address the benefits of fiber in cancer prevention.

Choice B reason: Lean beef is not recommended for reducing the risk of colon cancer, although salads and baked potatoes are healthy choices.

Choice C reason:

The correct answer is c) because oatmeal, raisins, and fruit with skin are high in fiber, which can help reduce the risk of colon and rectal cancers.

Choice D reason: Potatoes and low-fat breads are healthy but do not provide as much fiber as oatmeal, raisins, and fruit with skin.

A. Hypotension and venous pooling in the extremities. B. Pain and a burning sensation upon urination and hematuria. C. Profuse diaphoresis and severe, pounding headache. D. Reports of chest pain and shortness of breath.

Correct Answer is C

Explanation

Choice A reason: Hypotension and venous pooling in the extremities are not typical of autonomic dysreflexia. Autonomic dysreflexia usually results in hypertension due to an exaggerated autonomic response to a stimulus such as a full bladder. This condition is characterized by severe, uncontrolled hypertension rather than hypotension.

Choice B reason: While pain and a burning sensation upon urination and hematuria can be related to a urinary tract infection or bladder issue, they are not specific to autonomic dysreflexia. Autonomic dysreflexia presents with symptoms that result from the body's exaggerated response to the stimulus, such as severe headache and sweating.

Choice C reason:

The correct answer is c) because profuse diaphoresis (sweating) and a severe, pounding headache are hallmark signs of autonomic dysreflexia. This condition occurs in individuals with spinal cord injuries at or above the T6 level and is triggered by stimuli like a full bladder, causing a dangerous rise in blood pressure and severe autonomic responses.

Choice D reason: Reports of chest pain and shortness of breath are not typical signs of autonomic dysreflexia. While these symptoms may be concerning, they are not the primary indicators of this specific condition. The severe headache and sweating are more indicative of autonomic dysreflexia.

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A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?

Correct Answer is C

Explanation

A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

Correct Answer is C

Explanation

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