A nurse is assessing a client with suspected acute cholecystitis. Which of the following physical examination findings is a hallmark sign of this condition?
Rebound tenderness in the right upper quadrant
Murphy's sign
Hypoactive bowel sounds
Left lower quadrant abdominal pain
The Correct Answer is B
Choice A reason:
Rebound tenderness in the right upper quadrant is not a hallmark sign of acute cholecystitis. It may be present in conditions such as appendicitis or peritonitis.
Choice B reason:
This statement is correct. Murphy's sign is a hallmark sign of acute cholecystitis. It is elicited by asking the client to take a deep breath while the nurse palpates the right upper quadrant. If the client abruptly stops breathing due to pain upon palpation, it indicates inflammation of the gallbladder (positive Murphy's sign).
Choice C reason:
Hypoactive bowel sounds may be present in some gastrointestinal conditions but are not specific to acute cholecystitis.
Choice D reason:
Left lower quadrant abdominal pain is not associated with acute cholecystitis. This type of pain is more commonly seen in conditions such as diverticulitis or colitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
This statement is correct and does not indicate a need for further teaching. Eating a low-fat diet after cholecystectomy is recommended to prevent symptoms and complications related to the digestion of fatty foods.
Choice B reason:
This statement is correct and does not indicate a need for further teaching. Avoiding heavy lifting for at least four weeks after cholecystectomy is important to allow the surgical site to heal properly and prevent strain on the incision site.
Choice C reason:
This statement is correct and does not indicate a need for further teaching. It is essential to continue taking prescribed antibiotics until they are finished to prevent infection and promote proper healing after surgery.
Choice D reason:
This statement is incorrect and indicates a need for further teaching. The client should not resume their regular exercise routine immediately after the surgery. After cholecystectomy, clients should avoid strenuous physical activities for a period specified by the healthcare provider to promote proper healing and prevent complications. The nurse should educate the client on gradually increasing their activity level and resuming exercise after receiving clearance from their healthcare provider.
Correct Answer is B
Explanation
Choice A reason:
Administering pain medication is important, but assessing the client's vital signs and pain level takes priority to determine the severity of the pain and the appropriate intervention.
Choice B reason:
This statement is correct. Assessing the client's vital signs and pain level is the first action the nurse should take to evaluate the client's condition and determine the appropriate intervention.
Choice C reason:
Placing the client in a semi-Fowler's position may provide some comfort, but it does not address the underlying pain or assist in determining the severity of the situation.
Choice D reason:
Offering herbal tea for relaxation is a non-pharmacological intervention that can be helpful, but it is not the first action the nurse should take when the client is experiencing severe abdominal pain.
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