A nurse is caring for a client with cholecystitis who is experiencing severe abdominal pain. Which of the following actions should the nurse take first?
Administer pain medication as prescribed.
Assess the client's vital signs and pain level.
Place the client in a semi-Fowler's position.
Offer the client a cup of herbal tea for relaxation.
The Correct Answer is B
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Engaging in strenuous physical activities may exacerbate the pain and discomfort in a client with chronic cholecystitis. Moderate physical activity is encouraged, but strenuous activities should be avoided.
Choice B reason:
This statement is correct. Applying a heating pad on the abdomen can help alleviate pain and discomfort associated with chronic cholecystitis. Heat therapy helps relax muscles and may ease the tension in the affected area.
Choice C reason:
Consuming a high-fat diet is not recommended for a client with chronic cholecystitis. A low-fat diet is recommended to reduce gallbladder stimulation and prevent symptoms.
Choice D reason:
While over-the-counter NSAIDs can be effective for mild pain relief, they should be used with caution in clients with cholecystitis, especially if there is any concern about gallstone-related inflammation. It is best to consult with a healthcare provider before using NSAIDs in this case.
Correct Answer is C
Explanation
A. Mild, intermittent right upper quadrant (RUQ) pain is more characteristic of chronic cholecystitis rather than acute cholecystitis, which typically presents with severe pain.
B. Left lower quadrant (LLQ) pain with rebound tenderness is more indicative of conditions like diverticulitis, not acute cholecystitis.
C. Severe, colicky abdominal pain radiating to the right shoulder is the most common presentation of acute cholecystitis, often caused by gallbladder inflammation and obstruction of the cystic duct. The pain is due to irritation of the phrenic nerve, which supplies both the gallbladder and right shoulder.
D. Epigastric pain worsened by fatty meals is often seen in gallbladder disease but is more characteristic of biliary colic rather than acute cholecystitis.
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