A nurse is collecting data from a client who has acute cholecystitis. Which of the following findings should the nurse expect?
Pain in the right upper abdomen
Discomfort with urination
Pain radiating to the jaw
Increased abdominal discomfort prior to meals
The Correct Answer is A
A. Pain in the right upper abdomen is correct. Acute cholecystitis is the inflammation of the gallbladder, typically caused by gallstones blocking bile flow. This condition leads to severe right upper quadrant (RUQ) pain, often triggered by fatty meals and sometimes accompanied by nausea, vomiting, and fever.
B. Discomfort with urination is incorrect. Urinary discomfort is not associated with cholecystitis. This symptom is more indicative of urinary tract infections (UTIs) or kidney stones.
C. Pain radiating to the jaw is incorrect. Jaw pain is more characteristic of cardiac conditions, such as myocardial infarction (MI), rather than gallbladder inflammation.
D. Increased abdominal discomfort prior to meals is incorrect. Clients with cholecystitis typically experience more pain after meals, especially fatty foods, due to gallbladder contractions attempting to release bile.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Inspect the preschooler's tonsils for edema.: While tonsil inspection might be part of a general assessment, in a child with suspected epiglottitis, inspecting the throat should be avoided as it can trigger airway obstruction or cause further distress.
B. Collect a sputum sample.: Sputum collection is not typically indicated for epiglottitis diagnosis. A rapid diagnosis is essential to ensure timely intervention, and sputum samples are not a key diagnostic tool for this condition.
C. Determine the preschooler's oxygen saturation level.: Epiglottitis can lead to significant airway obstruction, so monitoring the oxygen saturation level is critical to assess for hypoxia and ensure adequate oxygenation. Early intervention may be required to maintain the child's airway.
D. Obtain a specimen for throat culture.: A throat culture should not be obtained in suspected epiglottitis, as manipulating the throat could cause complete airway obstruction. Immediate intervention to secure the airway is the priority.
Correct Answer is B
Explanation
A. The client should use a hair dryer on a warm setting to relieve itching inside the cast is incorrect. Using a hair dryer could cause skin burns or damage the cast. Additionally, the client should avoid introducing moisture into the cast, which could lead to skin irritation or infection.
B. The client's extremity should be elevated after the cast is applied is correct. Elevating the extremity helps reduce swelling and inflammation during the initial phase after cast application. It is important to elevate the limb above the level of the heart to promote venous return and reduce swelling.
C. The client can shower with the cast after 24 hr is incorrect. The plaster cast should not get wet. The nurse should instruct the client to keep the cast dry at all times. A plastic cover or cast protector should be used when showering to prevent moisture from seeping into the cast.
D. The client should keep the cast covered until it is dry is incorrect. It is true that the cast should be kept dry, but keeping it covered is not enough. The primary concern is preventing moisture and ensuring the plaster cast is allowed to air dry in a well-ventilated area without getting wet.
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