A nurse is collecting data from a patient who is African American and has cholecystitis.
Which of the following areas should the nurse inspect to monitor for the presence of jaundice?
The sclera
Nail beds
Periumbilical area
Webbed areas of the fingers .
The Correct Answer is A
Choice A rationale
Jaundice, a common symptom of cholecystitis, is a yellow discoloration of the skin and whites of the eyes (sclera) caused by an excess of bilirubin in the blood. The sclera is often the first place where jaundice is noticeable because the high amount of elastin in the sclera binds to bilirubin, causing a yellowish discoloration.
Choice B rationale
While nail beds can sometimes show signs of certain health issues, they are not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.
Choice C rationale
The periumbilical area (around the belly button) is not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.
Choice D rationale
The webbed areas of the fingers are not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Pain is a subjective experience and can be expressed both verbally and nonverbally. It is important for the nurse to be attentive to both types of expressions to effectively manage the patient’s pain.
Choice B rationale
While it is true that opioids should be used with caution due to the risk of addiction, this statement can be misleading. Opioids are often necessary for managing postoperative pain, and the risk of addiction is low when they are used appropriately and under medical supervision.
Choice C rationale
Considering the patient’s individual expression of pain is crucial in pain management. Pain is a subjective experience and can vary greatly between individuals. Tailoring pain management strategies to the individual patient can improve pain control.
Choice D rationale
Using a pain scale is a common and effective way to monitor the severity of a patient’s pain. It provides a quantifiable measure of pain that can be used to guide treatment decisions.
Correct Answer is D
Explanation
Choice A rationale
Famotidine is a histamine-2 blocker used to decrease the amount of acid the stomach produces. It is not typically associated with liver disease.
Choice B rationale
Levothyroxine is a thyroid hormone used to treat hypothyroidism. It is not typically associated with liver disease.
Choice C rationale
Furosemide is a diuretic used to treat fluid retention (edema) in people with congestive heart failure, liver disease, or a kidney disorder such as nephrotic syndrome. It is not typically associated with liver disease.
Choice D rationale
Acetaminophen is a common over-the-counter medication used to relieve pain and reduce fever. However, high doses or long-term use of acetaminophen can cause liver damage.
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