A nurse is providing education to a client who needs a cholecystectomy due to a build-up of calculi or gallstones. Which of the following is the best response from the nurse to explain what caused this problem?

The gallbladder has become blocked by a tumor and is no longer working.

The gallbladder has become inflamed due to a build-up of gallstones that are blocking the common bile duct.

The gallbladder has become inflamed due to the cholesterol in the gallstones.

The gallbladder became infected by a virus and needs to be removed.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

This option suggests that the gallbladder is blocked by a tumor. While tumors can cause blockages, they are not the most common cause of gallbladder inflammation requiring a cholecystectomy. Gallstones are a more frequent cause of such issues.

Choice B Reason:

This is the correct answer. Gallstones can block the common bile duct, leading to inflammation of the gallbladder, a condition known as cholecystitis. This blockage prevents bile from flowing out of the gallbladder, causing pain and potentially leading to infection.

Choice C Reason:

While cholesterol is a component of many gallstones, the inflammation of the gallbladder is typically due to the physical blockage caused by the stones rather than the cholesterol itself. The blockage leads to bile buildup and subsequent inflammation.

Choice D Reason:

Gallbladder infections caused by viruses are extremely rare. Most gallbladder infections are bacterial and occur secondary to blockages caused by gallstones.

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Correct Answer is D

Explanation

Choice A Reason: The client should maintain systolic BP between 130 and 135 mm Hg

Maintaining a systolic BP between 130 and 135 mm Hg is higher than the recommended range for someone who has experienced a transient ischemic attack (TIA). According to the American Heart Association, the goal for systolic BP in patients with a history of TIA or stroke should be lower to reduce the risk of recurrent events. While this range is not extremely high, it is still above the optimal target for secondary prevention.

Choice B Reason: The client should maintain systolic BP between 141 and 145 mm Hg

This range is significantly higher than the recommended target for systolic BP in patients with hypertension and a history of TIA. Elevated BP in this range increases the risk of recurrent stroke and other cardiovascular events. Effective BP management is crucial in reducing these risks, and maintaining a systolic BP in this range would not be advisable.

Choice C Reason: The client should maintain systolic BP between 136 and 140 mm Hg

Although this range is slightly lower than choice B, it is still above the optimal target for patients with a history of TIA. Research indicates that tighter BP control can significantly reduce the risk of recurrent strokes. Therefore, maintaining a systolic BP in this range would not be ideal for secondary prevention.

Choice D Reason: The client should maintain systolic BP between 120 and 129 mm Hg

This range aligns with the current guidelines for BP management in patients with a history of TIA or stroke. Maintaining a systolic BP between 120 and 129 mm Hg helps reduce the risk of recurrent cerebrovascular events4. This target is considered optimal for secondary prevention and is supported by evidence from various studies and clinical guidelines.

A. I will call your provider so we can discuss it. B. What are you thinking that you would like to do? C. You have the right to refuse if you don’t think you can do this. D. Many clients your age are able to adjust surprisingly well to a prosthesis.

Correct Answer is D

Explanation

Choice A Reason: I will call your provider so we can discuss it

While this response shows the nurse’s willingness to involve the healthcare provider, it does not directly address the client’s concern about their ability to manage the prosthesis. It is important to provide immediate reassurance and encouragement to the client, which this response lacks.

Choice B Reason: What are you thinking that you would like to do?

This response is open-ended and encourages the client to express their feelings and thoughts. While it is a good approach to understand the client’s perspective, it does not provide the immediate reassurance and encouragement that the client needs to feel confident about managing the prosthesis.

Choice C Reason: You have the right to refuse if you don’t think you can do this

This response acknowledges the client’s autonomy but may inadvertently reinforce their doubts and fears about managing the prosthesis. It is important to encourage and support the client rather than focusing on their right to refuse.

Choice D Reason: Many clients your age are able to adjust surprisingly well to a prosthesis

This response is the most appropriate as it provides reassurance and encouragement to the client. By sharing that many clients of a similar age have successfully adjusted to a prosthesis, the nurse helps to build the client’s confidence and reduce their anxiety about managing the new situation. This positive reinforcement can be very motivating for the client.

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A nurse is providing education to a client who needs a cholecystectomy due to a build-up of calculi or gallstones. Which of the following is the best response from the nurse to explain what caused this problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?

Correct Answer is D

Explanation

An older adult client returned to the nursing home after a lower limb amputation. The client is scheduled for a prosthesis fitting and states, “I am too old to learn how to manage this.” Which of the following responses from the nurse is appropriate?

Correct Answer is D

Explanation

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