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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Contact precautions are recommended for patients with MRSA to prevent the spread of the bacteria. This includes measures such as placing the patient in a single room, using personal protective equipment (PPE) like gowns and gloves, and ensuring proper hand hygiene. These precautions help to minimize the risk of transmission through direct or indirect contact with the patient or their environment.
Choice B Reason:
Protective precautions, also known as reverse isolation, are used to protect immunocompromised patients from infections. This is not applicable for MRSA patients, as the goal is to prevent the spread of MRSA to others, not to protect the patient from external infections.
Choice C Reason:
Airborne precautions are used for diseases that are transmitted through the air, such as tuberculosis or measles. MRSA is not transmitted through airborne particles, so this type of precaution is not appropriate.
Choice D Reason:
Droplet precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis. MRSA is primarily spread through direct contact, not through respiratory droplets, making droplet precautions unnecessary.
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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