A patient with cholelithiasis asks the nurse why he/she is jaundiced. What is the nurse's best answer?

“Your liver cannot manufacture bile."

"Your pancreas is no longer able to manufacture insulin."

"Your gall bladder is not contracting properly."

"A gallstone can prevent bile from flowing into the Intestines."

Answer and Explanation

The Correct Answer is D

A. "Your liver cannot manufacture bile": The liver can still manufacture bile, but the problem lies in bile flow, not production.

B. "Your pancreas is no longer able to manufacture insulin": This statement refers to diabetes, not cholelithiasis.

C. "Your gall bladder is not contracting properly": While gallbladder dysfunction can cause pain, jaundice specifically occurs due to bile flow obstruction, not just poor contraction.

D. "A gallstone can prevent bile from flowing into the intestines": Gallstones can obstruct the bile ducts, leading to a buildup of bilirubin in the blood, which manifests as jaundice.

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Correct Answer is A

Explanation

A. Avoid positioning the client supine: Orthopnea is the inability to breathe comfortably while lying flat, so the nurse should avoid placing the client in a supine position and instead elevate the head of the bed.

B. Limit the client's activity level: While activity may need to be adjusted, this is not the primary concern for orthopnea.

C. Administer supplemental oxygen at all times: Oxygen may be necessary, but the key issue with orthopnea is the need to avoid lying flat, not necessarily the need for constant supplemental oxygen.

D. Teach the client deep breathing and coughing exercises: While beneficial for other conditions, this does not directly address orthopnea, which is primarily positional.

A. "To the best of your knowledge, are your immunizations up to date?" B. "Have you ever worked in an occupation where you might have been exposed to toxins?" C. "How many alcoholic drinks do you typically consume in a week?" D. "Has anyone in your family ever experienced symptoms similar to yours?"

Correct Answer is C

Explanation

A. "To the best of your knowledge, are your immunizations up to date?" Immunization status is important but is not directly related to the symptoms of jaundice and increased abdominal girth.

B. "Have you ever worked in an occupation where you might have been exposed to toxins?" While toxin exposure could contribute to liver disease, it is less likely the immediate cause compared to alcohol consumption.

C. "How many alcoholic drinks do you typically consume in a week?" Alcohol consumption is a major risk factor for liver disease, which can lead to jaundice and ascites (increased abdominal girth).

D. "Has anyone in your family ever experienced symptoms similar to yours?" Family history is less relevant for acute symptoms of jaundice and abdominal girth, which are more likely related to lifestyle factors like alcohol use.

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A patient with cholelithiasis asks the nurse why he/she is jaundiced. What is the nurse's best answer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing a newly admitted client's electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated?

Correct Answer is A

Explanation

A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation?

Correct Answer is C

Explanation

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