The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis?
Right upper quadrant pain
Right lower leg pain
Positive Babinski sign
Yawning at mass
The Correct Answer is A
Choice A reason: Right upper quadrant pain is a common clinical manifestation of cholecystitis, which is inflammation of the gallbladder. The pain is often severe and can radiate to the back or shoulder. It is usually triggered by the intake of fatty foods and may be accompanied by other symptoms such as nausea and vomiting.
Choice B reason: Right lower leg pain is not associated with cholecystitis. This type of pain could indicate other conditions such as deep vein thrombosis or musculoskeletal issues.
Choice C reason: A positive Babinski sign indicates central nervous system dysfunction and is not related to cholecystitis. It involves dorsiflexion of the big toe and fanning of the other toes when the sole of the foot is stimulated.
Choice D reason: Yawning at mass is irrelevant to the diagnosis of cholecystitis. It could indicate tiredness or boredom but has no clinical significance related to gallbladder inflammation.
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Correct Answer is C
Explanation
Choice A reason: Telling the client that they are hospitalized due to a heart attack when it is not the case can cause unnecessary anxiety and fear. It is important to provide accurate information and reassurance.
Choice B reason: Stating that it will never happen again is unrealistic and provides false reassurance. It is important to focus on managing the client's condition and reducing the risk of future episodes.
Choice C reason: Explaining that the client did not have a heart attack but emphasizing the importance of monitoring and managing chest pain provides accurate information and reassurance. It helps reduce the client's anxiety and provides a clear plan of action.
Choice D reason: Saying it is normal to feel chest pain without further explanation can cause confusion and anxiety. It is important to clarify that chest pain needs to be monitored and managed to prevent complications.
Correct Answer is B
Explanation
Choice A reason: While knowing if the client is taking any medications is important, it does not directly relate to diagnosing Guillain-Barré syndrome.
Choice B reason: Guillain-Barré syndrome often follows a recent infection, such as a respiratory or gastrointestinal infection. The immune response to the infection can trigger an autoimmune reaction that damages the peripheral nerves, leading to the symptoms of GBS. Therefore, asking about recent infections helps establish a potential cause for the syndrome.
Choice C reason: Travel history can be relevant for certain infectious diseases, but it is not a primary question for diagnosing GBS.
Choice D reason: A history of chronic alcohol abuse is more relevant to other neurological conditions, such as peripheral neuropathy, but not specifically to Guillain-Barré syndrome.
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