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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Clear-colored outflow is normal and indicates that the dialysis process is functioning correctly.
Choice B reason: Outflow amount exceeding inflow amount may be noted and reported, but it is not an immediate cause for concern unless accompanied by other symptoms.
Choice C reason: Cloudy opaque colored outflow indicates possible peritonitis, an infection of the peritoneum. This is a serious complication that requires immediate medical attention to prevent further complications.
Choice D reason: Non-purulent outflow is not an immediate cause for concern and indicates that there is no infection present.
Correct Answer is A
Explanation
Choice A reason: Hyperkalemia is a common finding in the oliguric phase of acute kidney injury due to reduced excretion of potassium by the kidneys. This electrolyte imbalance can have serious cardiac effects and should be expected and monitored in these patients.
Choice B reason: An increased glomerular filtration rate (GFR) would not be expected in the oliguric phase of acute kidney injury. Typically, GFR is decreased due to reduced kidney function during this phase.
Choice C reason: Decreased creatinine levels are not expected in acute kidney injury. Creatinine levels usually increase as kidney function declines and the body cannot adequately filter waste.
Choice D reason: Hypovolemia is not typically expected in the oliguric phase of acute kidney injury, as oliguria (reduced urine output) often indicates fluid retention rather than fluid loss.
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