Nokea
A nurse is assessing a patient who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the patients pain, the nurse should anticipate that it may radiate to what region?
- A. Left upper chest
- B. Inguinal region
- C. Neck or jaw
- D. Right shoulder
Correct Answer: D
Rationale: The patient may have biliary colic with excruciating upper right abdominal pain that radiates to the back or right shoulder. Pain from cholecystitis does not typically radiate to the left upper chest, inguinal area, neck, or jaw.
You may also like to solve these questions
A nurse is preparing a plan of care for a patient with pancreatic cysts that have necessitated drainage through the abdominal wall. What nursing diagnosis should the nurse prioritize?
- A. Disturbed Body Image
- B. Impaired Skin Integrity
- C. Nausea
- D. Risk for Deficient Fluid Volume
Correct Answer: B
Rationale: While each of the diagnoses may be applicable to a patient with pancreatic drainage, the priority nursing diagnosis is Impaired Skin Integrity. The drainage is often perfuse and destructive to tissue because of the enzyme contents. Nursing measures must focus on steps to protect the skin near the drainage site from excoriation. The application of ointments or the use of a suction apparatus protects the skin from excoriation.
A patient is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention should the nurse perform in order to best address this diagnosis?
- A. Position the patient supine to facilitate diaphragm movement.
- B. Administer corticosteroids by nebulizer as ordered.
- C. Perform oral suctioning as needed to remove secretions.
- D. Maintain the patient in a semi-Fowlers position whenever possible.
Correct Answer: D
Rationale: The nurse maintains the patient in a semi-Fowlers position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. A supine position will result in increased pressure on the diaphragm and potentially decreased respiratory expansion. Steroids and oral suctioning are not indicated.
A patient with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure?
- A. Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure.
- B. Laparoscopic cholecystectomy can be performed in a clinic setting, while an open procedure requires an OR.
- C. A laparoscopic approach allows for the removal of the entire gallbladder.
- D. A laparoscopic approach can be performed under conscious sedation.
Correct Answer: A
Rationale: Open surgery has largely been replaced by laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus). As a result, surgical risks have decreased, along with the length of hospital stay and the long recovery period required after standard surgical cholecystectomy. Both approaches allow for removal of the entire gallbladder and must be performed under general anesthetic in an operating theater.
A patients abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the patients laboratory studies, what finding is most closely associated with this diagnosis?
- A. Increased bilirubin
- B. Decreased serum cholesterol
- C. Increased blood urea nitrogen (BUN)
- D. Decreased serum alkaline phosphatase level
Correct Answer: A
Rationale: If the flow of blood is impeded, bilirubin, a pigment derived from the breakdown of red blood cells, does not enter the intestines. As a result, bilirubin levels in the blood increase. Cholesterol, BUN, and alkaline phosphatase levels are not typically affected.
A 55-year-old man has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this patients health problem?
- A. Toxins have accumulated and inflamed your pancreas.
- B. Bacteria likely migrated from your intestines and became lodged in your pancreas.
- C. A virus that was likely already present in your body has begun to attack your pancreatic cells.
- D. The enzymes that your pancreas produces have damaged the pancreas itself.
Correct Answer: D
Rationale: Although the mechanisms causing pancreatitis are unknown, pancreatitis is commonly described as the autodigestion of the pancreas. Less commonly, toxic substances and microorganisms are implicated as the cause of pancreatitis.