Nokea
The nurse is assessing a client with acute cholecystitis. Which of the following physical assessment findings would be expected?
- A. Stools that contain blood and mucus
- B. Pain with urination
- C. Episodic upper abdominal pain
- D. Hypoactive bowel sounds
Correct Answer: C
Rationale: Episodic upper abdominal pain (C), often in the right upper quadrant, is a hallmark of acute cholecystitis due to gallbladder inflammation.
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The emergency department (ED) nurse is caring for a 45-year-old male client.
Item 2 of 6
Nurses’ Notes
0600: The client reports sudden, severe epigastric pain. He has a history of chronic alcohol use disorder (30+ years), GERD, and hypertension. His home medications include pantoprazole and lisinopril. Upon assessment, the client is noted to be alert and oriented x4. He is mildly diaphoretic, with pulses 2+ and regular. Abdomen is distended, guarding on palpation, diminished bowel sounds, and no stool in the last 24 hours. He reports nausea and vomiting, and his pain is worse after eating fatty foods, rated 7/10 and radiating to his back. Breath sounds slightly diminished bilaterally, no adventitious sounds, denies cough or dyspnea. He reports heavy alcohol intake two days ago. Fingerstick glucose is 145 mg/dL (8.06 mmol/L) [70-110 mg/dL; 4-6 mmol/L]. Temperature is 101.3°F (38.5°C), heart rate of 112 bpm, respiratory rate of 24 breaths/min, blood pressure of 98/64 mmHg, and oxygen saturation of 95% on room air.
Orders
0600
• Cardiac monitoring
• NPO
• CBC
• CMP
• LFTs
• Amylase
• Lipase
• CT abdomen with contrast
The nurse is reviewing assessment findings to differentiate between acute pancreatitis and cholecystitis. For each assessment finding below, click to specify if the finding is consistent with the disease process of acute pancreatitis or cholecystitis. Each finding may support more than one (1) disease process. Each column must have at least one (1) response option selected.
- A. Severe epigastric pain
- B. Gray-blue discoloration of the flanks
- C. Nausea and vomiting
- D. Leukocytosis
- E. Elevated lipase and amylase
- F. Hypocalcemia
Correct Answer: A,C,D,E,F;A,C,D
Rationale: Acute pancreatitis: A (Severe epigastric pain), C (Nausea and vomiting), D (Leukocytosis), E (Elevated lipase and amylase), F (Hypocalcemia). Cholecystitis: A, C, D. Elevated lipase/amylase and hypocalcemia are specific to pancreatitis.
The nurse is caring for a 26-year-old patient who cannot meet their nutritional needs by mouth. The interdisciplinary team decided inserting an NG tube for enteral feedings would be best. After inserting the tube, the nurse knows which of the following is the most accurate way to verify the placement of the tube?
- A. Aspiration of stomach contents
- B. pH verification of the aspirate
- C. Injecting air into the tube and then auscultating the left upper quadrant (LUQ)
- D. Visualization on an X-ray
Correct Answer: D
Rationale: X-ray visualization (D) is the most accurate method to confirm NG tube placement, ensuring it is in the stomach and not the lungs.
Which of the following clients does the nurse suspect would benefit most from placement of a nasogastric tube?
- A. A 9-year-old client with a femur fracture.
- B. An 82-year-old client with congestive heart failure.
- C. A 65-year-old client on dialysis.
- D. A 52-year-old client with leukemia who is receiving chemotherapy.
Correct Answer: D
Rationale: A client receiving chemotherapy (D) may experience severe nausea and vomiting, necessitating an NG tube for decompression or feeding. The other conditions are less likely to require NG tube placement.
A nurse is conducting a dysphagia screening on a client who was recently extubated. Which assessment finding requires intervention?
- A. Slight cough after sipping water.
- B. Hoarseness of voice during speech.
- C. Reports of mild throat discomfort when swallowing.
- D. Presence of a wet, gurgling cough after drinking water.
Correct Answer: D
Rationale: A wet, gurgling cough after drinking water (D) indicates possible aspiration, requiring immediate intervention to prevent complications like pneumonia. Slight cough (A), hoarseness (B), and mild discomfort (C) are less urgent.
The nurse is screening individuals at risk for gastric cancer. It would be appropriate for the nurse to identify which of the following as a risk factor for gastric cancer?
- A. Irritable bowel syndrome
- B. Duodenal ulcer
- C. Chronic gastritis
- D. Sickle cell anemia
Correct Answer: C
Rationale: Chronic gastritis (C), often caused by H. pylori, is a known risk factor for gastric cancer. The other options are not directly associated.