gallbladder disease nclex
A client with acute cholecystitis is experiencing nausea and vomiting. Which nursing action should the nurse use to address this client's nutritional status? (Select all that apply.)
Rationale: Assessing height and weight, reviewing serum electrolytes, counseling on low-fat menu choices, and administering antiemetics as prescribed are all nursing actions that address the client's nutritional status. A high-protein, not low-protein, diet is used to treat cholecystitis.
The nurse is providing dietary teaching to a client with a history of gallstones. Which diet should the nurse recommend? (Select all that apply.)
Rationale: A low-carbohydrate, low-fat, high-protein diet reduces symptoms of cholecystitis. While fasting and very low-calorie diets are contraindicated, a moderate reduction in caloric intake and increased activity levels promote weight loss
A client is experiencing severe upper abdominal pain and jaundice. Which finding on the cholescintigraphy should indicate to the nurse that the client has cholelithiasis?
Rationale: Cholelithiasis is almost always caused by a gallstone lodged in the cystic duct. Accumulation of bile in the hepatic duct would not lead to cholecystitis. Neither the accumulation of fat nor a viral infection leads to cholecystitis.
The nurse is teaching a client with cholelithiasis about lifestyle modification. Which statement made by the client indicates that the nurse's teaching has been successful?
Rationale: Obesity is commonly associated with the development of gallbladder disease. A balanced diet and exercise will help keep the client's weight within normal limits. There is no reason to eliminate salt from the diet. Ground beef is high in fat and should be limited. Frying adds additional fat and should be avoided.
A client is experiencing pain and nausea related to biliary colic. Which statement should the nurse make to manage this client's symptoms? (Select all that apply.)
Rationale: Clinical therapies for treating biliary colic include administering analgesics, getting adequate rest, correcting fluid and electrolyte imbalances, and administering antiemetics.
A client scheduled for a cholecystectomy asks what caused the gallstones to develop. Which risk factor should the nurse list when responding to this client? (Select all that apply.)
Rationale: The risk factors for developing gallbladder disorders include age, family history of gallstones, American Indian ethnicity, obesity, hyperlipidemia, female sex, pregnancy, diabetes mellitus, cirrhosis, ileal disease, and sickle cell disease. Men have a lower risk of developing gallbladder disorders.
A client is recovering from a laparoscopic cholecystectomy. Which nursing action should the nurse use to reduce this client's risk of infection? (Select all that apply.)
Rationale: To reduce the risk of infection, the nurse will monitor vital signs, including temperature, every 4 hours, because changes may be the first sign of infection. Assessment of the abdomen can reveal signs of a surgical wound infection. Turning, breathing, and incentive spirometry help prevent postsurgical atelectasis and subsequent pneumonia. Antibiotics are used to control infection. Fowler position may enhance the client's comfort but will have no effect on postsurgical infection.
The nurse is teaching a client with cholelithiasis about a new prescription for ursodiol. Which client statement indicates to the nurse that the teaching was successful?
Rationale: Ursodiol is a bile acid. It is used to dissolve gallstones in clients who cannot have surgery to remove gallstones. Ursodiol is also used to prevent the formation of gallstones in clients who are overweight or who are losing weight very quickly. It works by decreasing the production of cholesterol and by dissolving the cholesterol in bile so that it cannot form stones. Ursodiol is generally well tolerated but can cause diarrhea or constipation.
A client with acute cholecystitis is experiencing jaundice. Which should the nurse consider as the reason for the jaundice?
Rationale: When acute cholecystitis is accompanied by jaundice, partial common duct obstruction is likely, which is usually due to stones or inflammation.
The nurse is planning an educational program about development and prevention of gallstones for a community group. Which population should the nurse identify to be most at risk for developing gallstones?
Rationale: Genetic considerations and risk factors vary depending on the nature of the inflammatory disorder. Female sex, being over the age of 40, American Indians, and Mexican Americans are most at risk for gallstones. Family history is also associated with increased risk.
The nurse evaluates a client's understanding of discharge teaching following a laparoscopic cholecystectomy. Which client statement indicates teaching has been effective? (Select all that apply.)
Rationale: Clients from a laparoscopic cholecystectomy are often treated in day surgery, but discharge instructions should be similar to those for other clients who have had abdominal surgery. Therefore, they should be informed to be sure to increase their activity level when they return home. Clients should take pain medications with food to diminish irritation to the stomach lining. The client should follow a diet low in fat and high in fat-soluble vitamins. Therefore, including hot chocolate and whole milk would not be appropriate food choices.
The nurse is preparing health promotion teaching for a client with gallbladder disease. Which topic should the nurse include in the teaching session? (Select all that apply.)
Rationale: Clients should be taught about the role of obesity, hyperlipidemia, and a high-cholesterol diet on gallstone formation; the importance of a high-fiber, low-fat, and low-cholesterol diet to reduce the incidence of gallbladder disorders; and the dangers of rapid weight loss. Hypolipidemia does not promote gallstone formation
A client with right upper quadrant abdominal pain asks why so many tests are being scheduled. Which is the reason that the nurse should give to this client? (Select all that apply.)
Rationale: Diagnostic tests are used to identify the presence and location of gallstones, identify possible complications of the gallstones, and help differentiate gallbladder disorders from other disease processes. Diagnostic tests do not prevent the formation of gallstones but can give information necessary for treatments that prevent recurrence.
A client who is morbidly obese is diagnosed with acute cholelithiasis. Which nonpharmacologic therapy should the nurse expect to be prescribed for this client?
Rationale: During an acute attack of cholecystitis, food should be eliminated and a nasogastric tube inserted to relieve nausea and vomiting. Parenteral nutrition is not indicated at this time. Once the client is eating again, dietary fat intake may be limited, especially if the client is obese. If bile flow is obstructed, fat-soluble vitamins (A, D, E, and K) and bile salts may need to be administered but this would be considered a pharmacologic therapy.
A client asks what causes gallstones to form. Which factor should the nurse explain as being present when these stones are formed? (Select all that apply.)
Rationale: Gallstones are formed due to abnormal bile composition, an inflammation of the gallbladder, biliary stasis, and excess cholesterol. Rapid weight loss, not weight gain, is a factor that contributes to the formation of gallstones. Next Question
A client with cholelithiasis is not a surgical candidate at this time. Which pharmacologic treatment should the nurse expect to be prescribed for this client? (Select all that apply.)
Rationale: Pharmacologic treatment for gallstones is used for clients who refuse surgery or for whom surgery is contraindicated. Medications used in the treatment of gallstones include ursodiol, chenodiol, antibiotics, cholestyramine, and opioid analgesics. Antipyretics are a pharmacologic treatment for fever, not cholelithiasis itself.
Which is a risk factor for gallbladder disease?
Rationale: Rapid weight loss, hyperlipidemia (not hypolipidemia), and female (not male) gender are risk factors for gallbladder disease. Hypocalcemia is not a risk factor.
A middle-aged female client who is obese has been experiencing right upper quadrant abdominal pain for the past several hours. For which risk factors of gallstone development should the nurse assess this client during the health history? (Select all that apply.)
Rationale: The formation of gallstones occurs when several factors are present, including abnormal bile composition, biliary stasis, inflammation of the gallbladder, and excess cholesterol. Excess cholesterol in bile is associated with obesity, a high-calorie and high-cholesterol diet, and drugs that lower serum cholesterol levels. Biliary colic is the pain described in cholelithiasis. This pain is localized to the epigastrium and the right upper quadrant of the abdomen. Biliary colic does not lead to the formation of gallstones.
A pregnant client of American Indian heritage experiences mild gastric distress and nausea after eating large meals and constant sharp abdominal pain. Which additional information should the nurse collect during the interview? (Select all that apply.)
Rationale: The nurse should note current manifestations, including right upper quadrant (RUQ) abdominal pain, and its character and relationship to meals, duration, and radiation; nausea and vomiting; other symptoms; duration of symptoms; risk factors or previous history of symptoms; chronic diseases such as diabetes, cirrhosis, or IBD; current diet; and use of oral contraceptives or possibility of pregnancy.
The nurse prepares discharge teaching for a client recovering from a cholecystectomy. Which topic should the nurse include in this teaching? (Select all that apply.)
Rationale: The nurse will instruct the client on the prescribed activity level, manifestations of postoperative complications that must be reported to the healthcare provider, pain control measures, and surgical incision care. A low-fat, not high-fat, diet must be followed by this client after discharge.
