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A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider?

A.

Flatulence.

B.

Amber urine.

C.

Belching.

D.

Yellow sclera.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Flatulence is not a specific indicator of a serious complication related to a gallstone lodged in the common bile duct.

 

Choice B rationale

 

Amber urine is normal and does not indicate a serious complication.

 

Choice C rationale

 

Belching is not a specific indicator of a serious complication related to a gallstone lodged in the common bile duct.

 

Choice D rationale

 

Yellow sclera indicates jaundice, which is a sign of bile duct obstruction and requires immediate medical attention.

 


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Asking the client to describe the pain is the best approach to assess the quality of pain. This allows the nurse to gather detailed information about the pain’s characteristics.

Choice B rationale

Identifying effective pain relief measures is important but does not directly assess the quality of pain.

Choice C rationale

Observing body language and movement can provide clues about pain but is not as effective as directly asking the client to describe the pain.

Choice D rationale

Providing a numeric pain scale helps quantify the pain but does not provide detailed information about the pain’s quality.

Correct Answer is A

Explanation

Choice A rationale

Lactulose is a synthetic sugar used to treat hepatic encephalopathy by reducing the absorption of ammonia in the intestines. Ammonia is a neurotoxin that can impair mental status in patients with liver dysfunction. By decreasing ammonia levels, lactulose helps improve cognitive function and mental status in patients with hepatic encephalopathy.

Choice B rationale

While lactulose can cause diarrhea as a side effect, the therapeutic goal in hepatic encephalopathy is not to reduce the number of liquid stools but to lower ammonia levels in the blood. The reduction in ammonia levels leads to improved mental status, not necessarily a reduction in liquid stools.

Choice C rationale

The ability to ambulate independently is not a direct therapeutic response to lactulose. The primary goal of lactulose therapy in hepatic encephalopathy is to improve mental status by reducing ammonia levels, not to enhance physical mobility.

Choice D rationale

Lactulose does not have a direct effect on urine output. Its primary mechanism of action is to reduce ammonia absorption in the intestines, thereby improving mental status in patients with hepatic encephalopathy.

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