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?
Flatulence.
Amber urine.
Belching.
Yellow sclera.
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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Correct Answer is B
Explanation
Choice A rationale
An increase in B-lymphocytes and IgM is not how HIV suppresses the immune system. B-lymphocytes are responsible for producing antibodies, and IgM is a type of antibody. HIV primarily affects T-lymphocytes, specifically helper T-cells (CD4 cells), rather than B-lymphocytes.
Choice B rationale
The destruction of helper T-cells and CD4 cells is the primary mechanism by which HIV suppresses the immune system. HIV targets and infects these cells, leading to their depletion. Helper T-cells play a crucial role in coordinating the immune response, and their loss results in a weakened immune system, making the body more susceptible to infections and diseases.
Choice C rationale
A deficiency of cytotoxic T cells is not the primary mechanism by which HIV suppresses the immune system. Cytotoxic T cells (CD8 cells) are involved in directly killing infected cells, but the main impact of HIV is on helper T-cells (CD4 cells), which are essential for orchestrating the immune response.
Choice D rationale
The proliferation of suppressor T-cells is not how HIV suppresses the immune system. Suppressor T-cells (regulatory T cells) help regulate and control the immune response, but HIV primarily affects helper T-cells (CD4 cells), leading to their destruction and a weakened immune system.
Correct Answer is D
Explanation
Choice A rationale
Determining the neurological baseline prior to the fall is important but not the immediate priority. The client’s current confusion and projectile vomiting suggest a potential acute condition that needs immediate assessment.
Choice B rationale
Determining the client’s last dose of corticosteroids is relevant for managing multiple sclerosis but does not address the immediate concern of confusion and vomiting.
Choice C rationale
Administering a PRN IV antiemetic as prescribed can help manage vomiting but does not address the underlying cause of the symptoms.
Choice D rationale
Completing a head-to-toe neurological assessment is the priority intervention. The client’s confusion and projectile vomiting could indicate increased intracranial pressure or another acute neurological condition that requires immediate attention.