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
Providing step-by-step verbal directions may not be effective for clients with Huntington’s disease due to their cognitive impairments, which can include forgetfulness, impaired judgment, and difficulty concentrating.
Choice B rationale
Escorting the client to the cafeteria is the best approach as it ensures the client reaches the destination safely. Clients with Huntington’s disease often have unsteady gait and involuntary movements, making it difficult for them to navigate independently.
Choice C rationale
Orienting the client to the color-coding system may not be effective due to the cognitive impairments associated with Huntington’s disease, such as difficulty concentrating and impaired judgment.
Choice D rationale
Using the hospital map to show the client where the cafeteria is located is not practical for clients with Huntington’s disease due to their cognitive impairments, which can include forgetfulness and difficulty concentrating.
Correct Answer is B
Explanation
Choice A rationale
Autoimmune response is not the correct type of immune reaction for a bee sting. Autoimmune responses involve the body’s immune system attacking its own tissues, which is not the case with bee stings.
Choice B rationale
IgE response hypersensitivity is the correct type of immune reaction for a bee sting. Bee stings can trigger an IgE-mediated hypersensitivity reaction, leading to symptoms such as rash, difficulty breathing, and low blood pressure. This type of reaction is also known as anaphylaxis.
Choice C rationale
Cell-mediated hypersensitivity is not the correct type of immune reaction for a bee sting. Cell-mediated hypersensitivity involves T cells and is typically associated with conditions like contact dermatitis, not bee stings.
Choice D rationale
Type II hypersensitivity is not the correct type of immune reaction for a bee sting. Type II hypersensitivity involves antibody-mediated destruction of cells, which is not the case with bee stings.