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A nurse is reinforcing teaching with a client who needs to have a cholecystectomy due to gallstones. Which of the following is the best response from the nurse to explain what caused this problem?

A.

The gallbladder became infected by a virus and needs to be removed.

B.

The gallbladder has become inflamed due to the cholesterol in the gallstones,

C.

The gallbladder has become blocked by a tumor and is no longer working.

D.

The gallbladder has become inflamed due to a build-up of gallstones that are blocking the common bile duct.

Answer and Explanation

The Correct Answer is B

A. The gallbladder became infected by a virus and needs to be removed. Gallstones are not caused by viral infections; they typically develop from an imbalance in the substances that make up bile, such as cholesterol and bilirubin.

 

B. The gallbladder has become inflamed due to the cholesterol in the gallstones.  Cholesterol is a common component of gallstones, and these stones can cause inflammation of the gallbladder (cholecystitis), leading to the need for removal.

 

C. The gallbladder has become blocked by a tumor and is no longer working. Tumors can obstruct the gallbladder, but this is not the cause of gallstones or the primary reason for a cholecystectomy.

 

D. The gallbladder has become inflamed due to a build-up of gallstones that are blocking the common bile duct. This describes choledocholithiasis, a condition where gallstones block the common bile duct, but it is not the primary cause of gallbladder inflammation requiring a cholecystectomy.


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Correct Answer is D

Explanation

A. Hypotension: Patients with SIADH typically have fluid retention, which can lead to hypertension, not hypotension.

B. Dry mucous membranes: In SIADH, fluid retention is common, so mucous membranes are usually moist, not dry.

C. Increased thirst: While thirst can occur in various conditions, it is not a primary symptom of SIADH.

D. Confusion or altered mental status: Confusion or altered mental status may occur in SIADH due to hyponatremia from excessive water retention.

Correct Answer is A

Explanation

A. Use written communication or visual aids to supplement verbal instructions. Written communication and visual aids are effective ways to enhance understanding and provide clear instructions to a patient with hearing loss.

B. Speak loudly and directly into the patient's ear. Speaking loudly can distort sounds and may make it harder for the patient to understand. Instead, clear and slow speech with normal volume is recommended.

C. Turn off all background noise and speak to the patient from behind. While reducing background noise is beneficial, speaking from behind is ineffective as the patient cannot see the nurse’s facial expressions or read lips.

D. Assume the patient can read lips and avoid using sign language or gestures. Assuming the patient can read lips is not appropriate; gestures or other visual aids should be used to enhance communication.

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