If a gastric acid perforates, which of the following actions should not be included in the immediate management of the client?

Correct Answer: B

Rationale: In the context of a gastric acid perforation, the immediate management should focus on addressing the critical issues related to the perforation. The correct answer, which is option B) Antacid administration, should not be included in the immediate management of the client. Antacids are not appropriate in the management of a gastric acid perforation because they may increase the risk of complications such as aspiration pneumonia or respiratory distress. Antacids can neutralize gastric acid, potentially masking the severity of the perforation and delaying appropriate interventions like surgical repair. On the other hand, options A, C, and D are crucial components of the immediate management of a gastric acid perforation. Blood replacement (option A) is necessary to address any potential blood loss from the perforation. Nasogastric tube suction (option C) can help decompress the stomach and prevent further leakage of gastric contents into the peritoneal cavity. Fluid and electrolyte replacement (option D) are essential to maintain hemodynamic stability and prevent complications of shock. Educationally, understanding the rationale behind each option enhances students' critical thinking skills and clinical reasoning abilities. By grasping the importance of appropriate interventions in different scenarios, nursing students can provide safe and effective care to clients in real-life situations.

Correct Answer: B

Rationale: In preventing cholecystitis, the most important guideline is to eat a low-fat, low-cholesterol diet (Option B). Cholecystitis is often linked to the formation of gallstones, which are commonly composed of cholesterol. By reducing fat and cholesterol intake, the gallbladder is less likely to be stimulated to release bile, thus decreasing the risk of gallstone formation and subsequent cholecystitis. Eating a low-protein diet (Option A) is not specifically indicated in preventing cholecystitis unless the individual has a specific medical condition that requires protein restriction. Protein intake is not directly linked to the development of cholecystitis. Limiting exercise to 10 minutes/day (Option C) is not a relevant guideline for preventing cholecystitis. In fact, regular physical activity is beneficial for overall health and can contribute to maintaining a healthy weight, which indirectly helps in preventing cholecystitis. Keeping weight proportionate to height (Option D) is important for overall health but is not as directly related to preventing cholecystitis as a low-fat, low-cholesterol diet. Weight management can impact gallstone formation, but the dietary component is more crucial in this context. In an educational context, it is important for nursing students to understand the connection between dietary choices and the development of cholecystitis. Teaching patients about the significance of a low-fat, low-cholesterol diet in preventing this condition empowers them to make informed decisions about their health and reduce their risk of experiencing cholecystitis.

Correct Answer: C

Rationale: In the context of medical surgical nursing, understanding Murphy's sign is crucial as it is a clinical indicator for cholecystitis, inflammation of the gallbladder. Choice C, "On deep inspiration, pain is elicited and breathing stops," best describes Murphy's sign. This sign is elicited during physical examination when pressure is applied to the right upper quadrant of the abdomen just below the rib cage while the patient takes a deep breath. The cessation of inspiration or the "stopping" of breathing due to pain indicates a positive Murphy's sign, suggesting gallbladder inflammation. Option A, periumbilical ecchymosis, is not related to Murphy's sign but may be indicative of other conditions like pancreatitis. Option B, pain on deep palpation and release, is more characteristic of rebound tenderness seen in peritonitis. Option D, abdominal muscle tightening in anticipation of palpation, is known as guarding and is seen in conditions like acute abdomen. For nursing students, recognizing and understanding clinical signs like Murphy's sign is essential for accurate assessment and timely intervention in patients with gastrointestinal issues. By differentiating between the options and understanding the specific characteristics of each sign, nurses can effectively contribute to the diagnosis and management of patients with abdominal pathologies.

Correct Answer: B

Rationale: The most commonly used test to diagnose cholecystitis is an abdominal ultrasound. This imaging study is preferred due to its high sensitivity and specificity in identifying gallstones, inflammation, and other abnormalities in the gallbladder. Abdominal CT scan (Option A) is not the first-line diagnostic test for cholecystitis because it is less sensitive in detecting gallstones compared to ultrasound. Barium swallow (Option C) is used to visualize the esophagus and upper gastrointestinal tract, not the gallbladder, making it an inappropriate choice for diagnosing cholecystitis. Endoscopy (Option D) is used to visualize the upper gastrointestinal tract and is not the indicated test for assessing the gallbladder and diagnosing cholecystitis. In an educational context, understanding the appropriate diagnostic tests for specific conditions is crucial for nursing practice. By knowing the rationale behind choosing the right test, nurses can provide optimal care to patients with suspected cholecystitis, ensuring timely and accurate diagnosis and treatment.

Correct Answer: B

Rationale: In the case of a client hospitalized for cholecystitis, the main focus of nursing management should be on option B) Assessment for complications. This is the correct answer because cholecystitis involves inflammation of the gallbladder, which can lead to serious complications such as infection, abscess formation, or even perforation of the gallbladder. Therefore, closely monitoring the client for any signs of worsening condition or complications is crucial for timely intervention and optimal patient outcomes. Option A) Administration of antibiotics may be a component of the treatment for cholecystitis, especially if it is caused by an infectious process. However, the primary focus should be on assessing for complications to prevent deterioration of the client's condition. Option C) Preparation for lithotripsy is not typically indicated for cholecystitis. Lithotripsy is a procedure used to break down gallstones, which may be a consideration for clients with gallstones but not necessarily for those with cholecystitis. Option D) Preparation for surgery may be necessary in some cases of cholecystitis, particularly if complications arise or if conservative management is not effective. However, the immediate priority is to assess for complications and stabilize the client's condition before considering surgical intervention. In an educational context, understanding the priority of nursing management in conditions like cholecystitis is essential for providing safe and effective care to patients. By focusing on assessing for complications, nurses can intervene promptly and prevent potential adverse outcomes, ultimately promoting the best possible patient care and recovery.