The nurse would assess the client experiencing an acute episode of cholecystitis for pain that is located in the right:

Correct Answer: B

Rationale: In assessing a client with acute cholecystitis, it is crucial for the nurse to understand the typical presentation of this condition. The correct answer is B) Upper quadrant and radiates to the right scapula and shoulder. This is because cholecystitis is inflammation of the gallbladder, which is located in the right upper quadrant of the abdomen. The pain typically radiates to the right shoulder and scapula due to referred pain patterns. Option A) Upper quadrant and radiates to the left scapula and shoulder is incorrect because cholecystitis pain does not typically radiate to the left side. Option C) Lower quadrant and radiates to the umbilicus is incorrect as cholecystitis pain is not typically located in the lower abdomen or radiating to the umbilicus. Option D) Lower quadrant and radiates to the back is also incorrect as cholecystitis pain is not usually felt in the lower quadrant or radiating to the back. Educationally, understanding the specific pain patterns associated with different conditions is essential for accurate assessment and diagnosis in nursing practice. By knowing the expected location and radiation of pain in cholecystitis, nurses can provide prompt and appropriate care to clients experiencing this condition.

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: C

Rationale: In the management of peptic ulcer disease, mucosal barrier fortifiers are used to stimulate mucus production (Option C). The correct answer is C because these medications help enhance the protective mucus layer in the stomach and duodenum, which acts as a physical barrier against gastric acid and digestive enzymes. By increasing mucus production, these fortifiers promote mucosal healing and protect the gastrointestinal lining. Option A (To inhibit mucus production) is incorrect because inhibiting mucus production would worsen the condition by reducing the protective barrier against stomach acid. Option B (To neutralize acid production) is incorrect as mucosal barrier fortifiers do not work by directly neutralizing acid but rather by strengthening the mucosal defense mechanisms. Option D (To stimulate hydrogen ion diffusion back into the mucosa) is also incorrect as this process would not contribute to mucosal protection and ulcer healing. Educationally, understanding the rationale behind using mucosal barrier fortifiers in peptic ulcer disease is crucial for nursing students to grasp the principles of ulcer management. By comprehending how these medications work to enhance mucosal protection, students can provide effective care to patients with peptic ulcers and promote optimal healing outcomes.

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.