Which of the following symptoms best describes Murphy's sign?

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: 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.

Correct Answer: D

Rationale: In the context of a client being treated for chronic cholecystitis, the correct instruction is to use anticholinergics as prescribed (Option D). Anticholinergics help to decrease the spasms in the smooth muscle of the gastrointestinal tract, including the gallbladder, which can be beneficial in managing the symptoms associated with cholecystitis. Option A, increasing rest, while important for overall health, does not directly address the treatment of cholecystitis. Option B, avoiding antacids, is not specifically indicated for cholecystitis treatment and may not have a direct impact on the condition. Option C, increasing protein in the diet, is not the priority in the management of cholecystitis as dietary modifications typically focus on reducing fat intake to decrease gallbladder stimulation. From an educational standpoint, understanding the rationale behind the correct answer helps students grasp the pharmacological management of gastrointestinal conditions. It reinforces the importance of tailored interventions for specific conditions and highlights the role of medications in symptom management. This question also emphasizes the need for critical thinking in selecting the most appropriate intervention based on the client's condition.

Correct Answer: C

Rationale: In a client with a duodenal ulcer, the presence of melena (option C) is a common finding on assessment. Melena refers to black, tarry stools caused by upper gastrointestinal bleeding. This occurs because the blood is partially digested as it passes through the gastrointestinal tract. Detecting melena indicates active bleeding and is a crucial sign in assessing the severity of the ulcer and the need for intervention. Option A, hematemesis, is vomiting of blood and is more commonly associated with gastric ulcers. Option B, malnourishment, can be a consequence of chronic gastrointestinal issues like ulcers, but it is not a direct finding on assessment for a duodenal ulcer. Option D, pain with eating, is a common symptom of duodenal ulcers but is not specific to their assessment findings. Educationally, understanding these assessment findings is crucial for nurses caring for patients with gastrointestinal issues. Recognizing the specific signs and symptoms associated with duodenal ulcers helps in prompt diagnosis, appropriate interventions, and effective patient care. It also highlights the importance of differentiating between various gastrointestinal conditions based on assessment findings for accurate treatment and management.

Correct Answer: D

Rationale: In distinguishing between the pain associated with duodenal and gastric ulcers, it is crucial to understand the pathophysiology of each condition. The correct answer, "D) Pain on an empty stomach," is indicative of a duodenal ulcer. This pain worsens when the stomach is empty due to the exposure of the ulcer to gastric acid during fasting periods. The presence of pain at night or in between meals is a classic symptom of a duodenal ulcer. Option A, "Early satiety," is more commonly associated with gastric ulcers. Gastric ulcers tend to cause pain or discomfort shortly after eating, leading to early satiety as a result of the irritation in the stomach lining postprandially. Option B, "Pain on eating," is not a typical characteristic of either duodenal or gastric ulcers. Pain that worsens with eating is more indicative of esophageal or gastric conditions such as gastritis. Option C, "Dull upper epigastric pain," is a general symptom that can be present in both duodenal and gastric ulcers. However, the specific characteristic that distinguishes duodenal ulcers is the relief of pain with food intake due to neutralization of stomach acid. Understanding these distinctions is vital in clinical practice as it guides healthcare providers in making accurate diagnoses and implementing appropriate treatment plans for patients with gastrointestinal ulcers.