Practice Quiz

CRNE Exam Prep

Category - Changes in Health

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An emergency nurse is admitting a 32-year-old female office clerk who was rushed to the emergency department for abdominal pain. Client history reveals occasional episodes of mild abdominal pain that occur especially after eating fatty foods. A significant nursing assessment that indicates inflammation and infection of the gall bladder is:
  1. Temperature of 37.9°C.
  2. Sudden and rapidly increasing right upper abdominal pain.
  3. Pain radiating to the back and left shoulder.
  4. Palpable abdominal mass.
Explanation
Answer: D - A significant nursing assessment that indicates cholecystitis is a palpable abdominal mass. The abdominal mass indicates inflammation of the gall bladder. The client would report constant right upper abdominal pain that radiates to the back and right shoulder. Further assessment would show increased temperature, abdominal tenderness, and difficulty of breathing because of severe pain. Sudden and rapidly increasing RUQ pain indicates gall bladder spasm due to gallstones. Biliary colic may last for 1-2 hours and occurs after eating high-fat food. Option C is incorrect; pain radiating the left shoulder may be attributed to angina or myocardial infarct.
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