Aclient is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. the physician diagnoses acute cholecystitis and cholelithiasis. for this client, which nursing diagnosis takes top priority?
a) acute pain related to biliary spasms
b) imbalanced nutrition: less than body requirements related to biliary inflammation
c) anxiety related to unknown outcome of hospitalization
d) deficient knowledge related to prevention of disease recurrence

A

Explanation:

R:The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

There are multiple acceptable ways

1. Count pulse for one full minute

2. Count pulse for 30 seconds and then multiply that number by 2

3. Count for 15 seconds and multiply that number by 4

Explanation: