History of present illness:
A 45-year-old female is admitted for abdominal pain. The client reports pain in the right upper quadrant that worsens after meals and sometimes induces vomiting. This has been present for the past couple months but has recently gotten worse. The client endorses vomiting several times before coming to the emergency department.
Body mass index (BMI) 36.
Hypothyroidism: onset at the age of 42
Social history:
Lives at home with spouse and two children ages 10 and 13
Home medications:
Levothyroxine 50 mcg daily
No known drug allergies (NKDA
The client is alert and oriented to person, place, time, and situation. No family at the bedside. The client reports a good understanding of English and responds to questions in broken English sentences. Some questions are answered inappropriately and need to be rephrased. Pupils equal, round, and reactive to light. Mucous membranes pink and moist, no lymphadenopathy. Heart rate elevated, regular rhythm, no murmurs or peripheral edema noted. Radial and pedal pulses +2 bilaterally. Respirations elevated regular rhythm. Denies dyspnea. The abdomen is soft and very tender to palpation in the right upper quadrant, with positive Murphy’s sign and bowel sounds present. The client is diaphoretic and reports a recent episode of vomiting. The vomitus is thin and yellow-green in color—no blood was noted. Extremities are strong with equal movement. Skin warm, dry, and intact.
The nurse is analyzing the results of the assessment to determine the client’s greatest needs.
Drag words from the choices below to fill in each blank in the following sentence.
Current pain levels
24-hour diet recall
family history of cholecystitis
English fluency
Based on the assessment, the nurse should obtain more information about ________ and __________ .