# A nurse is caring for a client with acute cholecystitis. Which assessment finding requires the most immediate nursing intervention?

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## 문제

A nurse is caring for a client with acute cholecystitis. Which assessment finding requires the most immediate nursing intervention?

A 40-year-old client presents to the emergency department with severe right upper quadrant pain that began 6 hours ago after eating a fatty meal. The client reports nausea, vomiting, and pain radiating to the right shoulder blade.

## 보기

1. Temperature of 100.8°F (38.2°C) with mild diaphoresis
2. Blood pressure 88/52 mmHg with heart rate 118 bpm and cool, clammy skin **✔ 정답**
3. Clay-colored stools and dark amber urine
4. Positive Murphy's sign with guarding in the right upper quadrant

**정답: 2**

## 해설

Hypotension with tachycardia and cool, clammy skin indicates shock, a life-threatening complication requiring immediate intervention. Other findings (fever, clay-colored stools, Murphy's sign) are less urgent.

## 심화 해설

Understanding the Priority: Airway, Breathing, Circulation

When a client with acute cholecystitis presents with multiple assessment findings, the nurse must use clinical judgment to prioritize interventions based on the most life-threatening condition. The NCLEX-RN frequently tests the ability to apply the ABC (Airway, Breathing, Circulation) framework, with a strong emphasis on identifying hemodynamic instability. While right upper quadrant pain, fever, and gastrointestinal symptoms are classic manifestations of gallbladder inflammation, they do not immediately threaten the client’s life. The correct answer is the finding that indicates the client is progressing to a state of systemic shock.

Analysis of the Correct Answer: Option 2

A blood pressure of 88/52 mmHg (hypotension) with a heart rate of 118 bpm (tachycardia) and cool, clammy skin is a classic clinical triad for distributive or septic shock. In the context of acute cholecystitis, this presentation is the most immediate concern because it signals that the localized infection and inflammation may have escalated to a systemic inflammatory response syndrome (SIRS) with resultant vasodilation and capillary leak, causing profound hypoperfusion [3]. This hemodynamic instability directly compromises the "Circulation" component of the ABCs. Without immediate intervention—such as notifying the provider, initiating IV fluid resuscitation, and preparing for potential urgent source control—the client is at high risk for multi-organ dysfunction. The evidence supports that while early laparoscopic cholecystectomy is the standard for low-risk patients, high-risk or deteriorating patients require rapid assessment for decompensation, which may necessitate interventional radiology procedures for gallbladder decompression as a bridge to definitive care [1][3].

Analysis of Incorrect Options

Option 1: A temperature of 100.8°F (38.2°C) with mild diaphoresis is an expected finding in acute cholecystitis due to the body’s inflammatory response to the gallbladder wall injury and potential bacterial infection. While this requires monitoring and antipyretic intervention, it does not represent an immediate threat to the client’s circulatory status.

Option 3: Clay-colored stools and dark amber urine are signs of a common bile duct obstruction, which can occur if a gallstone migrates from the gallbladder. The pale stools result from a lack of stercobilin, and the dark urine from excess conjugated bilirubin being excreted by the kidneys. This finding is clinically significant and requires further investigation, but it is a problem of bile flow, not an immediate hemodynamic crisis.

Option 4: A positive Murphy's sign (inspiratory arrest upon palpation of the right upper quadrant) with guarding is a hallmark physical exam finding for acute cholecystitis, indicating localized peritoneal irritation. While it confirms the diagnosis and causes the client significant pain, it is a localized finding and is not the priority over systemic circulatory collapse.References (research sources)

- [1]Percutaneous versus surgical treatment of acute cholecystitis.Research articleKryvoruchko IA. (2026) · DOI: 10.1186/s13017-026-00710-1

- [3]Interventional Radiology in Acute Cholecystitis: A Review of Contemporary Percutaneous Strategies and Emerging Techniques.Research articleGiannis D, Gianni P. (2026) · DOI: 10.3390/jcm15135106

## 임상 시나리오

Recognizing Septic Shock in CholecystitisPrioritizing Hemodynamic Instability
In a client with acute cholecystitis, the development of low blood pressure (88/52 mmHg), rapid heart rate (118 bpm), and cool, clammy skin signals a transition from localized infection to septic shock. This represents a hemodynamic emergency where systemic vasodilation and capillary leak cause profound hypoperfusion.

Immediate nursing actions focus on the Circulation component of the ABCs. Notify the provider urgently, establish large-bore IV access, and initiate rapid fluid resuscitation with isotonic crystalloids as prescribed. Continuous monitoring of vital signs and urine output is critical to assess response.

CautionDo not delay intervention for other findings like fever or a positive Murphy's sign. While these are important, they do not pose the same immediate threat to life as hemodynamic instability. Early recognition and treatment of shock prevent progression to multi-organ failure.

## 핵심 개념

- **Septic Shock** — A subset of sepsis with profound circulatory and metabolic abnormalities, presenting with hypotension requiring vasopressors and elevated lactate, associated with high mortality.
- **Murphy's Sign** — Pain and inspiratory arrest upon palpation of the right upper quadrant during inspiration, a classic physical exam finding for acute cholecystitis.
- **Systemic Inflammatory Response Syndrome (SIRS)** — A systemic response to infection or non-infectious insult, defined by abnormalities in temperature, heart rate, respiratory rate, or white blood cell count.
- **Charcot's Triad** — The classic presentation of ascending cholangitis: right upper quadrant pain, jaundice, and fever/chills, indicating a biliary tract emergency.
- **Hemodynamic Instability** — A state of abnormal blood pressure and heart rate leading to inadequate tissue perfusion, often manifesting as hypotension and tachycardia.

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