Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?
Fluid volume excess.
Risk for infection.
Ineffective thermoregulation.
Pain.
The Correct Answer is A
Fluid volume excess is wrong because appendicitis does not cause fluid retention or overload. It may cause fluid loss due to vomiting, fever, or rupture of the appendix. Therefore, a more appropriate nursing diagnosis would be the risk for deficient fluid volume.
Choice B. Risk for infection is correct because appendicitis is an inflammatory condition that can lead to bacterial infection, especially if the appendix ruptures and causes peritonitis or abscess formation.
Choice C. Ineffective thermoregulation is correct because appendicitis can cause fever due to inflammation and infection.
Choice D. Pain is correct because appendicitis causes acute abdominal pain that usually starts in the periumbilical area and then localizes to the right lower quadrant. The pain may be accompanied by nausea, vomiting, and rebound tenderness.
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Related Questions
Correct Answer is D
Explanation
Increasing regular weight-bearing activities can help prevent osteoporosis by stimulating bone formation and improving muscle strength. Weight-bearing activities are those that make your bones and muscles work against gravity, such as walking, jogging, dancing, or lifting weights.
Choice A is wrong because protecting the client’s bones with strict bedrest can actually increase the risk of osteoporosis by reducing bone density and muscle mass. Bedrest should be avoided unless medically necessary.
Choice B is wrong because providing the client with assisted range of motion exercises twice daily is not enough to prevent osteoporosis. While these exercises can help maintain joint mobility and flexibility, they are not weight bearing and do not stimulate bone formation.
Choice C is wrong because decreasing the amount of calcium in the client’s diet can also increase the risk of osteoporosis. Calcium is an essential mineral for bone health and adults need 700mg a day, which can be obtained from foods such as dairy products, leafy green vegetables, tofu, and dried fruit. Vitamin D is also important for bone health as it helps the body absorb calcium.
Correct Answer is A
Explanation
Urinary catheterization is a common cause of health care-associated infections (HAIs), which are infections that patients get while receiving medical treatment in a health care facility. Urinary catheterization involves inserting a tube into the bladder to drain urine, which can introduce bacteria into the urinary tract and cause infections.
Choice B is wrong because malnutrition is not a direct cause of HAIs, although it can weaken the immune system and increase the risk of infections.
Choice C is wrong because multiple caregivers are not a direct cause of HAIs, although they can increase the exposure to different pathogens and cross contamination if they do not follow proper hygiene and infection control practices.
Choice D is wrong because chlorhexidine washes are not a cause of HAIs, but rather a preventive measure to reduce the risk of HAIs by disinfecting the skin and mucous membranes.
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