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.

Answer and Explanation

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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Correct Answer is C

Explanation

The client may have a ruptured appendix, which is a life-threatening complication of appendicitis. A ruptured appendix can cause peritonitis, which is an infection of the lining of the abdomen, or an abscess, which is a collection of pus around the appendix. These conditions require immediate medical attention and surgery to remove the appendix and clean the abdominal cavity.

Choice A is wrong because administering the prescribed medication may mask the symptoms of a ruptured appendix and delay diagnosis and treatment.

Choice B is wrong because repositioning the client and applying a heating pad may increase the risk of rupture or spread of infection.

Choice D is wrong because calling the operating room team is not the nurse’s responsibility and may not be feasible depending on the availability of the surgical team and the operating room.

A. Review all ordered treatments in relation to the client’s culture. B. Listen to the client’s perceptions. C. Explain the purpose of the treatments, without regard to the client’s culture. D. Acknowledge that the client will have to adapt their perceptions to the dominant culture.

Correct Answer is ["A","B"]

Explanation

A cultural assessment is a systematic way to identify the beliefs, values, meanings, and behaviours of people while considering their history, life experiences, and social and physical environments. A nurse should include reviewing all ordered treatments in relation to the client’s culture and listening to the client’s perceptions as part of a cultural assessment.

These actions show respect for the client’s preferences and facilitate communication and understanding.

Choice C is wrong because explaining the purpose of the treatments without regard to the client’s culture may be insensitive or inappropriate for some clients who have different beliefs or practices about health and illness. Choice D is wrong because acknowledging that the client will have to adapt their perceptions to the dominant culture may be disrespectful or oppressive for some clients who value their cultural identity and diversity.

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Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is performing a cultural assessment with a client; the nurse should include which of the following? (Select All That Apply).

Correct Answer is ["A","B"]

Explanation

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