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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice B is wrong because laying down for 1 hour after meals can increase the pressure on the diaphragm and make breathing more difficult. It can also increase the risk of aspiration and reflux.
Choice C is wrong because restricting the client’s fluid intake to less than 1 L/day can lead to dehydration and thickening of secretions, which can obstruct the airways and impair gas exchange. Fluid intake should be adequate to maintain hydration and thin secretions.
Choice D is wrong because using the upper chest for respiration is a sign of inefficient breathing and respiratory distress.
It can increase the oxygen demand and cause fatigue. The client should be encouraged to use the diaphragm and abdominal muscles for respiration, which are more efficient and reduce the work of breathing.
Normal ranges for oxygen saturation are 95% to 100%, for arterial blood gas pH are 7.35 to 7.45, for PaCO2 are 35 to 45 mmHg, for PaO2 are 80 to 100 mmHg, and for HCO3 are 22 to 26 mEq/L.
Correct Answer is A
Explanation
A lack of insurance or lack of sufficient insurance is a huge barrier in accessing health care. According to the Kaiser Family Foundation, uninsured people are less likely to receive preventive care and services for major health conditions and chronic diseases. They also face greater difficulties in affording care and paying medical bills.
Choice B is wrong because politics is not the only factor that affects the availability and affordability of health insurance. Other factors include income, employment status, age, health status, and geographic location. Nurses have a professional and ethical responsibility to advocate for the health needs of their clients and communities, which may involve engaging with political issues. Choice C is wrong because language is not the only problem for uninsured or underinsured clients. Other problems include cost, access, quality, and continuity of care. Language barriers may affect communication and understanding between clients and providers, but they can be addressed by using interpreters, translators, or culturally competent staff.
Choice D is wrong because the Joint Commission does not regulate insurance coverage. The Joint Commission is an independent, nonprofit organization that accredits and certifies health care organizations and programs in the United States. It sets standards for quality and safety of care, but it does not determine who is eligible for insurance or what benefits are covered.
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