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 ["A","C","D","E"]

Explanation

These are some of the criteria used to assist in making the diagnosis of chronic fatigue syndrome (CFS) according to the Institute of Medicine (IOM) 2015 report.

Choice B is wrong because recent exposure to influenza is not a criterion for CFS diagnosis. Although some cases of CFS may be triggered by viral infections, such as Epstein-Barr virus or human herpes virus 6, there is no specific evidence that influenza causes CFS.

Choice A is correct because CFS is not caused by a primary condition. CFS is a diagnosis of exclusion, meaning that other possible causes of fatigue, such as sleep disorders, anemia, diabetes, thyroid problems, or mental health issues, must be ruled out before making the diagnosis.

Choice C is correct because unrefreshing sleep is one of the required symptoms for CFS diagnosis. Patients with CFS may not feel better or less tired even after a full night of sleep despite the absence of specific objective sleep alterations. Choice D is correct because fatigue that is not relieved by stress reduction is another required symptom for CFS diagnosis. Patients with CFS experience post-exertional malaise (PEM), which means that their symptoms worsen after physical, mental, or emotional exertion that would not have caused a problem before the illness.

Choice E is correct because severe tiredness for 2 months or more is one of the additional manifestations that must be present for CFS diagnosis. The IOM 2015 report states that the fatigue associated with CFS must last for more than 6 months and occur at least half the time at moderate, substantial or severe intensity.

A. Instruct the client to use pursed-lip breathing. B. Plan to have the client lay down for 1 hr after meals. C. Restrict the client’s fluid intake to less than 1 L/day. D. Encourage the client to use the upper chest for respiration.

Correct Answer is A

Explanation

Pursed-lip breathing is a technique that helps to slow down the breathing rate and keep the airways open longer. This improves gas exchange and reduces the work of breathing. Pursed-lip breathing also helps to prevent air trapping and hyperinflation of the lungs, which are common complications of COPD.

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.

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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

A nurse is caring for a client with chronic fatigue syndrome. Which of the following criteria were used to assist in making this diagnosis? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

The nurse graduate is reviewing his scope of practice. Which of the following does he correctly identify as outlining the legal scope of practice for nursing?

While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

A nurse is preparing to administer a medication to a client. Which of the following actions by the nurse demonstrates advocacy for client rights?

A nurse is discussing the reporting of elder abuse with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

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

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