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 C
Explanation
This statement indicates an understanding of the ethical principle of respect for autonomy, which means that the nurse respects the client’s right to make their own decisions about their care and respects their values and beliefs.
Choice A is wrong because “A nurse’s personal values are not considered when making ethical decisions.” This statement contradicts the ethical principle of integrity, which means that the nurse acts in accordance with their personal and professional values and standards.
Choice B is wrong because “A nurse’s behaviors and actions are called values.” This statement confuses values with morals, which are the judgments about behaviors and actions based on personal or societal beliefs.
Choice D is wrong because “Value clarification involves maintaining clinical competency.” This statement confuses value clarification with professionalism, which involves maintaining clinical competency, accountability, and responsibility. Value clarification is a process of self-exploration and reflection that helps the nurse identify their own values and understand how they affect their ethical decisions.
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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