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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hypothermia is a condition where the body temperature drops below 35°C (95°F) and affects the normal functioning of the body. Elderly people are more at risk for hypothermia because they have a lower muscle mass, a decreased
shiver reflex, and lower immunity. They also tend to have a lower body temperature and may not develop fevers when they contract a viral or bacterial illness.
Choice B. Normothermia is wrong because it means having a normal body temperature, which is around 37°C (98.6°F).
Choice C. Hyperthermia is wrong because it means having a high body temperature, which is above 37.5°C (99.5°F).
Hyperthermia can be caused by heat exposure, infection, inflammation, or certain medications.
Choice D. Malignant hyperthermia is wrong because it is a rare genetic disorder that causes a severe reaction to certain anesthetics or muscle relaxants.
It is not related to thermoregulation in elderly people.
Question 5.
Correct Answer is B
Explanation
The HOPE Tool for spiritual assessment is a questionnaire that explores the sources of hope, meaning, comfort, strength, peace, love, and connection for patients in healthcare settings. It does not ask about the correctness of one’s belief, but rather about the relevance and importance of one’s spirituality to one’s overall health and well-being. Therefore, choice B is not part of the HOPE Tool.
Choice A is wrong because it is part of the HOPE Tool. It asks about the personal spirituality and practices of the patient.
Choice C is wrong because it is part of the HOPE Tool. It asks about the organized religion or spiritual community of the patient.
Choice D is wrong because it is part of the HOPE Tool. It asks about the sources of hope or sustenance for the patient.
Normal ranges are not applicable to this question as it is not a numerical or quantitative measure.
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