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 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.
Correct Answer is ["A","B","C"]
Explanation
These actions ensure the safety of the client by reducing the risk of falls, confusion and injury.
Keeping a call bell within the client’s reach allows them to ask for help when needed.
Keeping a dim light on at night helps them orient themselves and see their surroundings.
Keeping unnecessary furniture out of the way prevents tripping and cluttering. Choice D is wrong because keeping all side rails up at all times can be considered a form of physical restraint, which is associated with many professional, legal and ethical challenges. Physical restraint should only be used as a last resort when other alternatives have failed or are not feasible. Keeping all side rails up can also increase the risk of injury if the client tries to climb over them.
Choice E is wrong because keeping all lights off at night can increase the risk of falls and confusion for the client.
Older adults may have impaired vision and cognition, and they may need to use the bathroom frequently at night. Keeping all lights off can make it difficult for them to find their way and increase their anxiety.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.