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","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.
Correct Answer is A
Explanation
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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