A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis?
Imbalanced nutrition: Less than body requirements related to decreased oral intake
Risk for infection related to possible rupture of appendix
Chronic pain related to appendicitis
Constipation related to decreased bowel motility and decreased fluid intake
The Correct Answer is B
A. Imbalanced nutrition: Less than body requirements related to decreased oral intake: While this may be relevant, it is not the highest priority in acute appendicitis. Infection prevention is more critical.
B. Risk for infection related to possible rupture of appendix: The primary concern in appendicitis is the risk of rupture, leading to peritonitis and sepsis. This makes infection control the top priority.
C. Chronic pain related to appendicitis: Pain in appendicitis is acute, not chronic. Managing infection risk is more urgent.
D. Constipation related to decreased bowel motility and decreased fluid intake: Constipation is not a priority concern in the context of acute appendicitis. The risk of infection takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notify the health care provider: While it may eventually be necessary to notify the healthcare provider, the immediate action should involve confirming the balloon pressure, which is within the scope of respiratory therapy.
B. Call respiratory therapy to obtain the pressure within the balloon: This is the most appropriate action. Respiratory therapists are skilled in managing and measuring the cuff pressure to ensure it is within the correct range (typically 20-30 cm H2O).
C. Add air to the balloon port: Adding air without knowing the current pressure could lead to over inflation, which might cause tracheal injury.
D. Remove air from the balloon port: Similarly, removing air could lead to underinflation, increasing the risk of aspiration or inadequate ventilation.
Correct Answer is A
Explanation
A. Pulmonary crackles/rales: Left-sided heart failure leads to a buildup of fluid in the lungs, causing pulmonary congestion and crackles/rales on auscultation.
B. Weight gain: This is more commonly associated with right-sided heart failure due to fluid retention, though it can be seen in both types of heart failure.
C. Hepatomegaly: Hepatomegaly is typically associated with right-sided heart failure due to congestion in the systemic circulation.
D. Jugular vein distention: JVD is a sign of right-sided heart failure, as it indicates increased central venous pressure.
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