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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. An increase in O2 saturation to greater than 90%: An increase in oxygen saturation is typically a positive sign and does not indicate worsening heart failure.

B. The onset of atrial fibrillation: The development of atrial fibrillation in a patient with heart failure is a sign of worsening heart failure, as it indicates increased atrial pressure and the potential for further hemodynamic compromise.

C. Louder S1 and S2 heart sounds: Louder heart sounds do not specifically indicate worsening heart failure. They may vary based on other factors such as body habitus or the position of the patient.

D. A decrease in heart rate to 66 bpm: A heart rate of 66 bpm is within the normal range and does not suggest worsening heart failure.

A. decreases contractility B. increases preload C. decreased afterload D. increases sympathetic stimulation

Correct Answer is C

Explanation

A. Decreases contractility: This is incorrect because ACE inhibitors do not directly affect myocardial contractility. They primarily work on the vascular system.

B. Increases preload: This is incorrect as ACE inhibitors do not increase preload. They may decrease preload by reducing fluid retention.

C. Decreased afterload: ACE inhibitors lower systemic vascular resistance (afterload) by inhibiting the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This reduces the workload on the heart.

D. Increases sympathetic stimulation: This is incorrect because ACE inhibitors actually reduce sympathetic stimulation by preventing the vasoconstrictive and sodium-retaining effects of angiotensin II.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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