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.
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Related Questions
Correct Answer is D
Explanation
Localized warmth at the site of injury is a sign of localized inflammation of the tissues, which is a response to tissue damage caused by an ankle injury. Localized inflammation involves changes in blood flow, vessel permeability, and leukocyte migration to the site of injury. Heat is one of the five classic signs of acute local inflammation, along with redness, swelling, pain, and loss of function.
Choice A is wrong because 3+ palpable pedal pulses below the affected injury site indicate normal blood flow to the foot and do not reflect inflammation.
Choice B is wrong because full range of motion at the site of injury is unlikely in the presence of inflammation, which usually causes pain and loss of function.
Choice C is wrong because sanguineous drainage at the site of injury is a sign of bleeding, not inflammation.
Inflammation may cause fluid leakage from blood vessels, but this fluid is usually clear or yellowish, not bloody.
Correct Answer is A
Explanation
Urinary catheterization is a common cause of health care-associated infections (HAIs), which are infections that patients get while receiving medical treatment in a health care facility. Urinary catheterization involves inserting a tube into the bladder to drain urine, which can introduce bacteria into the urinary tract and cause infections.
Choice B is wrong because malnutrition is not a direct cause of HAIs, although it can weaken the immune system and increase the risk of infections.
Choice C is wrong because multiple caregivers are not a direct cause of HAIs, although they can increase the exposure to different pathogens and cross contamination if they do not follow proper hygiene and infection control practices.
Choice D is wrong because chlorhexidine washes are not a cause of HAIs, but rather a preventive measure to reduce the risk of HAIs by disinfecting the skin and mucous membranes.
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