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.

Answer and Explanation

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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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.

A. Clinical education specialist. B. Quality improvement committee. C. Hospital ethics committee. D. Hospital administrator.

Correct Answer is C

Explanation

The nurse should report the situation to the hospital ethics committee, which is used to resolve ethical dilemmas in the health care setting. The hospital ethics committee can help the nurse and the client’s family reach a consensus on the best course of action for the client.

Choice A is wrong because a clinical education specialist is not directly involved in the client’s care and does not have the authority to intervene in ethical issues.

Choice B is wrong because a quality improvement committee is responsible for monitoring and evaluating the quality of care and services provided by the facility, not for addressing ethical conflicts.

Choice D is wrong because a hospital administrator is not usually involved in the clinical decision-making process and may not have the expertise or time to deal with ethical issues.

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Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues?

Correct Answer is D

Explanation

A nurse is caring for a client whose family is in a state of disagreement over the care of their family member. The nurse should report the situation to which of the following facility personnel?

Correct Answer is C

Explanation

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