The client who has sleep apnoea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?
Disturbed Sleep Pattern related to difficulty staying asleep
Disturbed Thought Processes related to chronic insomnia
Risk for injury related to somnambulism
Risk for Impaired Gas Exchange related to sleep apnea
The Correct Answer is C
The priority nursing diagnosis for this client should be Risk for injury related to somnambulism. Somnambulism, also known as sleepwalking, can put the client at risk for injury as they may engage in activities while not fully conscious. The client's report of falling asleep while driving and almost being involved in an accident further highlights the potential risk for injury. It is important for the nurse to address this risk and develop a plan to ensure the client's safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The appropriate response by the nurse in this situation would be to respect the young man's wish not to look at the wound during dressing changes. This response shows empathy and understanding toward the patient's feelings and emotions and allows him to have control over his own care. It is important for healthcare providers to respect their patient's autonomy and decisions regarding their own care.
Correct Answer is D
Explanation
The client would most likely exhibit tachycardia, which is an abnormally fast heart rate. Fever and infection can both cause an increase in heart rate as the body tries to fight off the infection. Severe pain can also cause an increase in heart rate due to the body's stress response. Therefore, it is likely that the client would have a fast pulse rate, or tachycardia.
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