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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse would question the discharge of a client to be cared for by the family if the client and family lack knowledge of the treatment regimen. It is important for the client and family to have a good understanding of the treatment regimen in order to provide safe and effective care at home. The other options (The client will need sterile dressing changes, The client will be discharged with a feeding tube, and The client will be receiving IV medications by home health nurses) are not situations that would necessarily prevent discharge to be cared for by the family.
Correct Answer is B
Explanation
When selecting interventions for a care plan, the nurse should consider several principles. One important principle is that actions should address the underlying cause (etiology) of the nursing diagnosis. By addressing the root cause of the problem, interventions can be more effective in achieving the desired outcomes. There is not necessarily one "best" intervention for each goal or outcome, as different clients may have different needs and respond differently to interventions. Interventions can include both "doing" actions and monitoring, and both independent and collaborative interventions may be appropriate depending on the situation.
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