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 D
Explanation
A normal state of awareness is characterized by being aware of oneself and one's surroundings. In this case, a nurse would document the client's condition as being "aware of self and environment" to indicate that the client has a normal state of awareness.
Correct Answer is C
Explanation
According to Maslow's hierarchy of needs model, physiological needs such as food, water, and shelter are the most basic and fundamental needs that must be met before higher-level needs can be addressed. In this scenario, the nursing diagnosis of Altered Nutrition, Less Than Body Requirements related to inability to absorb nutrients addresses a fundamental physiological need and should be identified as the highest priority for this client. The other nursing diagnoses listed address important needs related to safety, self-care, and psychological well-being, but these needs are considered higher-level needs according to Maslow's hierarchy and should be addressed after the client's basic physiological needs have been met.
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