A patient is diagnosed with obstructive sleep apnea. Which assessment is the priority?
Respiratory status
Neurological function
Circulatory status
Gastrointestinal function
The Correct Answer is A
Choice A reason: Obstructive sleep apnea causes airway collapse, leading to hypopnea, apnea, and hypoxia. Assessing respiratory status, including oxygen saturation, respiratory rate, and snoring, is critical to detect life-threatening desaturations or respiratory failure. This priority ensures airway patency and adequate oxygenation, addressing the primary pathophysiology of the condition.
Choice B reason: Neurological function may be affected by hypoxia in severe sleep apnea, causing daytime sleepiness or cognitive issues. However, respiratory status is the priority, as airway obstruction directly threatens oxygenation. Neurological assessment is secondary, as it does not address the immediate risk of respiratory compromise.
Choice C reason: Circulatory status, like blood pressure, may be impacted by chronic sleep apnea due to hypoxia-induced hypertension. However, respiratory status takes precedence, as airway obstruction is the primary issue causing desaturation. Circulatory changes are secondary and less urgent than ensuring adequate ventilation.
Choice D reason: Gastrointestinal function is unrelated to obstructive sleep apnea’s primary effects. While reflux may contribute to sleep issues, it is not a priority compared to respiratory status, which
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Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
Choice A reason: Cheyne-Stokes breathing, alternating cycles of deep breathing and apnea, is a hallmark of impending death, often seen in the final hours. It reflects brainstem dysfunction as the body shuts down. This finding signals the nurse to prepare the family for imminent death, providing emotional support and guidance.
Choice B reason: Redness of skin may indicate pressure injuries or fever but is not a specific sign of imminent death. In the dying process, skin may become mottled or pale, not red. This finding does not prompt immediate preparation for death, making it an incorrect choice.
Choice C reason: Tense muscle tone is not typical in the last stages of dying, where muscles relax due to metabolic shutdown. Rigidity occurs post-mortem (rigor mortis). This finding does not indicate imminent death, so it does not require preparing the family, making it incorrect.
Choice D reason: Clear colored urine reflects hydration but is not a sign of impending death. In the dying process, urine output decreases, and color darkens due to reduced renal perfusion. This finding is irrelevant to preparing the family for death, as it does not signal the final stages.
Correct Answer is A
Explanation
Choice A reason: Agnosticism is the belief that the existence of ultimate reality or God is unknown or unknowable. The nurse should consider this when planning care, respecting the patient’s uncertainty about spiritual matters and avoiding assumptions about religious practices, ensuring care aligns with their belief system.
Choice B reason: Assuming the patient is devoid of spirituality is incorrect, as agnosticism does not preclude spiritual beliefs or practices. Agnostics may find meaning in non-religious spirituality. This assumption risks alienating the patient, making it an inappropriate consideration for care planning.
Choice C reason: Agnosticism does not imply finding no meaning in relationships. Patients may value human connections despite uncertainty about ultimate reality. This assumption misrepresents the patient’s beliefs and could lead to insensitive care, making it incorrect for planning based on their agnosticism.
Choice D reason: Agnostics are uncertain about God’s existence, not certain of its absence, which aligns with atheism. This misinterpretation of agnosticism could lead to inappropriate care assumptions, dismissing potential spiritual needs. The nurse should focus on the patient’s uncertainty, making this incorrect.
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