A patient’s spouse smokes cigarettes in the kitchen while the patient uses supplemental oxygen in the bedroom. Which is the priority nursing diagnosis for this family?

Risk for injury related to smoking near supplemental oxygen

Risk-prone health behavior related to inability to quit smoking

Ineffective health maintenance related to continued use of cigarettes

Ineffective family therapeutic regimen management related to noncompliance

Answer and Explanation

The Correct Answer is A

Choice A reason: This is correct. Risk for injury related to smoking near supplemental oxygen is the priority nursing diagnosis for this family. Smoking near supplemental oxygen can cause a fire or an explosion that can injure or kill the patient and the spouse. The nurse should educate the family about the dangers of smoking near oxygen and provide resources to help the spouse quit smoking.

Choice B reason: This is incorrect. Risk-prone health behavior related to inability to quit smoking is a relevant nursing diagnosis for this family, but not the priority. Smoking is a harmful habit that can cause various health problems, such as lung cancer, heart disease, and stroke. The nurse should assess the spouse's readiness to quit smoking and provide support and counseling.

Choice C reason: This is incorrect. Ineffective health maintenance related to continued use of cigarettes is a valid nursing diagnosis for this family, but not the priority. Smoking can impair the health of the patient and the spouse, especially if the patient has a respiratory condition that requires supplemental oxygen. The nurse should monitor the patient's and the spouse's vital signs, oxygen saturation, and respiratory status.

Choice D reason: This is incorrect. Ineffective family therapeutic regimen management related to noncompliance is an appropriate nursing diagnosis for this family, but not the priority. Smoking near supplemental oxygen can indicate that the family is not following the prescribed treatment plan for the patient's condition. The nurse should evaluate the family's understanding of the patient's oxygen therapy and the reasons for noncompliance.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason: This is a correct choice because providing personal hygiene before bedtime is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to feel more comfortable, relaxed, and refreshed, and to reduce the risk of infection or skin breakdown.

Choice B reason: This is a correct choice because synchronizing the schedule for medications and vital signs is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to have uninterrupted sleep cycles, and to avoid unnecessary disturbances or discomforts from frequent assessments or treatments.

Choice C reason: This is an incorrect choice because administering sleep aids every night at the same time is not an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can cause dependence, tolerance, or adverse effects from the sleep aids, and may not address the underlying cause of the sleep problem. The nurse should use non-pharmacological methods to promote sleep, and administer sleep aids only as prescribed and indicated.

Choice D reason: This is a correct choice because assisting the patient to use the toilet before bed is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to avoid nocturia, which is the need to urinate at night, and to prevent urinary tract infections or incontinence.

Choice E reason: This is a correct choice because straightening and changing any soiled bed linens is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to maintain a clean, dry, and comfortable sleeping environment, and to prevent skin irritation or infection.

A. The nurse braids the patient’s long hair to prevent tangles. B. The nurse checks the policy manual before changing the central line dressing. C. The nurse counts the patient’s pulse before administering digoxin. D. The nurse directs the nursing assistant to obtain the patient's weight.

Correct Answer is B

Explanation

Choice A reason: This is an incorrect choice because the nurse braids the patient’s long hair to prevent tangles is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Braiding the patient’s hair is a personal care task that does not require the nurse to use their own judgment or expertise.

Choice B reason: This is the correct choice because the nurse checks the policy manual before changing the central line dressing is an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Checking the policy manual before changing the central line dressing shows that the nurse is responsible for following the evidence-based guidelines and standards of practice for this procedure.

Choice C reason: This is an incorrect choice because the nurse counts the patient’s pulse before administering digoxin is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Counting the patient’s pulse before administering digoxin is a routine task that is prescribed by the physician and does not involve the nurse’s own decision making.

Choice D reason: This is an incorrect choice because the nurse directs the nursing assistant to obtain the patient's weight is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Directing the nursing assistant to obtain the patient's weight is a task that is delegated by the nurse and does not reflect the nurse’s own authority or initiative.

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A patient’s spouse smokes cigarettes in the kitchen while the patient uses supplemental oxygen in the bedroom. Which is the priority nursing diagnosis for this family?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To promote adequate sleep for a patient who suffers from a sleep pattern disturbance, what are the most appropriate nursing interventions? (Select all that apply).

Correct Answer is ["A","B","D","E"]

Explanation

Which action by the nurse demonstrates the concept of nurse autonomy?

Correct Answer is B

Explanation

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