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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is an incorrect choice because using empathy is not the correct term for the nursing action of deciding that a nonverbal patient who just had surgery is in pain and administering an analgesic, based on the observation that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. Empathy is a communication technique that involves understanding and sharing the feelings of another person. However, it is not the term that describes the cognitive process of drawing conclusions from the available data.
Choice B reason: This is an incorrect choice because setting priorities is not the correct term for the nursing action of deciding that a nonverbal patient who just had surgery is in pain and administering an analgesic, based on the observation that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. Setting priorities is a nursing skill that involves determining the order of importance of the patient's problems and interventions. However, it is not the term that describes the cognitive process of drawing conclusions from the available data.
Choice C reason: This is the correct choice because making inferences is the correct term for the nursing action of deciding that a nonverbal patient who just had surgery is in pain and administering an analgesic, based on the observation that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. Making inferences is a critical thinking skill that involves reaching a logical judgment or assumption based on the available data and evidence. The nurse makes an inference that the patient is in pain based on the patient's nonverbal cues and the fact that the patient just had surgery.
Choice D reason: This is an incorrect choice because recognizing inconsistencies is not the correct term for the nursing action of deciding that a nonverbal patient who just had surgery is in pain and administering an analgesic, based on the observation that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. Recognizing inconsistencies is a critical thinking skill that involves identifying discrepancies or contradictions in the data or information. However, it is not the term that describes the cognitive process of drawing conclusions from the available data.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because utilizing a no-rinse shampoo cap is the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A no-rinse shampoo cap is a disposable cap that contains a pre-moistened shampoo and conditioner. It can be heated in a microwave and applied to the patient's head without the need for water or rinsing. It can clean and condition the patient's hair without causing any discomfort or movement of the affected shoulder.
Choice B reason: This is an incorrect choice because using a handheld shower sprayer is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A handheld shower sprayer is a device that attaches to a faucet and allows the user to direct the water flow. It can be difficult and painful for the patient to use or hold the sprayer with the affected shoulder, and it can also wet the surgical dressing or incision site.
Choice C reason: This is an incorrect choice because having the patient lean over the wash basin is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A wash basin is a bowl or sink that contains water and soap for washing. It can be uncomfortable and risky for the patient to lean over the basin with the affected shoulder, and it can also wet the surgical dressing or incision site.
Choice D reason: This is an incorrect choice because having the patient lean back into the sink is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A sink is a basin with a faucet that provides water for washing. It can be uncomfortable and risky for the patient to lean back into the sink with the affected shoulder, and it can also wet the surgical dressing or incision site.
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