The client is a male who states his wife complains that his snoring awakens her at night.
The spouse is present.
To obtain further data, the nurse asks the spouse:
How loud is his snoring?
How often are you awakened at night due to his loud snoring?
Is there silence after snoring which then is followed with a snort?
How long does he snore each night? . . .
The Correct Answer is C
Choice A rationale
Asking "How loud is his snoring?" is subjective and difficult for the spouse to quantify accurately. While loudness can be a factor, it doesn't directly address potential underlying medical conditions like obstructive sleep apnea.
Choice B rationale
Determining the frequency of awakenings due to snoring provides some information about the impact on the spouse's sleep but doesn't offer specific details about the nature of the snoring itself or potential pauses in breathing.
Choice C rationale
Asking "Is there silence after snoring which then is followed with a snort?" directly inquires about a pattern indicative of obstructive sleep apnea. Apneic episodes involve cessation of breathing (silence), followed by a gasp or snort as the airway reopens.
Choice D rationale
Knowing the duration of snoring each night provides a general overview but doesn't offer specific details about the characteristics of the snoring, such as pauses in breathing or gasping, which are crucial for identifying potential sleep disorders. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Anticipatory Grieving is a normal response to an expected loss, such as the impending death of oneself or a loved one. While the client is facing death, her statement "Why me, Lord" and inability to pray suggest a struggle with her spiritual beliefs and meaning in the face of this event, rather than primarily focusing on the emotional preparation for loss.
Choice B rationale
Ineffective Coping refers to an inability to manage stressors effectively. While the client's distress indicates difficulty coping with her situation, the specific mention of spiritual questioning and inability to pray points towards a disturbance in her spiritual well-being, which is more accurately described by spiritual distress.
Choice C rationale
Low Self-Esteem involves negative feelings about oneself and one's worth. While facing death can impact self-esteem, the client's direct questioning of her faith and inability to connect spiritually are the more prominent indicators in this scenario, suggesting a conflict or disruption in her spiritual domain rather than primarily a devaluation of self.
Choice D rationale
Spiritual Distress is characterized by a disruption in one's belief or value system that provides strength, hope, and meaning to life. The client's cry of "Why me, Lord" and her inability to pray indicate a struggle with her faith and a potential feeling of abandonment or questioning of her spiritual beliefs in the face of death. This aligns directly with the defining characteristics of spiritual distress.
Correct Answer is D
Explanation
Choice A rationale
Expressing remorse indicates an awareness of the negative consequences of past actions, which aligns with the valuing process step of choosing, where the individual recognizes the value and impact of different choices. However, it doesn't fully demonstrate prizing, which involves cherishing and affirming the value.
Choice B rationale
Explaining how past choices contributed to the renal failure demonstrates understanding and cognitive processing of the situation, aligning with the choosing step of the valuing process, where the individual intellectually recognizes the value. However, it doesn't necessarily indicate an emotional investment or affirmation of new values.
Choice C rationale
Stating an intention to adopt new behaviors reflects the acting step of the valuing process, where the individual commits to and implements the chosen values in their actions. While important for change, it doesn't directly demonstrate the internal valuing or cherishing of these new actions.
Choice D rationale
Expressing pride in gaining knowledge and skills to manage diabetes signifies that the client now holds this self-management in high regard and finds personal worth in it. This aligns with the prizing step of the valuing process, where the individual emotionally embraces and values the new belief or behavior, leading to a sense of satisfaction and affirmation.
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