Which is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea?
Health-seeking behaviors related to expressed desire for better sleep
Impaired bed mobility related to presence of CPAP mask on face
Risk for impaired skin integrity related to tight-fitting mask on face
Risk for powerlessness related to inability to breathe regularly during sleep
The Correct Answer is D
Choice A reason: This is an incorrect choice because health-seeking behaviors related to expressed desire for better sleep is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Health-seeking behaviors are actions that a person takes to improve their health and well-being. However, this is not the most urgent or life-threatening problem for the patient, as it does not pose an immediate risk of harm or injury.
Choice B reason: This is an incorrect choice because impaired bed mobility related to presence of CPAP mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Impaired bed mobility is the limitation of the patient's ability to move in bed. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.
Choice C reason: This is an incorrect choice because risk for impaired skin integrity related to tight-fitting mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for impaired skin integrity is the potential for the patient's skin to be damaged or broken. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.
Choice D reason: This is the correct choice because risk for powerlessness related to inability to breathe regularly during sleep is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for powerlessness is the potential for the patient to feel a loss of control or self-efficacy. This is the most urgent and life-threatening problem for the patient, as it can result in psychological distress, anxiety, depression, or hopelessness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an incorrect choice because exposure-related accident is not the type of error when the wrong type of medication is administered to the patient. Exposure-related accident is an incident that occurs when a person is exposed to a harmful substance or environment, such as radiation, chemicals, or extreme temperatures.
Choice B reason: This is the correct choice because procedure-related accident is the type of error when the wrong type of medication is administered to the patient. Procedure-related accident is an incident that occurs when a person is harmed by a medical or surgical procedure, such as a wrong-site surgery, a medication error, or a catheter infection.
Choice C reason: This is an incorrect choice because organization-related accident is not the type of error when the wrong type of medication is administered to the patient. Organization-related accident is an incident that occurs due to a failure of the system or the management of an organization, such as a lack of communication, a poor policy, or a staffing shortage.
Choice D reason: This is an incorrect choice because equipment-related accident is not the type of error when the wrong type of medication is administered to the patient. Equipment-related accident is an incident that occurs due to a malfunction or misuse of a device or a machine, such as a ventilator, a defibrillator, or a syringe.
Correct Answer is C
Explanation
Choice A reason: This is an incorrect choice because insisting that the patient remove the bracelet and give it to a family member during surgery is not the most appropriate action of the nurse. This action may violate the patient's right to autonomy, religious freedom, and cultural sensitivity. The nurse should respect the patient's beliefs and preferences and try to accommodate them as much as possible, unless they pose a significant risk to the patient's safety or the surgical procedure.
Choice B reason: This is an incorrect choice because notifying the patient’s surgeon of the patient’s refusal to remove the bracelet before having surgery is not the most appropriate action of the nurse. This action may imply that the patient is non-compliant or difficult, and may create a conflict between the patient and the surgeon. The nurse should communicate with the patient and the surgeon in a respectful and collaborative manner, and seek a mutually agreeable solution.
Choice C reason: This is the correct choice because calling the operating room staff to determine if the bracelet can stay on during surgery is the most appropriate action of the nurse. This action shows that the nurse is willing to advocate for the patient and to consult with the relevant authorities to find out the best option. The nurse should follow the policies and protocols of the operating room and the infection control guidelines, and ensure that the bracelet does not interfere with the surgical site, the equipment, or the sterile field.
Choice D reason: This is an incorrect choice because removing the bracelet from the patient's wrist after sedating medication has been administered is not the most appropriate action of the nurse. This action may be considered unethical, dishonest, or disrespectful, as the nurse is taking advantage of the patient's altered mental status and going against the patient's wishes. The nurse should obtain the patient's informed consent before performing any intervention, and should not deceive or coerce the patient.
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