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 C
Explanation
Choice A reason: This is an incorrect choice because "When did you first seek health care for your symptoms?" is not an example of back-channeling. Back-channeling is a communication technique that involves using verbal or non-verbal cues to indicate that the listener is paying attention and encouraging the speaker to continue. This statement is an example of an open-ended question, which is another communication technique that involves asking questions that require more than a yes or no answer and elicit more information from the speaker.
Choice B reason: This is an incorrect choice because "I am sure the doctor will answer all of your questions shortly." is not an example of back-channeling. Back-channeling is a communication technique that involves using verbal or non-verbal cues to indicate that the listener is paying attention and encouraging the speaker to continue. This statement is an example of a reassurance, which is another communication technique that involves expressing confidence or support to the speaker and alleviating their anxiety or fear.
Choice C reason: This is the correct choice because "I completely understand. Can you tell me more?" is an example of back-channeling. Back-channeling is a communication technique that involves using verbal or non-verbal cues to indicate that the listener is paying attention and encouraging the speaker to continue. This statement is an example of a verbal cue, which involves using words or phrases that show empathy, interest, or agreement, and invite the speaker to elaborate or clarify their message.
Choice D reason: This is an incorrect choice because "Try not to worry. I'm sure that you will be just fine." is not an example of back-channeling. Back-channeling is a communication technique that involves using verbal or non-verbal cues to indicate that the listener is paying attention and encouraging the speaker to continue. This statement is an example of a false reassurance, which is a communication barrier that involves making unrealistic or unfounded promises or predictions to the speaker and dismissing their concerns or feelings.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect choice because tying the restraints to the footboard is not a safe or appropriate option when the nurse is applying soft wrist restraints to the patient. The footboard is the part of the bed that supports the foot end of the mattress. Tying the restraints to the footboard can cause the patient to slide down the bed and increase the risk of strangulation, pressure ulcers, or nerve damage.
Choice B reason: This is the correct choice because tying the restraints to the bedframe is the safest and most appropriate option when the nurse is applying soft wrist restraints to the patient. The bedframe is the metal or wooden structure that supports the mattress and the box spring. Tying the restraints to the bedframe can ensure that the restraints are secure and stable, and that the patient has enough room to move without causing injury or discomfort.
Choice C reason: This is an incorrect choice because tying the restraints to the headboard is not a safe or appropriate option when the nurse is applying soft wrist restraints to the patient. The headboard is the part of the bed that supports the head end of the mattress. Tying the restraints to the headboard can cause the patient to slide up the bed and increase the risk of strangulation, pressure ulcers, or nerve damage.
Choice D reason: This is an incorrect choice because tying the restraints to the side rails is not a safe or appropriate option when the nurse is applying soft wrist restraints to the patient. The side rails are the bars that run along the sides of the bed to prevent the patient from falling out. Tying the restraints to the side rails can cause the patient to twist or bend their wrists and increase the risk of circulation impairment, nerve damage, or skin breakdown.
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