Maslow's & Prioritization, Erikson's - NCLEX
A female patient is diagnoses with deep-vein thrombosis. Which nursing diagnosis should receive the highest priority at this time?
Altered peripheral tissue perfusion related to venous congestion. This is of highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis.
A client with a known history of panic disorder comes to the emergency department and states to the nurse, "Please help me. I think I'm having a heart attack ." What is the priority nursing action? 1 Check the client's vital signs. 2 Encourage the client to use relaxation techniques. 3 Identify the manifestations related to the panic disorder. 4 Determine what the client's activity involved when the pain started.
Answer: 1 Rationale: Clients with a panic disorder can experience acute physical symptoms, such as chest pain and palpitations. The priority is to assess the client's physical condition to rule out a physiological disorder. Although options 2, 3, and 4 may be appropriate at some point in the care of the client, they are not the priority. Priority Nursing Tip: A client complaint of chest pain is always a priority. Immediate assessment and treatment is needed.
A client is due in hydrotherapy for a burn dressing change. To ensure that the procedure is most tolerable for the client, the nurse takes which of the following actions? 1 Ensures that the client has a robe and slippers 2 Administers an analgesic 20 minutes before therapy 3 Sends dressing supplies with the client to hydrotherapy 4 Administers the intravenous antibiotic 30 minutes before therapy
Answer: 2 Rationale: The client should receive pain medication approximately 20 minutes before a burn dressing change. This will help the client tolerate an otherwise painful procedure. Antibiotics are timed evenly around the clock and not necessarily in relation to timing of burn dressing changes. Additionally, antibiotics do not affect pain level. Dressing supplies are generally available in the hydrotherapy area and do not need to be sent with the client. A robe and slippers are beneficial for the client's comfort if traveling by wheelchair, but pain medication is more essential. Priority Nursing Tip: A burn injury is extremely painful and the client is adequately medicated before a burn dressing change to reduce pain and prevent fear of future dressing changes. Strict aseptic technique is used for dressing changes because of the risk of infection.
A nurse is planning the discharge instructions from the emergency department for an adult client who is a victim of family violence. The nurse understands that the discharge plans must include: 1 Instructions to call the police the next time the abuse occurs 2 Exploration of the pros and cons of remaining with the abusive family member 3 Specific information regarding "safe havens" or shelters in the client's neighborhood 4 Specific information about available opportunities to enroll in local self-defense classes
Answer: 3 Rationale: For the victim of family violence, any of the options might be included in the discharge plan at some point if long-term therapy or a long-term relationship with the nurse is established. The question refers to an emergency department setting. It is most important to assist victims of abuse with identifying a plan for how to remove self from harmful situations should they arise again. An abused person is usually reluctant to call the police. It is not the best time for the nurse to explore the pros and cons of remaining with the abusive family member; additionally, this action does not ensure safety for the victim. Teaching the victim to fight back (as in the use of self-defense ) is not the best action when dealing with a violent person. Priority Nursing Tip: In a victim of violence, self-esteem becomes diminished with chronic abuse. The victim may blame herself or himself for the violence and be unable to see a way out of the situation.
A charge nurse observes a nursing assistant talking in an unusually loud voice to a client with delirium. The charge nurse should take which action? 1 The nurse enters the room and informs the client that everything is all right. 2 The nurse speaks to the nursing assistant immediately while in the client's room to solve the problem. 3 The nurse ensures the client's safety , calmly asks the nursing assistant to step outside the room, and informs the nursing assistant that her voice was unusually loud. 4 The nurse explains to the nursing assistant that yelling in the client's room is tolerated only if the client is talking loudly and the nursing assistant needs to get the client's attention.
Answer: 3 Rationale: The nurse must ascertain that the client is safe and then discuss the matter with the nursing assistant in an area away from the hearing of the client. If the client hears the conversation, the client may become more confused or agitated. Options 1, 2, and 4 are incorrect actions. Priority Nursing Tip: Methods that can be used to enhance communication include using written words if the client is able to see, read, and write; providing plenty of light in the room; getting the attention of the client before beginning to speak; facing the client when speaking ; and talking in a room without distracting noises.
A female client arrives at the emergency department and states she was just raped. In preparing a plan of care, the priority intervention is which of the following? 1. Providing instructions for medical follow-up 2. Obtaining appropriate counseling for the victim 3. Providing anticipatory guidance for police investigations, medical questions, and court proceedings 4. Exploring safety concerns by obtaining permission to notify significant others who can provide shelter
Answer: 4
The nurse prepares to teach a client to ambulate with a cane. Before teaching cane-assisted ambulation, the priority nursing assessment is to determine that the client has: 1 A high level of stamina and energy 2 Self-consciousness about using a cane 3 Full range of motion in lower extremities 4 Balance, muscle strength, and confidence
Answer: 4 Rationale: Assessing the client's balance, strength, and confidence helps determine if the cane is a suitable assistive device for the client. A high level of stamina and full range of motion are not needed for walking with a cane. Although body image (self-consciousness) is a component of the assessment, it is not the priority. Priority Nursing Tip: Safety is a priority concern when the client uses an assistive device such as a cane.
A community health nurse is working with older residents who were involved in a recent flood. Many of the residents are emotionally despondent, and they refused to leave their homes for days . When planning for the rescue and relocation of these older residents, what is the first item that the nurse needs to consider? 1 Contacting the older residents' families 2 Attending to the emotional needs of the older residents 3 Arranging for ambulance transportation for the oldest residents 4 Attending to the nutritional status and basic needs of the older residents
Answer: 4 Rationale: The question asks about the first thing that the nurse needs to consider when planning for the rescue and relocation of these older residents. The ABCs of community health are always attending to people's basic needs of food, shelter, and clothing. Options 1, 2, and 3 are other activities that may or may not be needed at a later date. Priority Nursing Tip: For any client, the nurse should address physiological needs first; then the nurse should assess safety and psychosocial needs.
A community health nurse is caring for a group of homeless people. When planning for the potential needs of this group, what is the most immediate concern? 1 Peer support through structured groups 2 Finding affordable housing for the group 3 Setting up a 24-hour crisis center and hotline 4 Meeting the basic needs to ensure that adequate food, shelter, and clothing are available
Answer: 4 Rationale: The question asks about the immediate concern. The ABCs of community health are always attending to people's basic needs of food, shelter, and clothing. Options 1, 2, and 3 are other activities that may be completed at a later time. Priority Nursing Tip: Primary prevention measures for community health nursing may include working to improve living conditions in shelters, reducing exposure to communicable diseases, and enhancing efforts to improve hygiene.
A client with a severe major depressive episode is unable to address activities of daily living (ADL). The appropriate nursing intervention would be to: 1 Have the client's peers confront the client about how noncompliance in addressing ADL affects the milieu. 2 Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for ADL. 3 Offer the client choices and describe the consequences for the failure to comply with the expectation of maintaining his own ADL. 4 Feed, bathe, and dress the client as needed until the client's condition improves so that he can perform these activities independently.
Answer: 4 Rationale: The symptoms of major depression include depressed mood, loss of interest or pleasure, changes in appetite and sleep patterns, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate, and recurrent thoughts of death. Often, the client does not have the energy or interest to complete activities of daily living. Option 1 will increase the client's feelings of poor self-esteem and of unworthiness. Option 2 is incorrect because the client still lacks the energy and motivation to do these independently. Option 3 may lead to increased feelings of worthlessness as the client fails to meet expectations. Priority Nursing Tip: For the client with depression, the nurse needs to avoid pushing the client to make decisions that the client is not ready to make.
An older adult client has been identified as a victim of physical abuse. In planning care, the nurse places highest priority on: 1 Obtaining treatment for the abusing family member 2 Adhering to federal mandatory abuse reporting laws 3 Notifying the case worker to intervene in the family situation 4 Removing the client from any situation that presents immediate danger
Answer: 4 Rationale: The priority nursing intervention is to remove the abused victim from the abusive environment. Options 1, 2, and 3 may be appropriate interventions but are not the priority. Priority Nursing Tip: Older clients at most risk for abuse include individuals who are dependent because of illness, immobility , or altered mental status.
The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process?
Diagnosing The nurse identifies human responses to actual or potential health problems during the nursing diagnoses step of the nursing process. During assessment, the nurse collects data. During planning, the nurse develops strategies to resolve or decrease the patient's problem. During evaluation, the nurse determines the effectiveness of the plan of care.