Nursing Diagnosis Prioritization Worksheet

Maslow's Hierarchy of Needs

1) Physiological: air, food, water, shelter, sleep, clothing, sex, elimination 2) Safety: personal security, employment, resources, health, property 3) Love/Belonging: friendship, family, sexual intimacy, sense of connection 4) Esteem: self-esteem, confidence, achievement, respect of others, status, recognition, strength, freedom 5) Self-actualization: desire to become the most that one can be, morality, creativity, spontaneity, problem-solving, lack of prejudice, acceptance of facts - achieved in order

NCLEX Priority (Helpful Tips)

1. identify the topic 2. assessment (observing) vs. intervention (actually doing) 3. physical vs. psychosocial 4. ABCD's * Airway * Breathing * Circulation * Disability (Maslow's) 5. evaluate your choice 6. acute vs chronic 7. real > potential (most of the time)

Imbalanced Nutrition: less than body requirements

Maslow's vs higher priorities such as the ABCs

A female patient is diagnosed with a pulmonary embolus. Which nursing diagnosis should receive the highest priority? a. impaired gas exchange related to decreased blood flow b. fluid volume excess related to peripheral vascular disease c. risk for injury related to edema d. altered peripheral tissue perfusion related to venous congestion

a.

Jack is a 54-year-old patient with cirrhosis of the liver. You have identified the following nursing diagnoses for him. Which of the following is the priority nursing diagnosis for Jack? a. excess fluid volume related to decreased plasma proteins b. risk for impaired liver function related to alcohol abuse c. imbalanced nutrition: less than body requirements related to impaired storage of vitamins d. risk for bleeding related to altered clotting factors

a.

Samantha is a quadriplegic and the following nursing diagnoses are appropriate for her. Which of the following nursing diagnoses would be the priority for Samantha? a. ineffective breathing pattern related to neuromuscular impairment of innervation of diaphragm b. grieving related to perceived loss of self c. bowel incontinence related to disruption of nerve innervation d. risk for autonomic dysreflexia related to altered nerve function

a.

You are caring for a patient. All of the following nursing diagnoses are appropriate for your patient, however, you've been asked to select one priority nursing diagnosis for this patient. Which nursing diagnosis would you select? a. ineffective airway clearance b. ineffective breathing pattern c. decreased cardiac output d. ineffective peripheral tissue perfusion

a.

You are caring for a patient who is hospitalized with a COPD exacerbation. You have identified Ineffective Airway Clearance as the priority nursing diagnosis. Which "related to" statement is most appropriate? a. increased production of thick sputum b. oxygen saturation at 90% on 2L via nasal cannula c. increased respiratory rate d. chronic obstructive pulmonary disease

a. - Oxygen and respiratory rate are "as evidence" - COPD is an actual diagnosis

James is a 36-year-old truck driver. He smokes a pack of cigarettes per day and has coronary artery disease. All of the following are appropriate nursing diagnoses for James. Please identify the priority nursing diagnosis for him. a. impaired gas exchange b. ineffective breathing pattern c. ineffective peripheral tissue perfusion d. peripheral neurovascular dysfunction

a. - ineffective breathing pattern is more breathing, while impaired gas exchange is more airway

You are writing a plan of care for a 56-year-old breast cancer patient. She presents with a BP of 114/76, P 80, R 16, T 98.8, O2 sat of 98% on room air, and a pain rating of 7/10. She reports feeling exhausted and has been nauseated - unable to keep food down for 48 hours - though her weight is unchanged from previous assessment. Which of the following would be considered a priority actual physical nursing diagnosis? a. fatigue b. imbalanced nutrition: less than body requirements c. acute/chronic pain d. impaired gas exchange

a. - not imbalanced nutrition, because have no data indicating that she is malnourished

You are caring for a patient who is suffering from heat-related illness. You have identified Fluid Volume Deficit as the priority nursing diagnosis. Which of the following data would be important to include in your "as evidenced by" statement? Please select all that apply. a. low urine output- in mL/hour b. elevated BUN c. body temperature d. hypotensive blood pressure

a. b. d.

You have identified Ineffective breathing pattern as the priority nursing diagnosis for your adult patient. Which of the following assessment data would you include in your "as evidenced by" statement? Select all that apply. a. respiratory rate of 36 b. dyspnea c. blood pressure of 80/60 d. shallow respirations e. orthopnea

a. b. d. e.

Your patient is in the immediate post-operative period. All of the following are appropriate nursing diagnoses for your patient. Which of the following would be the priority for your patient? a. acute pain related to surgical incision b. ineffective breathing pattern related to chemically induced muscular relaxation c. impaired skin integrity related to surgical incision d. decreased cardiac output related to blood loss (altered stroke volume)

b.

Mrs. Jones is a post-operative patient. She is post-operative day 1, and will likely be discharged tomorrow. She is ambulating 3 times per day with a walker in the hallway with the assistance of one. She rates her pain 4/10 with the administration of hydrocodone PRN as ordered. You have identified the following as nursing diagnoses for Mrs. Jones. Which is the priority nursing diagnosis for her? a. risk for infection b. risk for bleeding c. impaired physical mobility d. acute pain

c.

Mrs. Sanderson is a 71-year-old patient who presents with a transient ischemic attack. The following are all appropriate. Please select the priority nursing diagnosis for Mrs. Sanderson. a. anxiety related to change in health status b. risk for ineffective denial related to fear of consequences of illness c. ineffective cerebral tissue perfusion related to interruption of blood flow d. activity intolerance (Level 3) related to generalized weakness

c.

Your patient has Multiple Sclerosis. Which of the following is the priority nursing diagnosis for this patient? a. fatigue related to increased energy requirements to perform activities b. powerlessness related to unpredictability of disease c. ineffective airway clearance related to neuromuscular dysfunction d. risk for impaired skin integrity

c.

Your patient is bleeding and his vital signs are as follows: BP 80/42, P 124, R 18, T 98.8, O2 Sat 89%. The patient reports dyspnea at rest and is lightheaded. Which of the following nursing diagnoses is your priority? a. activity intolerance (level IV) b. fluid volume deficit c. impaired gas exchanged. ineffective tissue perfusion d. ineffective tissue perfusion

c.

A 3-year-old child is on mechanical ventilation, which has been effective in treating oxygenation problems secondary to hypovolemic shock. When developing the plan of care for this child, which nursing diagnosis should the nurse consider a priority at this time? a. impaired gas exchange b. fear c. risk for infection d. risk for impaired skin integrity

c. - Critical illness and mechanical ventilation increase the risk for infection. The child is already compromised from the inadequate tissue perfusion that occurred with hypovolemic shock, so the priority at this time is to prevent an infection that would further compromise the child's physical condition.

Which of the following is highest priority to the nurse? a. safety b. belonging c. elimination d. security

c. - Maslow's - physiological first

The nurse assists a patient with a bed bath. She observes that the patient's skin is excessively dry flaky skin with visible scratches from the patient. During the procedure, the patient tells the nurse that he is very thirsty. Which of the following would be the most appropriate nursing diagnosis? a. risk for impaired skin integrity related to altered gland function b. risk for impaired skin integrity related to dehydration c. impaired skin integrity related to dehydration d. impaired skin integrity related to altered circulation

c. - flaky skin = already impaired skin integrity - thirst = dehydration

You are caring for Ms. Jackson, a 77-year-old patient who is in the immediate post-operative period after total knee arthroplasty. She is generally healthy, other than having degenerative joint disease. Her current medications include morphine and Zofran. Which of the following would be a priority physical potential nursing diagnosis? a. risk for constipation b. risk for falls c. risk for bleeding d. risk for infection

c. - risk for bleeding because that can happen now, fall and constipation is later and not as worried immediate post-op

Janessa is a 5-year-old cystic fibrosis patient. She is quiet and withdrawn, even though you've cared for her over the past 3 shifts. She has dyspnea on exertion and requires 2 liters of oxygen per nasal cannula to keep her oxygen saturations above 95%. She coughs up thick, yellow sputum after her nebulizer treatment with chest percussion therapy. Which of the following would be an actual priority physical nursing diagnosis for Janessa? a. risk for infection b. imbalanced nutrition: less than body requirements c. compromised family coping d. ineffective airway clearance

d.

Jessica is a 23-year-old bulimic patient. She has a BMI of 25. She is dehydrated and her electrolytes are imbalanced. Assuming all of the following are appropriate nursing diagnoses for the patient, which of the following would be of priority for her? a. Acute pain related to reflux b. ineffective coping related to poor self-esteem and insufficient support system c. constipation related to decreased fluid volume d. deficient hypertonic fluid volume related to inadequate free water supplementation

d.

You are caring for an 82-year-old female in a long-term care facility. The patient is diabetic and has developed a wound on her foot. You have identified Ineffective peripheral tissue perfusion as your priority nursing diagnosis. Which of the following would be the most appropriate "related to" statement? a. physical immobilization b. neuromuscular impairment c. moisture d. poor glycemic control

d.

Your patient has Kawasaki disease and all of the following are appropriate nursing diagnoses for your patient. Which of them is the priority nursing diagnosis for your patient? a. impaired skin integrity b. acute pain c. risk for decreased cardiac output d. hyperthermia

d.

Your patient is receiving chemotherapy treatment for breast cancer. Each of the following are appropriate nursing diagnoses for your patient. Which of the following nursing diagnoses is the priority for your patient? a. risk for infection related to side effects of therapeutic agents b. disturbed body image related to loss of hair and weight c. risk for deficient fluid volume related to interference with adequate intake d. imbalanced nutrition: less than body requirements related to nausea

d.

Mrs. Sable is a 93-year-old patient living at home alone. She takes metoprolol once daily for hypertension, but is otherwise healthy. Which of the following would be the most appropriate priority potential physical nursing diagnosis? a. risk for impaired skin integrity b. risk for imbalanced body temperature c. risk for chronic low self-esteem d. risk for falls

d. - Due to the fact that metoprolol could cause orthostatic hypotension.

A male patient who has undergone general anesthesia is transferred to the post-anesthesia care unit. Which nursing diagnosis takes highest priority for this patient? a. impaired physical mobility related to surgery b. acute pain related to surgery c. deficient fluid volume related to blood and fluid loss from surgery d. risk for aspiration related to anesthesia

d. - if aspirating = no airway

Constipation

is Maslow's

"As Evidence By"

is a symptom (respiratory rate, pulse, actual things happening)

Impaired Gas Exchange

is more airway, but both airway and breathing

Fatigue

is physical vs psychosocial because actually exhausted

"Related To"

is why it is happening, but cannot give an actual diagnosis, so it is a description of a diagnosis (cant use Diabetic, use poor glycemic control)

Acute/Chronic Pain

pain is psychosocial instead of physical