04.01 Maslow's Hierarchy of Needs
Question 3 of 10 The nurse knows to make clinical priority decisions based on which hierarchy of needs? A.Maslow's B.Lou Gehrig's C.Kussmal's D.Erickson's
ANSWE A ✅Maslow's Maslow's hierarchy of needs is used to help the nurse prioritize nursing interventions. Kussmal's This is not a type of hierarchy. Kussmal refers to a type of respiratory pattern. Lou Gehrig's This is not a type of hierarchy. Lou Gehrig's is the name of a disease process Erickson's This is not a type of hierarchy. Erickson's is a theory of psychosocial development.
Question 2 of 10 A nurse is preparing to start a shift at the hospital and is considering which clients are highest priority to see first. Which of the following clients would be considered second level priority for the nurse to see? Select all that apply. A. A client who requires a ventilator to help him breath B. A client who has a mental status change C. A client who is going into cardiogenic shock D. A client who has low blood sugar E. A client who has developed severe peripheral edema
ANSWE B,D,E ✅A client who has low blood sugar A nurse must establish priorities that are based on the conditions of assigned clients. Secondary priority situations are those that could wait for care after the nurse manages first-priority conditions of managing client's airway, breathing, and circulation. Secondary priority situations are not life-threatening, but could cause severe complications for the client if they are not treated soon. ✅A client who has a mental status change A nurse must establish priorities that are based on the conditions of assigned clients. Secondary priority situations are those that could wait for care after the nurse manages first-priority conditions of managing client's airway, breathing, and circulation. Secondary priority situations are not life-threatening, but could cause severe complications for the client if they are not treated soon. ✅A client who has developed severe peripheral edema A nurse must establish priorities that are based on the conditions of assigned clients. Secondary priority situations are those that could wait for care after the nurse manages first-priority conditions of managing client's airway, breathing, and circulation. Secondary priority situations are not life-threatening, but could cause severe complications for the client if they are not treated soon. A client who requires a ventilator to help him breath This is a first order priority, because it is an immediate threat to safety and survival. A client who is going into cardiogenic shock This is a first order priority, because it is an immediate threat to safety and survival.
Question 6 of 10 The nurse is caring for a client who began to cough and became short of breath while eating a meal. What is the nurse's priority? A.Check inside the client's mouth B.Listen to lung sounds C.Reassure the client D.Place a pulse ox on the client's finger
ANSWER A ✅Check inside the client's mouth The nurse would follow prioritization using the ABC's, or airway, breathing, circulation. The first thing the nurse will do is to check airway patency by looking in the client's mouth. Place a pulse ox on the client's finger The nurse will immediately check the airway and attempt to remove the source of the occlusion if possible. Listen to lung sounds The first priority is airway, not auscultation of the lungs. Reassure the client The nurse needs to take action to remove the airway occlusion first. Physiological needs take precedence over feelings of safety and belonging in this scenario, because the client's airway is obstructed, which is life-threatening.
A float nurse comes to help in the emergency room and is triaging clients with an experienced nurse. The experienced nurse helps the float nurse understand that the client with which of the following is the priority? A.Cough and congestion after finishing an antibiotic treatment regimen, no respiratory distress B.Anxiety attack and depression after failing a college exam C.A motor vehicle accident; the right sclera completely red, ecchymosis noted around right eye D.Left flank pain with hematuria
ANSWER C ✅A motor vehicle accident; the right sclera completely red, ecchymosis noted around right eye The client with a red sclera and ecchymosis is concerning for a globe rupture, as this client could lose their sight in if not treated immediately. A globe rupture is an ophthalmic condition when the integrity of the outer membranes of the eye are disrupted. Cough and congestion after finishing an antibiotic treatment regimen, no respiratory distress The cough and congestion may not have been covered by the correct antibiotic or may be viral in nature, but since the client is not in respiratory distress it is not emergent. Anxiety attack and depression after failing a college exam While the client with anxiety and depression must be addressed, they are not the clinical priority at this time. Left flank pain with hematuria The flank pain with hematuria is most likely someone with a kidney stone that is passing the stone. This is also not life threatening, just very uncomfortable.
Question 1 of 10 A nurse is caring for a client who was admitted to the hospital and is experiencing nausea. The nurse suspects that the client has not been getting enough sleep while staying in the hospital. Which actions describe how the nurse could help improve the client's sleep? Select all that apply. A.Prioritize testing over sleep B,Explain to the client why a test is being done to C.interrupt his sleep C. Help the client to get at least 20 minutes of natural sunlight each morning D. Bundle the client's care and medication administration together E. Ensure the client's nausea is under control
ANSWER C,D,E ✅Bundle the client's care and medication administration together Sleep deprivation is a common complaint in hospitalized clients. As health care practitioners recognize the positive effects of a good sleep routine, more is being done to help the client achieve good sleep. To set the client up for successful sleep, the nurse can organize tasks and interventions together to avoid interrupting the client multiple times at night. If vital signs need to be monitored regularly, the nurse can get a set of vital signs when the client calls for something during the night. Prioritize testing over sleep Prioritizing anything over sleep is not going to improve sleep for a hospitalized client. ✅Help the client to get at least 20 minutes of natural sunlight each morning Natural sunlight in the morning is helpful to fully awaken a client, making it more likely for them to sleep at night. ✅Ensure the client's nausea is under control When the nurse ensures that the client is comfortable, the client will sleep better. Explain to the client why a test is being done to interrupt his sleep Unless the client is in an emergent situation, testing should not be done when it interrupts the client's nighttime sleep routine.
A client with post-traumatic stress disorder has been brought into the emergency department after attempting suicide by carbon monoxide poisoning. The nurse assesses the client and finds that the client is short of breath, with a respiratory rate of 30/min, HR 98 bpm, and a blood pressure 110/80 mmHg. The client is irritable and withdrawn and his wife is at his side. Which intervention is the highest priority in this situation? A. Ask the client why he tried to end his life B. Contact the provider for a prescription for antidepressants C.Help the client's spouse by making her D.comfortable and providing support D.Administer oxygen and connect the client to a hemodynamic monitor
ANSWER D . ✅Administer oxygen and connect the client to a hemodynamic monitor Carbon monoxide poisoning can cause alterations in oxygenation in the body, because excess carbon monoxide affects the body's ability to carry oxygen to the tissues. In the situation described, the nurse must first assess and care for the client's airway, breathing, and circulation. The client is short of breath because of the carbon monoxide, so the nurse should first administer oxygen. Ask the client why he tried to end his life The client needs oxygen. Act now, ask questions later. Help the client's spouse by making her comfortable and providing support The spouse is not a concern for the nurse at this moment, because the client assessment shows that the client needs additional oxygen. Contact the provider for a prescription for antidepressants The client is in an urgent situation that requires an intervention, not a prescription for antidepressants.
A nurse is caring for a client who has been diagnosed with lung cancer. The client tells the nurse that she has not spoken with her mother in 8 years and really wants to reconnect with her. The nurse recognizes that this need falls under which category of Maslow's Hierarchy of Needs? a.Safety b.Physiological c.Self-esteem d.Love and belonging
ANSWER D: ✅Love and belonging Maslow's Hierarchy of Needs is a system that describes the fundamental human needs based on a pyramid formation. Those needs on the lowest tier, which are physiological needs, must be met before a person can have their needs met on higher levels. This client is talking about her relationship with her mother, which falls in the need category of love and belonging. Self-esteem This client is demonstrating needs in the love and belonging category. Safety This client is demonstrating needs in the love and belonging category. Physiological This client is demonstrating needs in the love and belonging category.
Question 9 of 10 What is the highest order of Maslow's Hierarchy of needs? A. Self-actualization B. Self-esteem C. Physiological D. Safety and security
ANSWER: A ✅Self-actualization From lowest to highest, the needs are ranked as follows; physiological, safety and security, love and belonging, self-esteem, and finally self-actualization. Self-esteem Self-actualization is the highest and final order in Maslow's hierarchy. Safety and security Self-actualization is the highest and final order in Maslow's hierarchy. Physiological Self-actualization is the highest and final order in Maslow's hierarchy.
Question 4 of 10 A nurse is caring for a client in the ICU who has been severely burned. According to Maslow's hierarchy of needs, which of the following actions demonstrates that the nurse is meeting the client's highest priority needs? Select all that apply. A.Contacting the client's family so they can visit B.Maintaining the ventilator settings C.Using a hemodynamic monitor D.Keeping the room quiet and dark E.Suctioning the client's airway as needed
ANSWER: B,C,E ✅Maintaining the ventilator settings Maslow's hierarchy of needs states that certain basic needs must be met before trying to meet further client needs. Basic care needs of airway, breathing, and circulation must first be met for any client before attempting to meet needs for safety, love, or belonging . ✅Suctioning the client's airway as needed Maslow's hierarchy of needs states that certain basic needs must be met before trying to meet further client needs. Basic care needs of airway, breathing, and circulation must first be met for any client before attempting to meet needs for safety, love, or belonging. ✅Using a hemodynamic monitor Maslow's hierarchy of needs states that certain basic needs must be met before trying to meet further client needs. Basic care needs of airway, breathing, and circulation must first be met for any client before attempting to meet needs for safety, love, or belonging. Contacting the client's family so they can visit Love and belonging is a lower priority need than the basic survival needs of airway, breathing, and circulation. Keeping the room quiet and dark This is a lower priority need than airway, breathing, and circulation maintenance.
Which is an example of a first-order priority need when providing client care? A.Starting an IV B.Managing a patient's nausea C.Providing pain medications D.Maintaining a patient's airway
ANSWER: D ✅Maintaining a patient's airway First-order priority needs are situations that threaten the patient's safety. Without meeting first-order priority needs, the patient could experience severe harm or even death. An example would be establishing an open airway for a patient: without an open airway the patient cannot breathe, and no other interventions can be done until the patient is able to breathe and obtain oxygen. Managing a patient's nausea Nausea does not threaten the patient's safety or survival. Starting an IV Although IV access is important, this is not a situation that threaten the patient's safety or survival. Providing pain medications Pain does not threaten the patient's survival. Pain medication falls into the comfort category, and therefore is a second-order priority.