A Medical-Surgical nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Choice A rationale:

Love and belonging. Maslow's Hierarchy of Needs outlines a pyramid of human needs, starting from basic physiological needs at the bottom and progressing to higher-level psychological and self-fulfillment needs. Love and belonging are higher-level needs, and individuals typically address them after their basic physiological needs are met. Basic needs like food, water, and shelter take precedence over higher-level emotional needs. In this case, the client's most immediate need would be to satisfy their hunger and thirst.

Choice B rationale:

Psychological security. Psychological security is another higher-level need related to safety and a sense of protection. While it is important, it is not the most immediate need according to Maslow's Hierarchy of Needs. The client would prioritize fulfilling their basic physiological needs before seeking psychological security.

Choice C rationale:

Self-actualization. Self-actualization is the highest level of need in Maslow's Hierarchy, encompassing personal growth, fulfillment, and achieving one's potential. It is a need that individuals pursue once their lower-level needs are satisfied. Since the question pertains to the first need the client would seek to meet, self-actualization is not the correct answer.

Choice D rationale:

Food and water. Food and water are fundamental physiological needs that form the base of Maslow's Hierarchy. These needs must be met before an individual can move on to addressing higher-level needs. Without addressing the need for sustenance, the client's ability to seek love, belonging, security, or self-actualization would be compromised.

Choice A rationale:

Protective precautions (also known as reverse isolation) are implemented to protect clients with compromised immune systems from potential pathogens brought in by healthcare providers or visitors. This choice would be appropriate for clients who are highly susceptible to infections, but it's not the primary choice for managing a wound infected with MRSA.

Choice B rationale:

Droplet precautions are utilized for diseases spread by respiratory droplets. MRSA is primarily spread through direct contact with contaminated skin or objects. Therefore, droplet precautions are not the most appropriate choice for this scenario.

Choice C rationale:

Airborne precautions are designed for diseases that spread via small particles suspended in the air, such as tuberculosis. MRSA does not spread through the airborne route, so airborne precautions are not necessary for a wound infection with MRSA.

Choice D rationale:

Contact precautions are the correct choice when dealing with MRSA infections. MRSA is primarily transmitted through direct physical contact or contact with contaminated objects. By implementing contact precautions, the nurse can effectively prevent the spread of the infection to other clients and healthcare workers.