A nurse is caring for a client with a scheduled procedure. While preparing the client for the transport they appear anxious and ask the nurse where they should hide their cellphone during the procedure. The nurse offers to lock the item in a secure area. Which category of Maslow's hierarchy of needs is the nurse addressing?

Safety needs

Esteem needs

Love and belonging needs

Physiological needs

Answer and Explanation

The Correct Answer is A

A) Safety needs:
In Maslow's hierarchy of needs, safety needs are the second level, after physiological needs, and include the need for security and protection from harm. In this scenario, the client’s concern about where to hide their cellphone during the procedure reflects anxiety related to the potential loss or theft of personal property, which relates to safety and security. By offering to lock the cellphone in a secure area, the nurse is addressing the client's need for safety and reassurance about their belongings while undergoing a medical procedure.

B) Esteem needs:
Esteem needs are related to feelings of self-worth, accomplishment, and respect from others. While a person’s sense of esteem can be affected by how others treat their belongings, this particular situation does not relate to the client seeking recognition or respect. The client’s anxiety about where to place the cellphone is more about feeling secure and protected, rather than about esteem or recognition from others.

C) Love and belonging needs:
Love and belonging needs are associated with the need for interpersonal relationships, affection, and social connections. While the nurse’s interaction with the client may help foster a sense of comfort and connection, the concern about the cellphone does not stem from a need for social support or relationships. Instead, it is related to safety and security.

D) Physiological needs:
Physiological needs represent the most basic level of Maslow's hierarchy and include things like air, food, water, and shelter. Although the client is preparing for a medical procedure, their concern about the cellphone does not fall under this category. The focus here is on the safety of the client’s belongings, which is a higher-level need than basic physiological survival.

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Correct Answer is C

Explanation

A) A client who has early dementia and awoke confused to their location this morning:
Confusion in a client with early dementia could indicate a range of possible causes, such as infections, medication side effects, or changes in routine. However, while this warrants investigation, confusion alone does not represent an immediate life-threatening situation according to the ABCDE priority framework. The focus is on managing airway, breathing, circulation, and disability issues first.

B) A client who is scheduled for discharge and has a 38.4°C (101.1°F) temperature this morning:
A fever may indicate infection, which would require further assessment and potentially treatment. While this is a concern, it does not immediately threaten the client's airway, breathing, or circulation. Since the client is not in an acute crisis and is scheduled for discharge, this would be a lower priority compared to clients with more urgent issues like breathing problems or insufficient urine output.

C) A client who has pneumonia and has developed wheezing:
Wheezing indicates potential airway constriction, which could impair the client's breathing. Given that breathing difficulties are a primary concern in the ABCDE priority framework (Airway, Breathing, Circulation, Disability, and Exposure), this client requires immediate attention. Pneumonia combined with wheezing can signify a worsening respiratory condition, which poses an acute risk to the client's oxygenation and overall stability.

D) A client who is postoperative and has a urine output of 50 mL for the past 3 hours:
Oliguria (low urine output) postoperatively is concerning, as it may indicate kidney dysfunction, hypovolemia, or other complications. While it is an important issue that requires attention, it is not immediately life-threatening unless the client shows signs of worsening shock or kidney failure. However, given that this issue does not immediately affect the client’s airway or breathing, it is a lower priority than the client with pneumonia and wheezing.

A. Crushing the medication would release all the medication at once, rather than over time." B. Crushing the medication might cause you to have a stomachache or indigestion. C. "Crushing the medication is a good idea, and I can mix in some ice cream for you." D. "Crushing is unsafe, as it destroys the ingredients in the medication."

Correct Answer is B

Explanation

A) Crushing the medication would release all the medication at once, rather than over time:. Enteric-coated aspirin is designed to bypass the stomach and release the medication in the small intestine to avoid irritation of the stomach lining. Crushing the tablet could potentially release the entire dose all at once, which could lead to gastrointestinal irritation, but this isn't the primary concern. The key issue is that crushing destroys the enteric coating, which is crucial for protecting the stomach.

B) Crushing the medication might cause you to have a stomachache or indigestion:
Enteric-coated medications are specifically designed to protect the stomach lining by delaying the release of the drug until it reaches the small intestine. Crushing the medication would destroy the enteric coating, which can lead to stomach irritation, upset, or even ulcer formation due to the direct exposure of the stomach lining to the medication. Therefore, crushing could cause significant discomfort or damage to the digestive system.

C) "Crushing the medication is a good idea, and I can mix in some ice cream for you.":
Crushing enteric-coated medications, such as aspirin, can lead to adverse effects like stomach irritation, ulceration, and poor absorption. The nurse should not recommend this method of administration without first consulting with the prescribing provider or pharmacist to explore alternatives.

D) "Crushing is unsafe, as it destroys the ingredients in the medication.":
Crushing does not destroy the active ingredients in the medication, but it does destroy the enteric coating, which is the key concern. The enteric coating's function is to prevent the aspirin from irritating the stomach. While it's important to recognize that crushing is unsafe, the reason is more about the loss of this protective coating rather than the destruction of the medication's active ingredients themselves.

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Naxlex Comprehensive Predictor Exams

A nurse is receiving report on a group of clients. Using the ABCDE priority framework which f the following clients should the nurse see first?

Correct Answer is C

Explanation

A nurse is caring for client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide?

Correct Answer is B

Explanation

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