A nurse is caring for a patient who is experiencing shortness of breath and has low oxygen saturation levels. According to Maslow's hierarchy of needs, what should be the nurse's first action?
Administer oxygen therapy to improve oxygen saturation levels
Provide emotional support to the patient.
Discuss the patient's concerns about their safety in the hospital
Assist the patient in meeting their self-actualization needs
The Correct Answer is A
A. Administer oxygen therapy to improve oxygen saturation levels: According to Maslow’s hierarchy, physiologic needs such as oxygenation take highest priority. Hypoxemia compromises cellular metabolism and can rapidly become life-threatening if not corrected. Immediate oxygen therapy supports airway and breathing, making it the nurse’s first action.
B. Provide emotional support to the patient: Emotional reassurance addresses psychosocial needs, which are important but secondary to physiologic stability. A patient experiencing shortness of breath requires correction of oxygen imbalance before anxiety can be effectively managed. Psychological support is more effective once oxygenation improves.
C. Discuss the patient's concerns about their safety in the hospital: Safety concerns fall under Maslow’s safety and security needs. While relevant, these needs are prioritized after physiologic needs such as adequate oxygen delivery. Addressing safety without stabilizing breathing places the patient at continued risk.
D. Assist the patient in meeting their self-actualization needs: Self-actualization represents the highest level of Maslow’s hierarchy and is only addressed after all basic and psychological needs are met. A patient with respiratory compromise is not physiologically stable enough for this level of intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Ignore the client's mention of folk practices and focus solely on professional care: Ignoring cultural beliefs can undermine trust and hinder the therapeutic relationship. Cultural competence requires acknowledging and respecting the client’s practices.
B. Collaborate with the client to integrate folk healing practices into the treatment plan alongside professional care: Working with the client to safely incorporate culturally significant practices promotes adherence, respects autonomy, and fosters a therapeutic alliance. Integration ensures that folk remedies do not interfere with evidence-based treatments.
C. Encourage the client to stop all folk practices and rely solely on evidence-based medical treatments: This approach is confrontational and dismissive of cultural beliefs. Forcing compliance may increase resistance and reduce engagement in care.
D. Advise the client to use folk healing practices only after professional care has been completed: Imposing sequencing or conditional acceptance can be perceived as disrespectful. Collaborative planning that considers timing, safety, and compatibility with medical care is more effective.
Correct Answer is C
Explanation
A. Stage II: Stage II pressure injuries involve partial-thickness skin loss with exposed dermis. There may be a shallow open ulcer, blister, or abrasion, but subcutaneous fat is not visible. The described wound is deeper, so it does not fit Stage II criteria.
B. Stage I: Stage I pressure injuries are characterized by intact skin with non-blanchable erythema. There is no tissue loss or ulceration, making this stage inconsistent with the wound described.
C. Stage III: Stage III pressure injuries involve full-thickness skin loss with visible subcutaneous fat. The wound extends below the dermis into the subcutaneous tissue, creating a deep depression. This description matches the characteristics of a Stage III pressure injury.
D. Stage IV: Stage IV pressure injuries involve full-thickness skin and tissue loss with exposed bone, tendon, or muscle. Since the description mentions subcutaneous fat but no bone, tendon, or muscle exposure, Stage IV is not appropriate.
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