A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first?

Anxiety

Not seeing family members

Not eating

Mental Health

Answer and Explanation

The Correct Answer is C

A) Anxiety: While anxiety is a significant concern, Maslow’s hierarchy of needs emphasizes addressing physiological needs first, as they form the foundation for higher-level needs. Anxiety can be a secondary concern, but it is often tied to unmet basic needs like hunger, so addressing the physiological need for nourishment should take priority.

B) Not seeing family members: Emotional support from family members is important for mental health and well-being, but according to Maslow's hierarchy, psychological needs like social connection come after physiological needs. The patient’s refusal to see family members may be influenced by underlying physiological issues such as hunger or anxiety, making it less urgent to address initially.

C) Not eating: According to Maslow’s hierarchy, the most immediate priority is addressing physiological needs such as food, water, and shelter. If a patient is not eating, it can lead to further health complications like malnutrition, weakness, and decreased energy. Ensuring the patient’s basic physiological needs are met, such as eating, should be the nurse's first priority to stabilize the patient before addressing other concerns.

D) Mental Health: Mental health concerns, like anxiety, are important but are considered a higher-level need in Maslow's hierarchy, following physiological needs. Addressing mental health issues such as anxiety may be necessary, but it is more effective once the basic physiological needs, such as eating and hydration, are met.

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Correct Answer is C

Explanation

A) Thrombus formation:
While immobility increases the risk of thrombus formation due to stasis of blood in the veins, hypercalcemia is not directly linked to thrombus formation. However, immobility and hypercalcemia could contribute to increased clotting risk indirectly, but renal stones are a more direct concern in this situation.

B) Pressure ulcers:
Pressure ulcers are a common concern for immobilized patients due to prolonged pressure on bony prominences. However, hypercalcemia does not directly cause or increase the risk of pressure ulcers. While immobility is a risk factor for pressure ulcers, hypercalcemia is not the primary cause for concern in this case.

C) Renal stones:
Hypercalcemia (elevated calcium levels in the blood) can lead to the formation of renal stones (kidney stones), as excess calcium is often excreted in the urine, where it can crystallize and form stones. This is the most direct and significant concern for a patient with high calcium levels. Monitoring for renal stones would be the priority action for the nurse in this case.

D) Hypostatic pneumonia:
Hypostatic pneumonia occurs due to immobility, causing mucus accumulation in the lungs and subsequent infection. While immobility is a concern for pneumonia, it is not specifically linked to hypercalcemia. The nurse should be monitoring for pneumonia in any immobilized patient, but the more immediate risk related to hypercalcemia is renal stones.

A. Ensure four fingers fit under the restraints to prevent constriction. B. Secure the restraints to the lowest bar of the side rail. C. Secure the restraints using a quick-release tie. D. Anticipate removing the restraints every 4 hr.

Correct Answer is C

Explanation

A) Ensure four fingers fit under the restraints to prevent constriction: While it is important to ensure that restraints are not too tight, the general recommendation is to allow enough room for two fingers, not four. The primary goal is to prevent impaired circulation and nerve damage while also ensuring that the restraint is secure enough to prevent the patient from causing harm to themselves or others. Four fingers may be too loose and could lead to unnecessary movement.

B) Secure the restraints to the lowest bar of the side rail: Restraints should never be secured to a side rail, as the side rails may move and cause the restraint to become tight, which could lead to injury. Restraints should be tied to a fixed part of the bed frame to prevent them from becoming loose or causing undue pressure. Securing to side rails can increase the risk of harm.

C) Secure the restraints using a quick-release tie: This is the correct action. The nurse should always use a quick-release tie to ensure that the restraints can be removed immediately if needed. Quick-release ties allow for rapid removal in case of emergency, reducing the risk of injury or distress to the patient. This ensures safety while still maintaining control over the restraint application.

D) Anticipate removing the restraints every 4 hr: While restraints should be removed periodically to check the skin, circulation, and comfort of the patient, the time frame for removal varies depending on the patient's condition and the facility's protocol. Restraints should be removed more frequently than every 4 hours, if possible, to ensure the patient’s safety and comfort. The nurse should follow the facility's specific protocol for restraint monitoring and removal.

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A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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