A nurse must assess which patient to treat first. Which patient aligns with the highest priority in Maslow's hierarchy of needs?
A patient with severe dehydration and hypotension
An elderly patient with confusion who may try to wander off
A patient experiencing loneliness and seeking social interaction
A patient requesting help to organize their discharge plan
The Correct Answer is A
A. A patient with severe dehydration and hypotension: These findings indicate a critical deficit in the physiological needs for water and circulatory stability at the base of Maslow's hierarchy. Hypotension suggests impaired tissue perfusion that can lead to rapid multi-organ failure if not addressed immediately. This is the most urgent life-threatening condition listed.
B. An elderly patient with confusion who may try to wander off: This concern relates to the safety and security tier, which is the second level of the hierarchy. While protecting the patient from injury is a high priority, it follows the stabilization of basic biological functions like circulation. Physiological integrity must be established before addressing environmental safety.
C. A patient experiencing loneliness and seeking social interaction: Loneliness falls under the love and belonging category, which is a psychosocial need located in the middle of the hierarchy. While important for mental health, it does not pose an immediate threat to physical life. This patient is addressed only after physiological and safety needs are met.
D. A patient requesting help to organize their discharge plan: Discharge planning is associated with self-actualization or security needs regarding future care transitions. It is a complex cognitive task that is prioritized much lower than acute medical stabilization. It is addressed during the stabilization phase, not during the initial triage of acute needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Document the patient's pain and notify the physician:While documentation and communication are necessary, the nurse must first gather objective assessment data to provide a meaningful report. Notifying the provider without a physical assessment prevents the identification of acute surgical complications. Physical assessment must always precede notification in the nursing process.
B. Encourage the patient to use non-pharmacologic methods like relaxation:While relaxation is a helpful adjunct, it is insufficient as a primary intervention for "severe" acute postoperative pain. Using only non-pharmacologic methods ignores the potential for serious surgical complications that require medical attention. This approach delays necessary diagnostic evaluation of the patient's distress.
C. Administer a stronger dose of pain medication:Administering more analgesia without an assessment is dangerous and could mask the symptoms of a worsening condition like hemorrhage or dehiscence. It violates safe practice standards by treating a symptom without investigating the underlying cause. Nurses cannot independently increase doses beyond prescribed limits.
D. Perform a focused assessment of the surgical site and evaluate for any complications:Severe pain that is refractory to standard analgesics can be an early warning sign of hematoma, infection, or internal injury. The nurse must inspect the dressing, check for distension, and monitor vital signs to rule out emergencies. Assessment is the critical first step in clinical decision-making.
Correct Answer is A
Explanation
A. Asthma:While asthma causes wheezing due to bronchoconstriction, it does not typically cause a global decrease in breath sounds unless the attack is severe and air movement is minimal. In many cases of asthma, breath sounds are audible but adventitious. Decreased sounds suggest a more significant barrier to air transmission.
B. Normal lung function:Normal lung function is characterized by clear, vesicular breath sounds in the periphery and bronchial sounds over the larger airways. Decreased or absent breath sounds are always an abnormal finding that requires further investigation. They indicate an interruption in the normal transmission of sound through the lung tissue.
C. Bronchitis:Bronchitis typically manifests as loud, coarse rhonchi or wheezes caused by mucus and inflammation in the large airways. Breath sounds are usually present but distorted by the adventitious noises. It does not typically result in the diminished intensity of sound associated with "decreased" breath sounds.
D. Pleural effusion:The accumulation of fluid in the pleural space acts as a physical barrier that dampens the transmission of sound from the lungs to the chest wall. This results in significantly diminished or absent breath sounds over the area of the effusion. It is a classic clinical finding for this pathological state.
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