After performing an initial patient assessment, which finding would the nurse address first according to Maslow's Hierarchy?
Patient reports feelings of loneliness
Patient's elevated anxiety about diagnosis
Low blood oxygen saturation levels
A history of depression
The Correct Answer is C
A. Patient reports feelings of loneliness: These social concerns belong to the love and belonging tier of the hierarchy. While significant for long-term psychological health, they do not pose an immediate threat to physical survival. They are addressed only after physiological and safety needs are stabilized.
B. Patient's elevated anxiety about diagnosis: Anxiety is a psychological response that falls under the categories of safety or self-esteem. Though it can impact physiological parameters, it is not the primary life-threatening priority in an acute clinical setting. Psychological stabilization follows the resolution of urgent biological deficits.
C. Low blood oxygen saturation levels: Oxygenation is a fundamental physiological requirement located at the base of the hierarchy. Hypoxemia can lead to rapid organ failure, cardiac arrest, and cellular death within minutes. It must be corrected before any higher-level psychosocial or emotional needs are considered.
D. A history of depression: Chronic psychiatric conditions represent long-term health management challenges rather than acute physiological crises. While important for holistic care, a stable history of depression does not supersede the immediate need for respiratory or circulatory support. It is prioritized lower than acute survival needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. 50 gtt/min: This rate would deliver the 100 mL infusion in only 30 minutes, which is twice as fast as the prescribed rate. Rapid infusion of certain medications can lead to adverse effects or toxicity. Accurate calculation is essential when an electronic pump is not available.
B. 25 gtt/min: The manual drip rate is calculated by multiplying the total volume (100 mL) by the drop factor (15 gtt/mL) and dividing by the time in minutes (60 min). 1500 divided by 60 equals 25. This ensures the 100 mL is delivered precisely over the 1-hour period.
C. 75 gtt/min: This drip rate would result in the entire volume being infused in approximately 20 minutes. Such a high rate is incorrect for a 1-hour schedule and could cause fluid overload or infusion-related reactions. It significantly exceeds the required delivery speed of 1.67 mL per minute.
D. 60 gtt/min: Setting the rate to 60 drops per minute would infuse the medication in about 25 minutes. This does not align with the prescribed 1-hour duration for the 100 mL volume. Proper use of the drip factor formula prevents such timing errors in manual administration.
Correct Answer is B
Explanation
A. A patient with hyperthyroidism: Hyperthyroidism involves a hypermetabolic state that often leads to increased diaphoresis, tachypnea, and potential diarrhea, which increase insensible and sensible fluid loss. Patients with this condition are more susceptible to fluid volume deficit rather than excess. Their elevated metabolic rate generally prevents the accumulation of excess intravascular fluid.
B. A patient with congestive heart failure: In this condition, the heart cannot pump blood efficiently, leading to decreased renal perfusion and the activation of the renin-angiotensin-aldosterone system. This results in the pathological retention of sodium and water by the kidneys, causing systemic and pulmonary edema. It is a primary risk factor for hypervolemia and fluid overload.
C. A patient receiving loop diuretics: Loop diuretics increase the excretion of water and electrolytes by inhibiting reabsorption in the renal tubules. The primary therapeutic effect and common side effect of these medications is the reduction of total body fluid. This places the patient at a high risk for fluid volume deficit.
D. A patient with diabetic ketoacidosis: This acute metabolic complication causes profound osmotic diuresis due to extreme hyperglycemia. The high glucose concentration in the renal filtrate pulls water with it, leading to severe cellular and intravascular dehydration. Patients in this state require aggressive fluid resuscitation to correct a massive volume deficit.
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