The establishment of priorities of care during the planning phase of the nursing process often uses the framework of:

Maslow's hierarchy of needs.

Piaget's cognitive developmental theory.

Erikson's stages of psychosocial development.

Kohlberg's stages of moral development.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Maslow's hierarchy of needs is a framework that prioritizes human needs in a hierarchical order, starting with physiological needs, followed by safety, love and belonging, esteem, and self-actualization. In the planning phase of nursing, this framework helps nurses to establish priorities of care by addressing the most basic and urgent needs first before moving to higher-level needs.

Choice B rationale

Piaget's cognitive developmental theory describes the stages of intellectual development in children and adolescents. While understanding cognitive development can inform nursing care, it is not the primary framework used for establishing priorities of care during the planning phase.

Choice C rationale

Erikson's stages of psychosocial development outline the social and emotional challenges individuals face across the lifespan. While relevant to understanding a client's psychosocial well-being, it is not the primary framework for prioritizing immediate nursing interventions in the planning phase.

Choice D rationale

Kohlberg's stages of moral development describe the progression of moral reasoning. While understanding a client's moral perspective can be relevant in certain situations, it is not the central framework used for establishing the priorities of physiological and safety needs in the nursing care plan. .

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Correct Answer is C

Explanation

Choice A rationale

The orientation phase of the interview typically involves introducing oneself, explaining the purpose of the interview, and establishing rapport with the patient. Asking about the drug list occurs after this initial introduction.

Choice B rationale

The termination phase is the concluding part of the interview, where the nurse summarizes key information and discusses the plan of care. Medication history is gathered much earlier in the assessment.

Choice C rationale

The working phase is where the nurse actively collects data about the patient's health history, current condition, medications, and other relevant information. Asking about the drug list, including herbal supplements and over-the-counter medications, is a key component of this data gathering process.

Choice D rationale

The pre-interaction phase occurs before meeting the patient and involves the nurse reviewing available information such as the patient's chart. The actual questioning of the patient happens later.

Choice E rationale

The evaluation phase occurs after interventions have been implemented to assess their effectiveness. It is not the phase where the initial assessment and data collection, including medication history, take place. .

A. Impaired gas exchange related to alveolar inflammation and infection. B. Pruritus related to side effects of prescribed medications. C. Knowledge deficit related to pneumonia risk factors. D. Activity intolerance related to fatigue and shortness of breath.

Correct Answer is A

Explanation

Choice A rationale

Impaired gas exchange directly affects the patient's oxygenation and carbon dioxide elimination, which are fundamental physiological needs. Alveolar inflammation and infection in pneumonia disrupt the normal diffusion of gases in the lungs, potentially leading to hypoxemia and hypercapnia, posing an immediate threat to life if not addressed promptly. Normal partial pressure of oxygen (PaO₂) is 80-100 mmHg, and normal partial pressure of carbon dioxide (PaCO₂) is 35-45 mmHg.

Choice B rationale

Pruritus, or itching, while uncomfortable, is a symptom related to medication side effects and does not directly compromise vital physiological functions like gas exchange. Addressing the underlying cause and providing symptomatic relief are important but are a lower priority than ensuring adequate oxygenation.

Choice C rationale

Knowledge deficit regarding risk factors for pneumonia is important for long-term health management and prevention of future episodes. However, in the acute phase of pneumonia, the immediate physiological compromise of impaired gas exchange takes precedence over addressing knowledge gaps.

Choice D rationale

Activity intolerance due to fatigue and shortness of breath is a consequence of the physiological changes associated with pneumonia, primarily the impaired gas exchange. While it affects the patient's quality of life, it is a manifestation of the primary problem rather than the most immediate threat to physiological stability.

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The establishment of priorities of care during the planning phase of the nursing process often uses the framework of:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse completes the assessment for a patient who has just been admitted to the hospital.The nurse carefully documents the patient's current drug list and asks about the use of any herbal supplements or over-the-counter medications.Which phase of the interview does this occur in?

Correct Answer is C

Explanation

Which nursing diagnosis is the highest priority for a patient with pneumonia?

Correct Answer is A

Explanation

A charge nurse is reviewing the documentation completed by a newly licensed nurse.Which of the following entries should the charge nurse recommend for revision?

The person responsible for analyzing and interpreting data to arrive at a nursing diagnosis is the:

The laboratory technician must have had a hard time getting the blood sample drawn as the patient's arm is now bruised.The patient developed a large hematoma where the laboratory technician had drawn blood earlier in the shift.Which statement is appropriate to enter in the patient's chart?

The establishment of priorities of care during the planning phase of the nursing process often uses the framework of:

An example of an appropriate nursing diagnosis is:

The patient has a goal of maintaining urinary output of at least 80 mL/hour as part of the nursing care plan.However, the patient's urinary output for the shift was only 20 mL/hour.What is the appropriate action of the nurse?

The nurse realizes that the wrong vital signs were recorded on a patient's chart.How will the nurse correct this error?

The nurse is caring for a patient who came to the hospital with acute shortness of breath.What is the priority action of the nurse as the assessment process is started?