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?

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. .

Choice A rationale

Data in a client's medical record is confidential and protected under privacy laws such as HIPAA. Sharing this information with all employees, regardless of their direct involvement in the client's care, would be a breach of confidentiality. Access should be limited to those with a need-to-know for providing care.

Choice B rationale

Documentation should primarily focus on objective data, including direct observations and factual information about the client's condition, care provided, and responses. The nurse's personal interpretations or opinions should be avoided as they introduce bias and may not be clinically relevant or accurate.

Choice C rationale

A medical record serves as a legal document that provides a comprehensive account of a client's healthcare journey. In legal proceedings, it can be presented as evidence to support or refute claims related to the care provided, the client's condition, and adherence to professional standards.

Choice D rationale

Timely and organized documentation ensures accurate and efficient communication among healthcare team members. Completing records promptly after care delivery helps maintain data integrity and facilitates continuity of care. Organized documentation allows for easy retrieval of information, supporting effective clinical decision-making.

Choice E rationale

Accuracy in medical documentation is paramount for patient safety and quality of care. Incorrect information can lead to misunderstandings, errors in treatment, and potential harm to the client. Nurses are accountable for ensuring that all recorded information is truthful, precise, and reflects the care provided.