A client is hospitalized with numerous acute health problems. According to Maslow's hierarchy of needs model, which nursing diagnosis should the nurse identify as being the highest priority for this client?
Self-Care Deficit related to weakness and debilitation
Powerlessness related to chronic disease state
Altered Nutrition, Less Than Body Requirements related to the inability to absorb nutrients
Risk for Injury related to unsteady gait
The Correct Answer is C
According to Maslow's hierarchy of needs model, physiological needs such as food, water, and shelter are the most basic and fundamental needs that must be met before higher-level needs can be addressed. In this scenario, the nursing diagnosis of Altered Nutrition, Less Than Body Requirements related to inability to absorb nutrients addresses a fundamental physiological need and should be identified as the highest priority for this client. The other nursing diagnoses listed address important needs related to safety, self-care, and psychological well-being, but these needs are considered higher-level needs according to Maslow's hierarchy and should be addressed after the client's basic physiological needs have been met.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement indicates a need for further teaching because it is not accurate. Positioning a client in good body alignment and changing the position regularly are essential aspects of nursing practice, but the position should be changed more frequently than every 3 hours. It is generally recommended to reposition clients at least every 2 hours to prevent pressure ulcers and other complications. The other options (Frequent change in position helps to prevent muscle discomfort, undue pressure resulting in pressure ulcers, damage to superficial nerves and blood vessels, and contractures; Any position, correct or incorrect, can be detrimental if maintained for a prolonged period; and For all clients, it is important to assess the skin and provide skin care before and after a position change) are accurate statements and do not indicate a need for further teaching.
Correct Answer is A
Explanation
During a lung assessment on a client suspected of having pneumonia, the nurse should report asymmetrical chest expansion to the physician immediately. Asymmetrical chest expansion can be a sign of a serious lung condition such as pneumonia. The other options (Breath sounds equal bilaterally, Bilateral symmetric vocal fremitus, and Chest symmetrical) are normal findings and do not need to be reported immediately.
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