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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A stage II pressure ulcer is a wound that presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. This type of wound is caused by unrelieved pressure on the skin, resulting in damage to the underlying tissue. In this scenario, the nurse notes an area of tissue injury on the client's sacral area that matches the description of a stage II pressure ulcer. Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin, while stage III and IV pressure ulcers involve full-thickness tissue loss and may expose underlying muscle, bone, or other structures.

A. "Describe the type of pain you have." B. "How did that make you feel?" C. "Did you take those drugs?" D. "What medications do you take at home?"

Correct Answer is C

Explanation

A closed-ended question or statement is one that can be answered with a simple "yes" or "no" or with a specific piece of information. In this case, the question "Did you take those drugs?" is an example of a closed-ended question because it can be answered with a simple "yes" or "no".

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

Correct Answer is A

Explanation

Which is an example of a closed-ended question or statement?

Correct Answer is C

Explanation

The client has a documented stage II pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate to use with this client?

The nurse manager has determined that a new staﬀ nurse is demonstrating characteristics of a critical thinker. Which of the following did the manager observe the nurse perform? Select all that apply.

The nurse is caring for a postpartum client who is receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician?

A nurse is assessing a client who has a fever, an infection of a ﬂank incision, and is in severe pain. Which type of pulse rate would the client most likely exhibit?

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

The nurse has performed an assessment of a client scheduled for discharge to be cared for by the family. Which situation would the nurse question regarding discharge of this client to be cared for by the family?

During discharge planning, the nurse is responsible for teaching the client how to maintain comfort, promote healing, and restore wellness. However, one of the actions listed below is not correct.