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
When providing education to a postoperative client on how to use an incentive spirometer, an accurate step that should be included in the education plan is to instruct the client to inhale slowly and as deeply as possible through the mouthpiece without using the nose ¹⁴. This helps the client to take deep breaths and fully expand their lungs. The other options (Instruct the client to inhale normally and then place the lips securely around the mouthpiece, Encourage the client to perform incentive spirometry 2 to 3 times every 1 to 2 hours, if possible, and When the client cannot inhale anymore, the client should hold his breath and count to 10) are not accurate steps that should be included in the education plan.
Correct Answer is B
Explanation
The nursing diagnosis was "Risk for Deficient Fluid Volume" related to excessive fluid loss, secondary to diarrhea and vomiting. The goal was set that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week and has had no diarrhea or vomiting for the past 5 days, indicating that the problem has been resolved. Therefore, the nurse should document that the problem has been resolved and the goal has been met.
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