A nurse formulates several nursing diagnoses then prioritizes using Maslow's hierarchy. What nursing diagnosis should have the highest priority?
Altered Nutrition: Less Than Body Requirements
Ineffective Coping
Risk for Falls
Impaired Mobility
The Correct Answer is A
A. Maslow’s hierarchy prioritizes physiological needs first, including nutrition, hydration, and oxygenation. This is the most immediate concern.
B. While mental health is important, psychosocial needs are a lower priority than basic physiological needs like nutrition.
C. Fall prevention is essential, but it is a potential problem rather than an existing physiological issue, making it a lower priority than inadequate nutrition.
D. Mobility is important, but ensuring adequate nutrition is more critical to prevent further complications such as muscle wasting and delayed wound healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","F"]
Explanation
A. The patient will be educated about the signs of infection. This is incorrect because it is not specific or measurable. The statement does not describe how the nurse will evaluate whether the patient has understood the information.
B. The patient will know how to manage diabetes effectively. This is incorrect because "know" is not measurable. A better outcome statement would describe a specific action the patient will perform to demonstrate their understanding of diabetes management.
C. The patient will understand the importance of medication adherence. This is incorrect because "understand" is not an observable or measurable behavior. Instead, an outcome should describe an action the patient will take, such as demonstrating how to take medication correctly.
D. The patient will walk 50 feet with a walker unassisted by the end of the week. This is correct because it is specific, measurable, and time-bound. It describes a clear action that the nurse can assess.
E. The patient will demonstrate correct use of an inhaler by the end of the teaching session. This is correct because it is measurable and observable. The nurse can directly assess whether the patient correctly uses the inhaler.
F. The patient will report a pain level of less than 4 on a scale of 0 to 10 within 24 hours of receiving pain medication. This is correct because it is specific, includes a measurable criterion (pain scale), and has a clear timeframe.
Correct Answer is D
Explanation
A. A patient who is scheduled for a routine follow-up visit for hypertension management. This is incorrect because this patient is stable and does not require immediate assessment. Routine follow-ups do not take priority over acute conditions.
B. A patient who is receiving antibiotics for a urinary tract infection and is requesting assistance with personal hygiene. This is incorrect because while personal hygiene is important, it is not urgent or life-threatening.
C. A patient who is recovering from an appendectomy and is asking about discharge instructions. This is incorrect because discharge teaching is important but can be scheduled later in the shift when more urgent needs have been addressed.
D. A patient who is complaining of sudden onset chest pain and shortness of breath. This is correct because sudden onset chest pain and shortness of breath can indicate a life-threatening condition such as myocardial infarction or pulmonary embolism. The nurse must immediately assess this patient to determine the cause and initiate emergency interventions if necessary.
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