A nurse is admitting a client who has a wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following types of precautions should the nurse plan to initiate?

Choice A rationale:

Decreased heart rate is not an anticipated finding in response to acute pain. Pain typically triggers sympathetic nervous system activation, leading to an increased heart rate as a physiological response to the stressor.

Choice B rationale:

Hyperactive bowel sounds are not typically associated with acute pain. Acute pain is more likely to induce a sympathetic response, which can lead to decreased gastrointestinal motility and hypoactive bowel sounds.

Choice C rationale:

Decreased blood pressure is not a common response to acute pain. Pain often leads to an increase in blood pressure due to the activation of the sympathetic nervous system and the release of stress hormones.

Choice D rationale:

Increased respiratory rate is the anticipated finding in response to acute pain. Acute pain can cause an increase in the sympathetic nervous system activity, leading to a higher respiratory rate as the body prepares for a fight-or-flight response. This increased respiratory rate helps oxygenate the blood and meet the potential increased demand for energy during stress.

Choice A rationale:

Love and belonging. Maslow's Hierarchy of Needs outlines a pyramid of human needs, starting from basic physiological needs at the bottom and progressing to higher-level psychological and self-fulfillment needs. Love and belonging are higher-level needs, and individuals typically address them after their basic physiological needs are met. Basic needs like food, water, and shelter take precedence over higher-level emotional needs. In this case, the client's most immediate need would be to satisfy their hunger and thirst.

Choice B rationale:

Psychological security. Psychological security is another higher-level need related to safety and a sense of protection. While it is important, it is not the most immediate need according to Maslow's Hierarchy of Needs. The client would prioritize fulfilling their basic physiological needs before seeking psychological security.

Choice C rationale:

Self-actualization. Self-actualization is the highest level of need in Maslow's Hierarchy, encompassing personal growth, fulfillment, and achieving one's potential. It is a need that individuals pursue once their lower-level needs are satisfied. Since the question pertains to the first need the client would seek to meet, self-actualization is not the correct answer.

Choice D rationale:

Food and water. Food and water are fundamental physiological needs that form the base of Maslow's Hierarchy. These needs must be met before an individual can move on to addressing higher-level needs. Without addressing the need for sustenance, the client's ability to seek love, belonging, security, or self-actualization would be compromised.