A nurse uses Maslow's hierarchy of needs to plan care for a patient with mental illness. Which problem will receive priority? The patient:
a. refuses to eat or bathe.
b. reports feelings of alienation from family.
c. is reluctant to participate in unit social activities.
d. is unaware of medication action and side effects.
ANS: A
The need for food and hygiene are physiological and therefore take priority over psychological or meta-needs in care planning.
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The nurse is instructing a new mother on the strategies to prevent the development of postpartum depression. Which instructions will the nurse include in the teaching session with the client?
Select all that apply. A) Restrict fluids and eat a low-fat diet help to avoid the onset of postpartum depression. B) Realize that feeling depressed after delivering a baby is normal and can last for months. C) The only way to avoid postpartum depression is to not have children. D) Encourage the client to plan how to manage the baby's care needs at home to help adjust to motherhood. E) Instruct the client to recognize the signs and symptoms of postpartum depression and phone the health care provider if these occur.
What does the nurse recognize as a risk factor for the development of delirium in older adults?
1. A lack of rigorous exercise that leads to decreased cerebral blood flow 2. Decreased social interaction that leads to profound isolation and psychosis 3. Administration of multiple medications that may cause medication interactions or toxicity 4. Age-related cognitive changes that make older adult patients more susceptible to changes in mental status
A nurse is reviewing the medical record of a child and finds that the child has a grade III murmur. After auscultating the child's heart sounds, the nurse would document this murmur as which of the following?
A) Loud without a thrill B) Loud with a precordial thrill C) Soft and easily heard D) Loud, audible with a stethoscope
The nurse observes for manifestations of typical migraine headaches, which include
a. aura, visual disturbances, and nausea. b. bilateral pain, abrupt onset, and tinnitus. c. diarrhea, nasal congestion, and eye redness. d. scalp tenderness, sensation of pressure, and nighttime onset.