The nurse is caring for a patient who has undergone abdominal surgery. The patient stated prior to surgery that "I don't think I'll be able to handle this if I get a colostomy
I wouldn't know how to manage it." There is no "next of kin" listed in the patient's record. The patient is complaining of severe surgical pain. The nurse is correct when addressing which nursing diagnosis first?
a.
Pain
b.
Alteration in body image
c.
Knowledge deficit
d.
Risk for falls
ANS: A
Use of Maslow's hierarchy of needs helps to organize the most-urgent to less-urgent needs. This framework organizes patient data according to basic human needs common to all individuals. Maslow's theory suggests that basic needs, such as physiologic needs, must be met before higher needs, such as self-esteem. The first level is "physiologic" and includes basic survival needs such as airway patency, breathing, circulation, oxygen level, nutrition, fluid intake, body temperature regulation, warmth, elimination, shelter, sexuality, infection, and pain level. The next level is "safety and security" includes physical safety (prevention of falls and drug side effects) and knowledge of routines and procedures. The level of "love and belonging" involves the need for love and affection, including compassion from the care provider, information from family and significant others, and strength of a support system. "Self-esteem" refers to the need to feel good about oneself and includes changes in body image (from injury, surgery, puberty) and changes in self-concept.
You might also like to view...
It is vital that nurses working in outpatient clinics use safe injection practices to prevent spreading infectious agents from patient to patient and from patient to health care providers to prevent the transmission of which of the following?
a. measles and mumps c. hepatitis B and hepatitis C b. pneumonia and influenza d. encephalitis and hepatitis A
The validity of comments and ratings related to performance is enhanced by:
a. Maintenance of anecdotal notes over the entire evaluation period. b. Quantity of information gathered for appraisal purposes. c. Agreement of the employee with the ratings and comments. d. Whether or not other individuals have contributed to the observations.
Care planning for a patient undergoing detoxification for both alcohol and sedative-hypnotics is based on the treatment principle that states that:
a. medications are used to treat symptoms as they appear. b. a cross-tolerant drug is used to gradually wean the patient. c. liver function is preserved best by avoiding detoxification drugs. d. forcing fluids is therapeutic since detoxification mainly occurs in the kidneys.
A resident with aphasia feeds himself lunch but does not eat the food on the left side of his plate. You know that
A) the resident probably was not hungry. B) the resident's visual field is imperfect. C) aphasia has caused blindness in the left eye. D) stroke may cause visual problems.