Upon assessment, the nurse notices that the patient's respirations have increased, and the tip of the nose and earlobes are becoming cyanotic. The nurse finds that the patient's pulse rate is over 100 beats per minute
According to Maslow's hierarchy of needs, which patient need should the nurse address first?
a. Self-esteem
b. Physiological
c. Self-actualization
d. Love and belonging
ANS: B
Maslow's hierarchy is useful in setting patient priorities. Basic physiological and safety needs are usually the first priority. After the physiological and safety needs are met, the nurse can move to love and belonging, self-esteem, and self-actualization.
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The nurse is planning care for a patient who is terminally ill. The nurse chooses spiritual distress as the patient's nursing diagnosis. What clinical observations or manifestations warrant this nursing diagnosis?
1. Lack of initiative 2. Decreased or flat affect 3. Expressing lack of control 4. Expressing lack of purpose in life
After an assessment, the nurse determines that the diagnosis of constipation is appropriate for an older client recovering from surgery. What would be a goal for this nursing diagnosis?
1. Decrease the frequency of narcotic pain medication administration. 2. Explain the importance of hydration and activity in regard to constipation. 3. Drink at least 800 ml of non-caffeinated and nonalcoholic beverages each day. 4. Evacuate a formed bowel movement at least every 2 days with minimal distress.
To enhance gas exchange, the nurse would position a patient who had a left pneumonectomy this morning:
1. on the right side. 2. on the left side. 3. in a semi-Fowler's position. 4. flat, with a small pillow.
When observing a wound, you can do which of the following?
a. Culture the wound drainage. b. Insert packing material into the wound. c. Observe the surrounding skin. d. Measure the wound's depth.