USE MASLOW’S NEEDS TO ESTABLISH PRIORITIES

Because physiological needs are necessary for survival, they have highest priority and must be met first. If you don’t have oxygen to breathe or food to eat, you really don’t care if you have stable psychosocial relationships!!!

Example:

The nurse plans care for a 14 year old girl admitted with eating disorder. On admission, the girl weighs 82 lbs. And is 5’4" tall. Lab test indicate severe hypokalemia, anemia and dehydration. The nurse should give which of the following nursing diagnoses the highest priority?

A.  Body image disturbance related to weight loss
B.   Self-esteem disturbance related to feelings of inadequacy
C.  Altered nutrition: less than body requirements related to decreased intake
D.  Decreased cardiac output related to the potential for dysrhythmias

1.  Look at the answer choices. If the answer choices are both physical and psychosocial, eliminate all psychosocial answer choices. (physiological needs must be met first) … meaning, eliminate choice A and B.

2.  Consider the remaining answer choices (C and D). Does the choice make sense with regard to the disease or situation as described in the question?

3.  Can you apply ABC’s (airway, breathing, circulation)? If ABC does not apply, what is the highest priority?

Letter C makes sense since the patient is anorexic and is 5’4" tall and weighs 82 lbs.
Letter D makes sense since dysrhythmias are a concern for a patient with severe hypokalemia, which often occurs with anorexia.

Correct answer: Letter D – decreased cardiac output is higher priority than altered nutrition.

A woman is admitted to the hospital with a ruptured ectopic pregnancy. A laparotomy is scheduled. Preoperatively, which of the following goals is most important for the nurse to include on the patient’s plan of care?

A.  fluid replacement
B.  pain relief
C.  emotional support
D.  respiratory therapy

Correct answer : letter A

Options B and C are eliminated because they are psychosocial in nature (in the NCLEX, pain is considered a psychosocial problem)

Letter A – fluid replacement makes sense since a ruptured fallopian tube causes extensive bleeding in the abdominal cavity

Letter D – does not make sense; an obstetrical patient is not likely to need respiratory care prior to surgery

Example:

A 4 year old child undergoes a tonsillectomy for treatment of chronic tonsillitis unresponsive to antibiotic therapy. After surgery, the child is brought tot he recovery room. Which of the following actions should the nurse include in his plan of care?

A.  institute measures to minimize crying
B.  perform postural drainage every two hours
C.  cough and deep breathe every hour
D.  give ice cream as tolerated

1.  Reworded question: What should you do after tonsillectomy?
2.  Are all answer choices implementations?…..yes.
3.  If you are still not sure of your answer, ask yourself: "What will cause my patient the least amount of harm?"

A.  will help prevent bleeding….consider this
B.  may cause bleeding….eliminate
C.  may cause bleeding…eliminate
D.  may cause child to clear his throat causing bleeding….eliminate

Correct Answer: letter A

Priorities are important in deciding which nursing care to give. To help select correct answers, think:

• Maslow
• The Nursing Process
• Safety

DO EVERYTHING BY THE BOOK – use your real world experience to help you visualize the patient described in the question, BUT SELECT YOUR ANSWERS BASED ON WHAT IS FOUND IN THE TEXTBOOKS.

ASSESSMENT vs. IMPLEMENTATION

SAFETY – includes meeting basic needs (oxygen, food, fluids, etc.), reducing hazards that cause injury to patient (accidents, obstacles in the home), and decreasing thetransmission of pathogens (immunization, sanitation).