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How is Maslow's Hierarchy of Human Needs used by nurses in a clinical setting?
- A. It serves as a reminder of human growth and development across the life span
- B. It helps in prioritizing nursing diagnoses and care
- C. It outlines the basic psychological needs that people have when they are hospitalized and feel anxiety
- D. It is a framework for thinking critically
Correct Answer: B
Rationale: Maslow's hierarchy (B) prioritizes care by addressing physiological needs first, then safety, love, esteem, and self-actualization. A, C, and D are less accurate uses.
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Patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation
During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:
- A. signs of fluid overload
- B. symptoms
- C. data clustering
- D. urinary retention
Correct Answer: C
Rationale: Grouping signs like flushed skin and fever (C) is data clustering, suggesting dehydration or infection. Fluid overload (A) shows edema, symptoms (B) are subjective, and urinary retention (D) involves bladder issues.
Patient was administered a stat insulin dose
The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:
- A. the insulin was administered based per the nurse's testimony
- B. none of the answers are correct
- C. the insulin was administered based on the witness testimony
- D. the insulin was not administered because it was not charted
Correct Answer: D
Rationale: Legally, 'if it wasn't documented, it wasn't done' (D). Without MAR documentation, the insulin administration cannot be verified, despite testimony (A, C). B is incorrect as D is accurate.
Patient with dyspnea
The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is:
- A. implementation
- B. evaluation
- C. planning
- D. assessment
Correct Answer: C
Rationale: Planning (C) involves selecting interventions for patient needs, like dyspnea. A, B, and D represent other phases.
What is the major concern when using a computer for documentation?
- A. confidentiality
- B. adequate forms for documentation
- C. incorrect information
- D. of the answers are correct
Correct Answer: A
Rationale: Confidentiality (A) is the primary concern due to risks of unauthorized access or breaches. B and C are managed by system design, and D is incorrect.
When discovering subjective data, recognize that they relate to:
- A. signs
- B. objective cues
- C. symptoms
- D. observable data
Correct Answer: C
Rationale: Subjective data relates to symptoms (C) reported by the patient, like pain or nausea. Signs (A), objective cues (B), and observable data (D) are objective, measurable findings.