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The nurse is prioritizing the care of a client who has a diagnosis of uncontrolled diabetes and may have the left foot amputated related to a nonhealing ulcer. What need would the nurse place at the lowest level of Maslow's hierarchy while prioritizing this client's care?
- A. Physiologic needs
- B. Safety and security needs
- C. Love and belonging needs
- D. Self-actualization needs
Correct Answer: D
Rationale: Self-actualization needs are the fifth and last level of Maslow's hierarchy. Physiologic needs are the first level, safety and security needs are the second level, and love and belonging needs are the third level.
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Which of the following is the highest level of human need according to Maslow (1968)?
- A. Physiologic
- B. Love and belonging
- C. Esteem and self-esteem
- D. Self-actualization
Correct Answer: D
Rationale: The highest level need is self-actualization. The first level of need is physiological needs. Love and belonging are third-level needs. Esteem and self-esteem are fourth-level needs.
A nurse is creating a plan of care and has identified several problems for the client including a collaborative problem. Which statement distinguishes a collaborative problem from a problem-focused nursing diagnosis?
- A. A collaborative problem addresses the problem's related risk factors and defining characteristics.
- B. A collaborative problem denotes a complication that has a physiologic origin which can be addressed by independent and/or health care provider prescribed nursing interventions.
- C. A collaborative problem denotes a client's response to a physiologic condition that can be addressed solely by nursing interventions.
- D. A collaborative problem is a secondary risk factor that provides a more in-depth explanation of the problem.
Correct Answer: B
Rationale: Collaborative problems denote complications with a physiologic origin and differ from nursing diagnoses, which address client responses to various circumstances and are managed by nursing interventions. Related risk factors and defining characteristics are parts of a nursing diagnosis, not a collaborative problem. A nursing diagnosis describes a client's response to a physiologic condition or the environment and can be addressed by nursing interventions (independent or health care provider prescribed). Secondary risk factors can provide a more in-depth explanation of the cause of a problem in a nursing diagnosis. Collaborative problems do not have secondary risk factors.
Which of the following is a true statement about critical thinking in nursing?
- A. It involves purposeful, outcome-directed thinking.
- B. It shows trends and patterns in client status.
- C. It makes judgments based on conjecture.
- D. It supplies validation for reimbursement.
Correct Answer: A
Rationale: In nursing, critical thinking involves purposeful, outcome-directed thinking. Critical thinking makes judgments based on evidence rather than conjecture. Providing a foundation for evaluation and quality improvement and showing trends and patterns in client status are functions served by documentation.
The LPN plays a vital role in the development of a nursing diagnosis for a client. What role does the LPN have?
- A. Report information that suggests actual or potential health problems.
- B. Examine and analyze the client database to formulate nursing diagnosis.
- C. Inform the physician about the specific development of the nursing diagnosis.
- D. Evaluate the effectiveness of the nursing diagnosis and how it pertains to the data.
Correct Answer: A
Rationale: As in other phases of the nursing process, the nurse's role depends on their level of practice. LPN/LVNs report information that suggests actual or potential health problems. RNs examine and analyze the client database to formulate a nursing diagnosis.. The The physician is generally not involved in the nursing process and care planning of care for the client. The RN's role is to evaluate the effectiveness or resolving of the nursing diagnosis..
Which of the following is an important element of implementation?
- A. Client database
- B. Critical thinking
- C. Nursing orders
- D. Documentation
Correct Answer: D
Rationale: An important element of implementation is documentation. The client database includes all the information obtained from the medical and nursing history. Physical examination and diagnostic studies are not an important element of implementation. Critical thinking is intentional, contemplative, and outcome-directed thinking. Developing good critical thinking skills will make nurses more efficient and effective at resolving situations necessitating multiple interventions. Nursing orders are specific nursing directions so that all healthcare team members understand what to do for the client; therefore, they are not an important element of implementation.