Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is prioritizing care for several clients on a busy hospital unit. Based on Maslow’s hierarchy of needs, which client should the nurse attend to first?
A. A client who is anxious about an upcoming surgery and requests emotional support.
Anxiety and emotional support fall under the category of safety and psychological needs. While important, they are not as urgent as physiological needs such as pain management.
B. A client who is complaining of severe pain and requests pain medication.
Severe pain is a physiological need, which is the most basic and urgent level in Maslow’s hierarchy. Addressing pain is essential for comfort, healing, and preventing complications such as increased stress response or impaired mobility.
C. A client who is requesting information about financial assistance for their medical bills.
Financial assistance relates to long-term security and social needs. It does not pose an immediate threat to the client’s physical well-being and can be addressed after urgent physiological concerns.
D. A client who is feeling very lonely and asks to speak with someone.
Loneliness is a social and emotional need. While it affects mental health, it does not take precedence over acute physical distress such as severe pain.
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Full Explanation
Choice A reason: Anxiety and emotional support fall under the category of safety and psychological needs. While important, they are not as urgent as physiological needs such as pain management.
Choice B reason: Severe pain is a physiological need, which is the most basic and urgent level in Maslow’s hierarchy. Addressing pain is essential for comfort, healing, and preventing complications such as increased stress response or impaired mobility.
Choice C reason: Financial assistance relates to long-term security and social needs. It does not pose an immediate threat to the client’s physical well-being and can be addressed after urgent physiological concerns.
Choice D reason: Loneliness is a social and emotional need. While it affects mental health, it does not take precedence over acute physical distress such as severe pain.
Similar Questions
A public health team is evaluating several proposals to reduce future cardiovascular disease in a low-income neighborhood. Which proposal demonstrates a secondary prevention approach?
A. Offering free cholesterol screenings at local clinics.
Secondary prevention focuses on early detection and prompt intervention to halt or slow the progression of disease. Offering cholesterol screenings identifies individuals at risk for cardiovascular disease before symptoms appear, allowing for timely management through lifestyle changes or medication.
B. Partnering with schools to provide healthy meals.
Partnering with schools to provide healthy meals is a form of primary prevention. It aims to prevent the development of cardiovascular risk factors by promoting healthy eating habits in children.
C. Launching a campaign to reduce sodium intake in adults.
Launching a campaign to reduce sodium intake is also primary prevention. It targets the general population to reduce the risk of hypertension and cardiovascular disease before any clinical signs emerge.
D. Installing walking and biking trails in the neighborhood.
Installing walking and biking trails is an example of primordial prevention. It modifies the environment to encourage physical activity, thereby preventing the emergence of sedentary lifestyles and associated risk factors.
Full Explanation
Choice A reason: Secondary prevention focuses on early detection and prompt intervention to halt or slow the progression of disease. Offering cholesterol screenings identifies individuals at risk for cardiovascular disease before symptoms appear, allowing for timely management through lifestyle changes or medication.
Choice B reason: Partnering with schools to provide healthy meals is a form of primary prevention. It aims to prevent the development of cardiovascular risk factors by promoting healthy eating habits in children.
Choice C reason: Launching a campaign to reduce sodium intake is also primary prevention. It targets the general population to reduce the risk of hypertension and cardiovascular disease before any clinical signs emerge.
Choice D reason: Installing walking and biking trails is an example of primordial prevention. It modifies the environment to encourage physical activity, thereby preventing the emergence of sedentary lifestyles and associated risk factors.
An older client with a history of lung disease is admitted to the hospital with shortness of breath and a productive cough. The client states, "I've been so nervous. I haven't eaten all day." What need should the nurse prioritize?
A. Lack of oxygen
Oxygenation is a fundamental physiological need and must be prioritized above all others, especially in a client with a history of lung disease presenting with shortness of breath and a productive cough. These symptoms suggest impaired gas exchange, which can rapidly become life-threatening. According to Maslow’s hierarchy of needs and clinical triage principles, airway and breathing are always addressed first to prevent hypoxia and respiratory failure.
B. Lack of nutrition
While nutrition is important, it is not immediately life-threatening in the context of acute respiratory distress. The client’s lack of food intake may contribute to weakness, but it does not supersede the need for oxygen.
C. Lack of support
Emotional support is part of psychosocial care and is essential for holistic nursing, but it is not the priority when a client is experiencing respiratory compromise. Support can be provided once the client is stabilized.
D. Lack of rest
Rest is beneficial for recovery, especially in respiratory illness, but it cannot be prioritized over oxygenation. Without adequate oxygen, rest alone will not improve the client’s condition and may worsen hypoxia if not addressed.
Full Explanation
Choice A reason: Oxygenation is a fundamental physiological need and must be prioritized above all others, especially in a client with a history of lung disease presenting with shortness of breath and a productive cough. These symptoms suggest impaired gas exchange, which can rapidly become life-threatening. According to Maslow’s hierarchy of needs and clinical triage principles, airway and breathing are always addressed first to prevent hypoxia and respiratory failure.
Choice B reason: While nutrition is important, it is not immediately life-threatening in the context of acute respiratory distress. The client’s lack of food intake may contribute to weakness, but it does not supersede the need for oxygen.
Choice C reason: Emotional support is part of psychosocial care and is essential for holistic nursing, but it is not the priority when a client is experiencing respiratory compromise. Support can be provided once the client is stabilized.
Choice D reason: Rest is beneficial for recovery, especially in respiratory illness, but it cannot be prioritized over oxygenation. Without adequate oxygen, rest alone will not improve the client’s condition and may worsen hypoxia if not addressed.
A nurse is planning care for a client who has recently lost a loved one and is struggling with their faith. Which intervention best supports the client's spiritual wellness?
A. Provide educational materials on coping with grief.
Educational materials may help the client understand grief, but they do not directly address spiritual distress or faith-related concerns. This approach is more cognitive and less personalized.
B. Facilitate a visit from the client’s clergy or advisor.
Facilitating a visit from the client’s clergy or spiritual advisor directly supports spiritual wellness by connecting the client with their faith community. This intervention respects the client’s beliefs and provides comfort, guidance, and meaning during a time of loss, which is essential for spiritual healing.
C. Assist the client in developing an exercise routine.
Exercise routines support physical and emotional health but do not specifically address spiritual needs. While beneficial, this intervention is not targeted toward the client’s expressed struggle with faith.
D. Encourage the client to join a grief support group.
Grief support groups offer emotional and social support, which may indirectly benefit spiritual wellness. However, they may not provide the faith-based guidance the client is seeking, making this a secondary option.
Full Explanation
Choice A reason: Educational materials may help the client understand grief, but they do not directly address spiritual distress or faith-related concerns. This approach is more cognitive and less personalized.
Choice B reason: Facilitating a visit from the client’s clergy or spiritual advisor directly supports spiritual wellness by connecting the client with their faith community. This intervention respects the client’s beliefs and provides comfort, guidance, and meaning during a time of loss, which is essential for spiritual healing.
Choice C reason: Exercise routines support physical and emotional health but do not specifically address spiritual needs. While beneficial, this intervention is not targeted toward the client’s expressed struggle with faith.
Choice D reason: Grief support groups offer emotional and social support, which may indirectly benefit spiritual wellness. However, they may not provide the faith-based guidance the client is seeking, making this a secondary option.