Maslows Doesn't apply here?

LifelongDream · Jul 30, 2009

This is a case where you just need to know that the priority after slow titration of insulin would be volume replacement with DKA.

Cindy-san · Jul 30, 2009

I chose 2 because of ABC's. THe answer is actually 1. I understand that his person is tachycardic due to fluid volume deficit but how come ABC's don't have priority?

ABC are always priority but it says nothing about an issue with his airway, breathing or poor circulation (first rule of the NCLEX: don't imagine stuff that isn't there). He's awake and oriented. You can have a sugar of 600 and not be in a diabetic coma. His problem is his high sugar has made him pee out all his fluid and electrolytes.

Option 2 is more for an HR of 170 and a BP of 80/40. Your question guy is probably tachy from the slight temp and fluid loss.

EMT-2-RN · Jul 30, 2009

Dont make this harder than it is. Remember CO = SV x HR (at this rate, the heart is beating slow enough it should not really decrease ventricular filling or SV) So the tachycardia could be due to the slight temp. or as you stated, the pt has a decreased intravascular vol. the and the elevated HR is a compensatory mechanism to increase the CO. Either way, as long as you have a normal rhythm, at this rate you would see an increase in CO, not a decrease so this would cancel out option 2.

Daytonite, BSN, RN · Jul 30, 2009

edit: sorry not maslow's, i mean abcs.
a client with a serum glucose of 618mg/dl is admitted to the facility. he's awake and orientated, has hot dry skin and has the following vital signs:
temp: 100.6f
hr: 116 beats/min
bp: 108/70
based on these assessment findings, which nursing diagnosis takes highest priority?
1. deficient fluid volume related to osmotic diuresis
2. decreased cardiac output related to elevated hr
3. imbalanced nutrition: less than body requirements related to insulin deficiency
4. ineffective thermoregulation related to dehydration.
i chose 2 because of abc's. the answer is actually 1. i understand that his person is tachycardic due to fluid volume deficit but how come abc's don't have priority?

#1 was the only answer choice and i will explain why. this is a question that tests your knowledge of the nursing process.

your mistake was assuming that all four answer choices were correct nursing diagnoses. they weren't. you had to first determine which nursing diagnoses were correct which means you have to know nursing diagnostic statement construction, or pes (problem-etiology-symptoms). you also had to know a little bit about the definitions of these diagnoses. you had to read through the brief scenario that was the stem of the question and pick out the abnormal data (symptoms) first. abnormal data become the symptoms that prove the existence of the nursing problems that are present.

glucose of 618mg/dl
hot dry skin
temp: 100.6f
hr: 116 beats/min

then, from your knowledge of the defining characteristics of the 4 nursing diagnoses complete the nursing diagnostic statements in order to find the correct answer. only one diagnostic statement could have been completed correctly and would have looked like this:

deficient fluid volume related to osmotic diuresis aeb hot dry skin, temp of 100.6f and hr of 116 beats/min

for the symptom of glucose of 618mg/dl a nursing diagnosis that would be more appropriate for it would be:

ineffective management of therapeutic regime r/t ??? aeb glucose of 618mg/dl but this nursing diagnosis was not one of your answer choices.

however, that is not a choice you were provided with.

decreased cardiac output is inadequate blood pumped by the heart to meet metabolic demands of the body (its definition). the stem of the question does not tell you that the heart rate is elevated. you are told an elevated heart rate is the related factor (etiology) of decreased cardiac output. if that is to be believedthen what are the resulting symptoms? there must be symptoms as a result. they are just not there. so, you cannot chose this diagnosis. no symptoms = no problem.

imbalanced nutrition: less than body requirements related to insulin deficiency aeb glucose of 618mg/dl cannot be chosen because the elevated glucose would not even be a symptom of this nursing diagnosis (nursing problem). when someone has symptoms of imbalanced nutrition: less than body requirements they will have weight loss and problems eating enough food for their caloric requirements. the definition of this diagnosis is intake of nutrients insufficient to meet metabolic needs. a glucose of 618mg/dl is really just describing the etiology (cause of the imbalanced nutrition: less than body requirements) and not telling us about any resulting symptom.

the other diagnosis, ineffective thermoregulation related to dehydration, has an inappropriate etiology attached to it (see a nursing diagnosis reference). temperature fluctuation (the definition of this diagnosis) is not what is going on here so diagnosing ineffective thermoregulation would be a misdiagnosis since no data of temperature fluctuation exists.

and as it turns out maslow's or the abcs don't end up applying here at all. the question is actually about your knowledge of the nursing process. assessment is the first step of that process. diagnosis (determination of the problem) is the second step. planning (goals and interventions) is the third step. nclex ,which is what you are preparing for (i read this on your other posts) and is very clear in the candidates booklet about testing the applicants on their knowledge of the nursing process. you should know what goes on in each step of the nursing process.

https://www.ncsbn.org/2007_nclex_rn_detailed_test_plan_candidate.pdf - "nursing process – a scientific problem-solving approach to client care that includes assessment, analysis, planning, implementation and evaluation."
- "the following processes are integrated into all client needs categories and subcategories of the test plan: nursing process, caring, communication and documentation, and teaching and learning."

ssing45 · Jul 30, 2009

116 is not too bad of a HR, he's certainly not going to decompensate with a rate like that. Plus that will come down when you deal with the temp, later. The elevated HR probably due to fluid volume deficit from DKA so that is what needs treatment first.

PostOpPrincess, BSN, RN · Jul 30, 2009

Let's make this simpler:

Patient is Awake, alert = reflexes intact = airway, breathing = intact

High Sugar = high fluid loss = decreased intravascular volume...always a priority unless above is compromised.

You are temporary compensating, but signs are there = elevated temp, increasing HR and (so-so depending on his baseline B/P) B/P.

If ABC's don't apply:

Focus on disease process and ITS priorities.......With the above example, high peeing equals lots and lots and lots of fluid loss.....

Virgo_RN, BSN, RN · Jul 30, 2009

Even simpler, what's going to kill him first? Use the process of elimination.

#4: A temp of 100.6 is not life threatening.

#3: Imbalanced nutrition takes a while to kill someone.

#2: A HR of 116 ain't great, but he's conscious and maintaining a decent BP. This is not immediately life threatening.

That leaves #1: Hypovolemia is the most immediately life threatening thing happening to this poor guy.

IcanHealYou · Jul 30, 2009

#1 was the only answer choice and i will explain why. this is a question that tests your knowledge of the nursing process.
your mistake was assuming that all four answer choices were correct nursing diagnoses. they weren't. you had to first determine which nursing diagnoses were correct which means you have to know nursing diagnostic statement construction, or pes (problem-etiology-symptoms). you also had to know a little bit about the definitions of these diagnoses. you had to read through the brief scenario that was the stem of the question and pick out the abnormal data (symptoms) first. abnormal data become the symptoms that prove the existence of the nursing problems that are present.
glucose of 618mg/dl
hot dry skin
temp: 100.6f
hr: 116 beats/min
then, from your knowledge of the defining characteristics of the 4 nursing diagnoses complete the nursing diagnostic statements in order to find the correct answer. only one diagnostic statement could have been completed correctly and would have looked like this:
deficient fluid volume related to osmotic diuresis aeb hot dry skin, temp of 100.6f and hr of 116 beats/min
for the symptom of glucose of 618mg/dl a nursing diagnosis that would be more appropriate for it would be:
ineffective management of therapeutic regime r/t ??? aeb glucose of 618mg/dl but this nursing diagnosis was not one of your answer choices.
however, that is not a choice you were provided with.
decreased cardiac output is inadequate blood pumped by the heart to meet metabolic demands of the body (its definition). the stem of the question does not tell you that the heart rate is elevated. you are told an elevated heart rate is the related factor (etiology) of decreased cardiac output. if that is to be believedthen what are the resulting symptoms? there must be symptoms as a result. they are just not there. so, you cannot chose this diagnosis. no symptoms = no problem.
imbalanced nutrition: less than body requirements related to insulin deficiency aeb glucose of 618mg/dl cannot be chosen because the elevated glucose would not even be a symptom of this nursing diagnosis (nursing problem). when someone has symptoms of imbalanced nutrition: less than body requirements they will have weight loss and problems eating enough food for their caloric requirements. the definition of this diagnosis is intake of nutrients insufficient to meet metabolic needs. a glucose of 618mg/dl is really just describing the etiology (cause of the imbalanced nutrition: less than body requirements) and not telling us about any resulting symptom.
the other diagnosis, ineffective thermoregulation related to dehydration, has an inappropriate etiology attached to it (see a nursing diagnosis reference). temperature fluctuation (the definition of this diagnosis) is not what is going on here so diagnosing ineffective thermoregulation would be a misdiagnosis since no data of temperature fluctuation exists.
and as it turns out maslow's or the abcs don't end up applying here at all. the question is actually about your knowledge of the nursing process. assessment is the first step of that process. diagnosis (determination of the problem) is the second step. planning (goals and interventions) is the third step. nclex ,which is what you are preparing for (i read this on your other posts) and is very clear in the candidates booklet about testing the applicants on their knowledge of the nursing process. you should know what goes on in each step of the nursing process.
https://www.ncsbn.org/2007_nclex_rn_detailed_test_plan_candidate.pdf - "nursing process - a scientific problem-solving approach to client care that includes assessment, analysis, planning, implementation and evaluation."
"the following processes are integrated into all client needs categories and subcategories of the test plan: nursing process, caring, communication and documentation, and teaching and learning."

your response is greatly appreciated =d

tlc2u · Jul 30, 2009

a client with a serum glucose of 618mg/dl is admitted to the facility. he's awake and orientated, has hot dry skin and has the following vital signs:

temp: 100.6f

hr: 116 beats/min

bp: 108/70

based on these assessment findings, which nursing diagnosis takes highest priority?

1. deficient fluid volume related to osmotic diuresis

2. decreased cardiac output related to elevated hr

3. imbalanced nutrition: less than body requirements related to insulin deficiency

4. ineffective thermoregulation related to dehydration.

as a brand new nurse fresh out of nursing school and just passed my nclex i would tackle this question using "test taking strategies" (see below) and whatever knowledge i could associate to the problem in the stem of the question.

test taking strategies_________________________________________

in preparing for my nclex i realized there are 3 basic reasons i answer questions incorrectly.

1. i did not read the stem carefully, and did not focus specifically on

what the question was asking. often i read the question and the answer

choices and in haste transfered info from the answers to the stem, creating a

completely different question and then selecting the wrong answer.

2. i did not use test taking strategies. (see below)

3. i did not have enough knowledge to answer the question.

saunders nclex test taking strategies as questions

say to yourself

did i.....

avoid reading into the question?
look for key words?
determine the issue of the question?
look for a true or false response question?
look for key words that indicate the need to ptioritize?
use the abc's?
use maslow's
use the nursing process?
look for key words that indicate i need to do an assessment?
or if it is an emergency do i need to do an intervention?
is this an analysis question?
planning, implementation, evaluation
use therapeutic communication techniques to answer this question?
eliminate similar options?
eliminate options that contain absolute words?
look for the umbrella option?
use the guidelines for delegating?
determine the class of drug by the end of it's name?
use medical terminology to break down words?

silvestri, l. (2005). saunders comprehensive review for the nclex-rn examination, (3rd ed.) st. louis: w. b. saunders.

test item check list

use this handy list to check yourself

every time you answer a question.

say to yourself

did i carefully...

- read the stem?

- read all of the options?

- read the stem again?

- look for key words?

- eliminate obviously incorrect answers?