After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. 1. Constipation 2. Anticipated grieving 3. Ineffective airway clearance 4. Ineffective tissue perfusion?

1. A

   3, 4, 2, 1

2. B

   4, 3, 2, 1

3. C

   1, 3, 2, 4

4. D

   3, 4, 1, 2

Appeared in: GMCH Chandigarh - 2019

Explanation

• The correct sequence is 3, 4, 2, 1, which follows standard nursing prioritization principles.
• The ABC (Airway, Breathing, Circulation) framework dictates that life-threatening physiological needs are addressed first.
• Ineffective Airway Clearance (3) is the highest priority as it corresponds to 'Airway'.
• Ineffective Tissue Perfusion (4) is the second priority, corresponding to 'Circulation'.
• After ABCs are stabilized, other needs are prioritized using frameworks like Maslow's Hierarchy. Psychosocial needs (Anticipated Grieving, 2) are typically addressed before non-life-threatening physical comfort issues (Constipation, 1).

Why Other Options Were Wrong

• Option B: This option incorrectly places Ineffective Tissue Perfusion (4) before Ineffective Airway Clearance (3).
• Option C: This option incorrectly places Constipation (1) as the highest priority, which is a low-priority, non-life-threatening condition in this context.
• Option D: This option incorrectly prioritizes Constipation (1) over Anticipated Grieving (2). While both are lower priority than airway and circulation, acute psychosocial needs that impact coping are generally considered more significant than a non-urgent physical comfort issue.

Related Visual

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Prioritization of Nursing Diagnoses in acute care settings.
• Prioritization is a critical skill for nurses to ensure patient safety and provide effective care, especially in environments with multiple patients and competing needs.
• Using systematic frameworks like ABCs and Maslow's Hierarchy helps prevent clinical decisions from being made in a haphazard way, reducing the risk of adverse events.
• Nurses must constantly reassess patients because priorities can shift rapidly. A stable patient can quickly become unstable, requiring a complete re-prioritization of care.

How to Approach the Question

• First, read all the nursing diagnoses provided.
• Identify any immediate life-threatening conditions. Use the ABC (Airway, Breathing, Circulation) framework as your primary guide.
• Look for the diagnosis related to 'Airway'. In this case, it's 'Ineffective airway clearance' (3). This is your number one priority.
• Next, look for diagnoses related to 'Breathing' or 'Circulation'. 'Ineffective tissue perfusion' (4) relates to circulation. This is your second priority.
• Once life-threatening issues are ordered, use Maslow's Hierarchy of Needs to prioritize the remaining diagnoses. This involves ranking physiological needs, safety needs, and psychosocial needs.
• Compare 'Anticipated grieving' (2, a psychosocial need) and 'Constipation' (1, a lower-level physiological need). Acute psychosocial distress is often prioritized over non-urgent physical problems.

Concept Tested & Keywords

• Concept Tested: Prioritization of Nursing Diagnoses
• Stem keywords: nursing diagnoses, priority, Constipation, Anticipated grieving, Ineffective airway clearance, Ineffective tissue perfusion
• Lead-in keywords: order of priority

Question ID

QE7NGyAzhaIotbEi5H2IKf

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 2 p. 22-24