After assessing the patient, 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: DHS Staff Nurse - 2018 (Shift-2nd)

Explanation

• The correct order is 3, 4, 1, 2, which follows established nursing prioritization principles.
• The ABC (Airway, Breathing, Circulation) framework dictates that airway issues are the highest priority. Therefore, 'Ineffective airway clearance' (3) must be first.
• Following airway, circulation is the next priority. 'Ineffective tissue perfusion' (4) is a circulation problem, making it the second priority.
• Maslow's Hierarchy of Needs is used to prioritize the remaining diagnoses. Basic physiological needs (Constipation - 1) take precedence over psychosocial needs (Anticipated grieving - 2).
• Therefore, constipation is the third priority, and anticipated grieving is the fourth.

Why Other Options Were Wrong

• Option A: This option (3, 4, 2, 1) incorrectly places a psychosocial need ('Anticipated grieving' - 2) as a higher priority than a physiological need ('Constipation' - 1).
• Option B: This option (4, 3, 2, 1) incorrectly prioritizes Circulation ('Ineffective tissue perfusion' - 4) over Airway ('Ineffective airway clearance' - 3). The ABC framework mandates that Airway is always the first priority.
• Option C: This option (1, 3, 2, 4) incorrectly prioritizes a non-life-threatening physiological problem ('Constipation' - 1) over immediately life-threatening airway and circulation problems.

Related Visual

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Prioritization of Nursing Diagnoses using ABCs and Maslow's Hierarchy in acute care settings.
• Prioritization is a critical nursing skill used to manage care for multiple patients and to respond to changing patient conditions, ensuring that the most life-threatening problems are addressed first to prevent adverse outcomes.
• Nurses must constantly reassess patients and re-prioritize care as conditions change. A stable patient can quickly become unstable, requiring a complete shift in priorities.
• What if? If the patient's diagnosis was 'Impaired gas exchange' instead of 'Ineffective airway clearance', it would still be a top priority, representing the 'B' (Breathing) in the ABCs, and would be addressed immediately after securing the airway.

How to Approach the Question

• First, identify that the question asks you to prioritize a list of nursing diagnoses.
• Recall the standard frameworks for nursing prioritization: ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs.
• Apply the ABC framework first. Look for diagnoses related to airway, breathing, or circulation. These are always the highest priority.
• In this list, 'Ineffective airway clearance' (3) is 'A' and 'Ineffective tissue perfusion' (4) is 'C'. Therefore, the order must start with 3, then 4.
• Next, use Maslow's Hierarchy to order the remaining diagnoses. 'Constipation' (1) is a basic physiological need, while 'Anticipated grieving' (2) is a psychosocial need.
• According to Maslow, physiological needs take priority over psychosocial needs. So, 1 comes before 2.

Concept Tested & Keywords

• Concept Tested: Prioritization of Nursing Diagnoses using ABCs and Maslow's Hierarchy
• Stem keywords: nursing diagnoses, priority, order, Constipation, Anticipated grieving, Ineffective airway clearance, Ineffective tissue perfusion
• Lead-in keywords: Place them in order of priority

Question ID

QR_ekO2nv-WiLZtov-E8hP

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 2 pp. 22-24, 72-74