Solutions
Maslow's Hierarchy of Needs - Correct Answer (level 1) Physiological Needs, (level 2) Safety and
Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization
Assessment of Comfort Level - Correct Answer ask patient if they are comfortable
If they have physcial discomfort, assess level of pain and plan intervention
if it's mental discomfort, have them describe the nature of the stress
Interventions to prevent impaired comfort - Correct Answer anticipate which patient may experience
them and provide preplanned interventions
pain - Correct Answer 5th vital sign
cutaneous pain - Correct Answer superficial pain usually involving the skin or subcutaneous tissue
visceral pain - Correct Answer pain originating in the internal organs and is non localized
deep somatic pain - Correct Answer ligaments, tendons, bones, blood vessels, nerves
radiating pain - Correct Answer starts at an origin but spreads to other locations
referred pain - Correct Answer pain that is felt in a location other than where the pain originates
phantom pain - Correct Answer pain or discomfort felt in an amputated limb
Assessment of Elimination - Correct Answer -take patient history
-monitor frequency, amount , and consistency
, Interventions to prevent changes in elimination - Correct Answer adequate nutrition and hydration
Interventions for patients with changes in elimination - Correct Answer -Monitor pt for signs of fluid
and electrolyte imbalance
-adults experiencing urinary incontinence require frequent toileting
-Patients with short term urinary retention require one or more catherization
stress incontinence - Correct Answer involuntary urine loss with physical strain, sneezing, or coughing
urge incontinence - Correct Answer loss of large amounts of urine accompanied with a strong urge to
urinate
overflow incontinence - Correct Answer small amounts of urine leak from a full bladder
functional incontinence - Correct Answer the person has bladder control but cannot use the toilet in
time
unconscious incontinence - Correct Answer loss of urine when the person does not realize the
bladder is full and has no urge to void
intake - Correct Answer -measured in mLs
-everything liquid
output - Correct Answer stools and urine
Assessment of Fluid Balance - Correct Answer -health hx
-monitor vitals especially pulse rate and quality
-assess skin and mucous membrane for dryness and decreased turgor
Interventions to prevent fluid and electrolyte imbalance - Correct Answer drink 8 glassess of water a
day and eat a balanced diet
Interventions for fluid imbalance - Correct Answer fluid deficit: replace fluids