NCLEX-RNManagement of CareMedium
A nurse is caring for four clients. Which client should the nurse assess first?
- AA client recovering from hip replacement surgery who reports pain rated 6/10 and requests medication
- BA client with schizophrenia who is pacing the hallway and expressing anger about hospital food
- CA client newly diagnosed with major depressive disorder who is tearful and states, 'I feel so hopeless'
- DA client one day postoperative from bowel resection who has not voided in 8 hours and reports suprapubic fullness
Show answer & explanationAnswer & explanation
Correct answer: D. A client one day postoperative from bowel resection who has not voided in 8 hours and reports suprapubic fullness
Using ABC and Maslow's hierarchy, physiologic needs take priority over psychosocial needs. Urinary retention with suprapubic fullness after surgery suggests a physiologic complication (bladder distension) requiring prompt assessment and intervention, ranking above pain management and psychosocial concerns.
Why the other options are wrong
- A. Pain requiring medication is important but not immediately life- or organ-threatening compared to urinary retention.
- B. Anger about food is a psychosocial concern lower on Maslow's hierarchy than physiologic needs.
- C. Emotional distress requires timely support but is not an acute physiologic emergency.
Maslow's Hierarchy in Prioritization
Physiologic needs (breathing, circulation, elimination) take priority over psychosocial or emotional needs when assigning nursing care order.
- Physiologic needs rank above safety, love, and self-esteem needs
- Urinary retention can cause bladder injury if untreated
- Pain management is important but ranks below acute physiologic threats
- Psychosocial distress should be addressed after physiologic stability
Memory trick: Body before mood—physiology rules the queue.