Maslow’s hierarchy of needs (Figure 1) is crucial to establishing priorities on the NCLEX-PN® exam. Maslow identifies five levels of human needs: physiological, safety and security, love and belonging, self-esteem, and self-actualization.
Because physiological needs are necessary for survival, they have the highest priority and must be met first. Physiological needs include oxygen, fluid, nutrition, temperature, elimination, shelter, rest, and sex. If you don’t have oxygen to breathe or food to eat, you really don’t care if you have stable psychosocial relationships!
Safety and security needs can be both physical and psychosocial. Physical safety includes decreasing what is threatening to the client. The threat may be an illness (myocardial infarction), accidents (a parent transporting a newborn in a car without using a car seat), or environmental threats (the client with COPD who insists on walking outside in 10° F [-12° C] temperatures).
To attain psychological safety, the client must have the knowledge and understanding about what to expect from others in his or her environment. For example, it is important to teach the client and his family what to expect after a cerebrovascular accident (CVA). It is also important that you allow a woman preparing for a mastectomy to verbalize her concerns about changes that might occur in her relationship with her partner.
To achieve love and belonging, the client needs to feel loved by family and accepted by others. When a client feels self-confident and useful, he will achieve the need of self-esteem as described by Maslow.
The highest level of Maslow’s hierarchy of needs is self-actualization. To achieve this level, the client must experience fulfillment and recognize his or her potential. In order for self-actualization to occur, all of the lower-level needs must be met. Because of the stresses of life, lower-level needs are not always met, and many people never achieve this high level of functioning.
The first strategy to use in establishing priorities is a four-step process, beginning with Maslow’s hierarchy. To use the Maslow strategy, you must first recognize the pattern in the answer choices.
Step 1. Look at your answer choices.
Determine if the answer choices are both physical and psychosocial. If they are, apply the Maslow strategy detailed in Step 2.
Step 2. Eliminate all psychosocial answer choices. If an answer choice is physiological, don’t eliminate it yet. Remember, Maslow states that physiological needs must be met first. Although pain certainly has a physiological component, reactions to pain are considered “psychosocial” on this exam and will become a lower priority.
Step 3. Look at each of the answer choices that you have not yet eliminated and ask yourself if the answer choice makes sense with regard to the disease or situation described in the question. If it makes sense as an answer choice, keep it for consideration and go on to the next choice.
Step 4. Can you apply the ABCs?
Look at the remaining answer choices. Can you apply the ABCs? The ABCs stand for airway, breathing, and circulation. If there is an answer that involves maintaining a patent airway, it will be correct. If not, is there a choice that involves breathing problems? It will be correct. If not, go on with the ABCs. Is there an answer pertaining to the cardiovascular system? It will be correct. What if the ABCs don’t apply? Compare the remaining answer choices and ask yourself, “What is the highest priority?” This is your answer.
Let’s apply this technique to a few sample exam-style test questions.
Look at the stem of the question. The words most important mean:
Step 1. Look at the answer choices.
You see that both physical and psychosocial interventions are included. Apply the Maslow strategy.
Step 2. Eliminate the answer choices that are psychosocial interventions.
Answer choice (2), which is pain relief, should be discarded. Remember, pain is considered a psychosocial problem on the NCLEX-PN® exam. Answer choice (3), emotional support, is also a psychosocial concern. Eliminate this answer. You have now eliminated two of the possible choices. You are halfway there!
Step 3. Now look at the remaining answer choices and ask yourself whether they make sense.
Answer choice (1), fluid replacement, makes sense, because this client has a ruptured ectopic pregnancy. An ectopic pregnancy is implantation of the fertilized ovum in a site other than the endometrial lining, usually the fallopian tube. Initially, the pregnancy is normal, but as the embryo outgrows the fallopian tube, the tube ruptures, causing extensive bleeding into the abdominal cavity. Answer choice (4), respiratory therapy, does not make sense with a ruptured ectopic pregnancy. The obstetrical client is not likely to need respiratory care prior to surgery. Eliminate this answer choice.
You are left with the correct answer, (1). After reading this question, many students select answer choices (2) or (3) as the correct answer. They justify this by emphasizing the importance of managing this woman’s pain or addressing her grief about losing the pregnancy. Neither answer choice takes priority over the physiological demand of fluid replacement prior to surgery.
Ready for another question? Try this one.
The first thing you should notice in this question stem is the phrase “highest priority.” This alerts you that there may be more than one answer that could be considered correct.
Step 1. Look at the answer choices.
Both physical and psychosocial interventions are included. Apply the Maslow strategy.
Step 2. Eliminate all answer choices that involve psychosocial concerns.
It is easy to see that body image disturbance, answer choice (1), is a psychosocial concern. The same is true of answer choice (2), self-esteem disturbance. Answer choices (3) and (4) are physiological. You have now eliminated all but two answer choices.
Step 3. Ask yourself whether the remaining answer choices make sense.
Answer choice (3), “Altered nutrition: less than body requirements related to decreased intake,” does make sense. Remember, the client has anorexia nervosa and is 5'4" tall and weighs 82 lbs. Answer choice (4), “Decreased cardiac output related to the potential for dysrhythmias,” also makes sense. Dysrhythmias are a concern for a client with severe hypokalemia, which often occurs with anorexia nervosa.
You still have work to do.
Step 4. Can you apply the ABCs? Yes.
Decreased cardiac output is a higher priority than altered nutrition. One answer choice remains: (4).
When you first read this question, you probably identified each of the answer choices as appropriate for a client with anorexia. Only one nursing diagnosis can be the highest priority. Using strategies involving Maslow and the ABCs will enable you to choose the correct answer on your NCLEX-PN® exam.