A client who sustained a cervical neck injury 2 days ago is demonstrating an irregular respiratory pattern with a rate of 8-10 breaths per minute. Based on this data, which is the priority nursing diagnosis?

Question

Quizplus · Accepted Answer

A)Because the client sustained the neck injury 2 days prior, the full extent of the injuries cannot yet be determined. The client's rate of respirations should be between 12 and 20 breaths per minute. Because the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need assisted ventilation or a tracheostomy. The priority nursing diagnosis for this client would be Ineffective Breathing Pattern. A diagnosis of Impaired Gas Exchange could occur because of the Ineffective Breathing Pattern diagnosis, but it would be the second in priority for this client. The diagnoses of Impaired Physical Mobility and Autonomic Dysreflexia could both be addressed at a later time.
B)Because the client sustained the neck injury 2 days prior, the full extent of the injuries cannot yet be determined. The client's rate of respirations should be between 12 and 20 breaths per minute. Because the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need assisted ventilation or a tracheostomy. The priority nursing diagnosis for this client would be Ineffective Breathing Pattern. A diagnosis of Impaired Gas Exchange could occur because of the Ineffective Breathing Pattern diagnosis, but it would be the second in priority for this client. The diagnoses of Impaired Physical Mobility and Autonomic Dysreflexia could both be addressed at a later time.
C)Because the client sustained the neck injury 2 days prior, the full extent of the injuries cannot yet be determined. The client's rate of respirations should be between 12 and 20 breaths per minute. Because the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need assisted ventilation or a tracheostomy. The priority nursing diagnosis for this client would be Ineffective Breathing Pattern. A diagnosis of Impaired Gas Exchange could occur because of the Ineffective Breathing Pattern diagnosis, but it would be the second in priority for this client. The diagnoses of Impaired Physical Mobility and Autonomic Dysreflexia could both be addressed at a later time.
D)Because the client sustained the neck injury 2 days prior, the full extent of the injuries cannot yet be determined. The client's rate of respirations should be between 12 and 20 breaths per minute. Because the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need assisted ventilation or a tracheostomy. The priority nursing diagnosis for this client would be Ineffective Breathing Pattern. A diagnosis of Impaired Gas Exchange could occur because of the Ineffective Breathing Pattern diagnosis, but it would be the second in priority for this client. The diagnoses of Impaired Physical Mobility and Autonomic Dysreflexia could both be addressed at a later time.

A Client Who Sustained a Cervical Neck Injury 2 Days