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

Question

Quizplus · Accepted Answer

A) Since 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 per minute. Since the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need assisted ventilation or a tracheostomy. The nursing diagnosis priority for this client would be Ineffective Breathing Pattern. An Impaired Gas Exchange could occur because of the Ineffective Breathing Pattern and would be the second in priority for this client. Impaired Physical Mobility and Autonomic Dysreflexia could be addressed at a later time.
B) Since 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 per minute. Since the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need assisted ventilation or a tracheostomy. The nursing diagnosis priority for this client would be Ineffective Breathing Pattern. An Impaired Gas Exchange could occur because of the Ineffective Breathing Pattern and would be the second in priority for this client. Impaired Physical Mobility and Autonomic Dysreflexia could be addressed at a later time.
C) Since 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 per minute. Since the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need assisted ventilation or a tracheostomy. The nursing diagnosis priority for this client would be Ineffective Breathing Pattern. An Impaired Gas Exchange could occur because of the Ineffective Breathing Pattern and would be the second in priority for this client. Impaired Physical Mobility and Autonomic Dysreflexia could be addressed at a later time.
D) Since 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 per minute. Since the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need assisted ventilation or a tracheostomy. The nursing diagnosis priority for this client would be Ineffective Breathing Pattern. An Impaired Gas Exchange could occur because of the Ineffective Breathing Pattern and would be the second in priority for this client. Impaired Physical Mobility and Autonomic Dysreflexia could be addressed at a later time.

A Client Who Sustained a Cervical Neck Injury 2 Days