The nurse is caring for a patient admitted with a diagnosis of muscular dystrophy resulting in inadequate muscle strength to draw enough air into the lungs.What nursing diagnosis would be most appropriate for this patient?
A) Ineffective Breathing Pattern
B) Ineffective Airway Clearance
C) Impaired Gas Exchange
D) Impaired Spontaneous Ventilation

Question

Quizplus · Accepted Answer

This patient's breathing is altered but does not fit this diagnosis because respiratory rate is unknown,so it is impossible to know what pattern of breathing is occurring based on the information given.There is no indication of an obstructed airway or increased secretions that would measure ability to clear airway.There is no indication in the question regarding the patient's gas exchange,so this is not the best choice,even though it would be easy to read into the question and suspect hypoxia.The best diagnosis for this patient is Impaired Spontaneous Ventilation because without external support,this patient's muscle strength is inadequate to maintain breathing adequate to support life.

The Nurse Is Caring for a Patient Admitted with a Diagnosis