A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client’s care, the nurse should assign highest priority to which nursing diagnosis?
a. Impaired physical mobility
b. Ineffective breathing pattern
c. Disturbed sensory perception (tactile)
d. Self-care deficient: Dressing/grooming
a. Impaired physical mobility
b. Ineffective breathing pattern
c. Disturbed sensory perception (tactile)
d. Self-care deficient: Dressing/grooming
Answer B.
Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. The other options may be appropriate for a client with a spinal cord injury - particularly during the course of recovery - but don’t take precedence over a diagnosis of Ineffective breathing pattern.