Author Question: A nursing assessment for a patient with a spinal cord injury leads to several pertinent problems ... (Read 26 times)

itsmyluck · **on:** Jul 23, 2018

A nursing assessment for a patient with a spinal cord injury leads to several pertinent problems that a nurse can treat. While developing the plan of care, which nursing diagnosis is the highest priority for this patient?

a. Risk for impaired skin integrity
b. Risk for infection
c. Spiritual distress
d. Reflex urinary incontinence

Question 2

The nurse is caring for seven patients this shift. After completing their assessments, the nurse states that he doesn't know where to begin in developing care plans for these patients. Which of the following is an appropriate suggestion by another nurse?

a. Choose all the interventions and perform them in order of time needed for each one.
b. Make sure you identify the scientific rationale for each intervention first.
c. Decide on goals and outcomes you have chosen for the patients.
d. Begin with the highest priority diagnoses, then select appropriate interventions.

amandalm · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: D
Reflex urinary incontinence is highest priority. If a patient's incontinence is not addressed, then the patient is at higher risk of impaired skin integrity and infection. Remember that the Risk for diagnoses are potential problems. They may be prioritized higher in some cases, but not in this situation. Spiritual distress is an actual diagnosis, but the adverse effects that could result from not assisting the patient with urinary elimination take priority in this case. Physiological problems do not always take priority, but the greatest harm could come to this patient if urinary incontinence is not prioritized.

Answer to Question 2

ANS: D
When developing a plan of care, the nurse needs to rank the nursing diagnoses in order of priority, then select appropriate interventions. Choosing all the interventions should take place after ranking of the diagnoses, and interventions should be prioritized by patient needs, not just by time. The chosen interventions should be evidence-based with scientific rationales, but the diagnoses need to be prioritized first to prioritize interventions. Goals for a patient should be mutually set, not just chosen by the nurse.