A client who sustained a cervical neck injury 2 days ago is ...

[bobypop]

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?
 
  A) Impaired Physical Mobility
  B) Autonomic Dysreflexia
  C) Ineffective Breathing Pattern
  D) Impaired Gas Exchange

Question 2

The nurse is planning care for a client admitted with a high thoracic spinal cord injury. Which interventions would be appropriate for the nursing diagnosis of Alteration in Perfusion?
 
  Select all that apply.
  A) Discuss future care needs when discharged.
  B) Increase fluids to 3,000 mL per day.
  C) Turn and reposition every 2 hours.
  D) Assess for a full bladder.
  E) Assess blood pressure every 2-3 minutes.

[momo1250]

Answer to Question 1

Answer: 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.

Answer to Question 2

Answer: D, E

An alteration in perfusion can be caused by autonomic dysreflexia, which is an emergency that requires immediate assessment and intervention. The nurse should continue to assess the client's blood pressure every 2-3 minutes in addition to elevating the head of the bed and removing TED hose to encourage the pooling of blood in the extremities and decrease the blood pressure. Once the blood pressure has stabilized or decreased, the nurse can then assess for the stimuli which caused the episode, such as a full bladder. Discussing future care needs when discharged is not a priority at this time, or an intervention for Alteration in Perfusion. Turning the client every 2 hours is not a priority at this time, or an intervention for Alteration in Perfusion.

[bobypop]

Excellent

[phuda]

Gracias!