In the intensive care unit, the nurse is taking care of a patient who is on a ventilator and is receiving succinylcholine (Anectine). Which is a priority nursing diagnosis for this patient?
a. Pain
b. Disturbed body image
c. Risk for injury
d. Self-care deficit
ANS: A
Pain is the highest priority, according to Maslow's hierarchy of needs. Succinylcholine, a neuromuscular-blocking agent, is used to paralyze muscles while a patient is on a ventilator. Neuromuscular-blocking agents do not relieve pain. Disturbed body image is not a priority for this situation, although it does apply. Risk for injury and self-care deficit are not as great of priorities for this situation.
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