The nurse is planning care for a client who has been admitted to the unit experiencing severe acute pain. When preparing the plan of care, the nurse considers which of the following to be a priority nursing diagnosis?
1. Impaired Mobility
2. Ineffective Breathing Pattern
3. Risk for Injury
4. Powerlessness
2. Ineffective Breathing Pattern
Rationale:
The client in severe acute pain is at risk for hyperventilation, which can lead to respiratory alkalosis. There is not enough information to know whether the client's mobility is impaired. Risk for injury and powerlessness are diagnoses to be considered for this client, but the highest priority is respiratory function.
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