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
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.
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