A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist
What nursing diagnosis should the nurse associate with this procedure?
A) Risk for impaired skin integrity
B) Risk for injury
C) Risk for autonomic dysreflexia
D) Risk for suffocation
Ans: B
Feedback:
If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patient's neck, which can result in extension of a cervical injury. Intubation does not directly cause autonomic dysreflexia and the threat to skin integrity is a not a primary concern. Intubation does not carry the potential to cause suffocation.
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