Which of the following would be a priority nursing diagnosis for a client with ARDS?

AIIMS Bhopal NO - 2018 (Shift-1st)

Medical & Surgical Nursing

Medium

Appeared in: AIIMS Bhopal NO - 2018 (Shift-1st)

Explanation

The ABC (Airway, Breathing, Circulation) framework is the standard for prioritizing nursing care in life-threatening situations.
ARDS is defined by a sudden and severe impairment of the lungs' gas exchange function, making 'Breathing' the top priority.
The nursing diagnosis 'Ineffective breathing pattern' directly addresses the hallmark signs of ARDS, such as severe dyspnea, use of accessory muscles, and hypoxemia.
Failure to address the ineffective breathing pattern will rapidly lead to respiratory arrest, multi-organ failure, and death.

Option A: While a patient on a ventilator or with chest tubes for ARDS may experience pain, it is a secondary priority to life-sustaining oxygenation and ventilation.
Option B: This diagnosis relates to a patient's ability to manage their own health over time (e.g., diet, exercise, medication adherence). It is completely inappropriate for an acute, life-threatening illness like ARDS.
Option D: While patients with ARDS are at high risk for infection (due to invasive lines, mechanical ventilation, and the underlying cause), the immediate threat to life is respiratory failure, not a potential infection.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Prioritization of nursing diagnoses for a client with Acute Respiratory Distress Syndrome (ARDS) in the correct sequence, documenting the action clearly, and monitoring for the expected response.
Prioritizing 'Ineffective breathing pattern' guides the nurse to perform critical assessments and interventions immediately, such as monitoring respiratory rate, oxygen saturation, and work of breathing.
This diagnosis justifies urgent nursing actions like administering high-flow oxygen, preparing for endotracheal intubation and mechanical ventilation, and positioning the patient to optimize lung expansion.
Patient Safety: Mis-prioritizing a diagnosis like 'Pain' over 'Ineffective breathing pattern' could lead to a delay in life-saving respiratory support, resulting in severe hypoxemia and cardiac arrest.

How to Approach the Question

First, identify the question type. This is a 'priority' question, which requires you to rank nursing actions or diagnoses based on urgency.
Recall the fundamental framework for prioritization in nursing: ABCs (Airway, Breathing, Circulation).
Analyze the patient's condition mentioned in the stem: ARDS (Acute Respiratory Distress Syndrome). The core problem in ARDS is severe respiratory failure.
Evaluate each option based on the ABCs. 'Ineffective breathing pattern' directly addresses the 'B' (Breathing) component.
Compare the chosen option to the others. Pain, health maintenance, and risk for infection are all less immediately life-threatening than a compromised breathing pattern.
Conclude that the diagnosis addressing the most immediate threat to life is the highest priority.

Concept Tested & Keywords

Concept Tested: Prioritization of nursing diagnoses for a client with Acute Respiratory Distress Syndrome (ARDS).
Stem keywords: priority nursing diagnosis, client, ARDS
Lead-in keywords: priority
Clinical cues: The diagnosis of ARDS itself is the primary clinical cue, indicating severe respiratory failure.

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E6 Nursing Brunner Adult Health 3SA Vol 1 Part 2 p. 5-7

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