问题
单项选择题
An unconscious client has been admitted with a head injury. Which of the following nursing diagnoses would receive the greatest priority in the plan of care
A．Disturbed sensory perception related to decreased level of consciousness.
B．Ineffective airway clearance related to inability to remove respiratory secretions.
C．Impaired gas exchange related to shallow irregular breathing.
D．Risk for injury related to disorientation and decreased level of consciousness.
答案
参考答案：B
解析：A major goal of nursing care of the unconscious client with a head injury is to establish and maintain an open airway. An obstructed airway can lead to hypoxia and carbon dioxide retention which will further increase intracranial pressure.
