The daughter of a client with AD who is receiving cholinesterase inhibitor therapy tells the nurse that her father has been getting more and more clumsy lately, saying, "He's almost fallen several times and he often gets out of bed at night
That's when I'm most concerned that he will fall." The daughter reports that his appetite is fair and that he takes his medication as prescribed. When developing the client's plan of care, the nurse would identify which nursing diagnosis as the priority?
A) Imbalanced Nutrition: Less Than Body Requirements
B) Risk for Injury
C) Ineffective Self Health Management
D) Deficient Knowledge: drug therapy
Ans: B
Feedback:
Based on the daughter's report, the client is at high risk for injury and this would be the priority. Imbalanced nutrition might be appropriate based on the daughter's report that her father's appetite is fair. However, additional information is needed to determine if this nursing diagnosis would be more of a priority than the risk for injury. The client is receiving his medication as prescribed, so ineffective self health management is not a concern. There is no evidence to suggest that there is a lack of knowledge about the drug therapy.
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