What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
a. Bathing/hygiene self-care deficit, related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks
b. Risk for injury, related to altered cerebral function, misperception of the environment, and unsteady gait
c. Disturbed thought processes, related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations
d. Fear, related to sensory perceptual alterations, as evidenced by hiding from imagined ferocious dogs
ANS: B
The physical safety of the patient is the highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful; when the patient exercises poor judgment; and when the patient's sensorium is clouded. The other diagnoses may be concerns but are lower priorities.
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