The nursing diagnosis established for a client with fluctuating levels of consciousness, disturbed

Question

orientation, and visual and tactile hallucinations that should be given priority is

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, as evidenced by sensory
perceptual alterations and unstable gait.
c. disturbed thought processes related to altered cerebral function resulting from
medication intoxication, as evidenced by confusion, disorientation, and
hallucinations.
d. fear related to sensory perceptual alterations, as evidenced by hiding from
hallucinated dog and wanting nurse to remove hallucinated bugs from her legs.

Answer 1

B
The physical safety of the client is of highest priority among the diagnoses given. Many
opportunities for injury exist when a client misperceives the environment as distorted, threatening,
or harmful; when the client exercises poor judgment; and when the client's sensorium is clouded.
The other diagnoses, although valid, are of lower priority.