An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, "My mother often wanders at night. Last night she fell down the stairs."
Which nursing diagnosis has priority?
a. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision
b. Wandering related to confusion and disorientation as evidenced by sleepwalking and falls
c. Chronic confusion related to degenerative changes in brain tissue as evidenced by nighttime wandering
d. Insomnia related to sleep disruptions associated with cognitive impairment as evidenced by wandering at night
ANS: A
The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to give constant supervision. Insomnia, chronic confusion, and wandering apply to this patient; however, the risk for injury is a higher priority.
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