A nurse is admitting an adolescent patient with a diagnosis of ataxia-telangiectasis. Which of the following nursing diagnoses should the nurse include in the patient's plan of care?
A) Fatigue Related to Pernicious Anemia
B) Risk for Constipation Related to Decreased Gastric Motility
C) Risk for Falls Due to Loss of Muscle Coordination
D) Disturbed Kinesthetic Sensory Perception Related to Vascular Changes
Ans: C
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Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder characterized by cerebellar ataxia (loss of muscle coordination), telangiectasia (vascular lesions caused by dilated blood vessels), and immune deficiency. Decreased coordination is likely to constitute a risk for falls. The patient does not characteristically lose tactile sensation or experience pernicious anemia or constipation.
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