A client, aged 82 years, has Alzheimer's disease. She lives with her daughter's family and goes to a

Question

day care facility on weekdays. The nurse at the day care center noticed the client was unkempt and
had multiple bruises.

When the daughter arrived to pick her up, the nurse discussed her observations.
The daughter became defensive and said that her mother was very difficult to manage. She stated
"My mother is not my mother anymore. She is confused and she wanders all night. When I have to
be out in the evening on business, one of my teenagers has to watch her. Then I have to watch her all
night. Last night I fell asleep and she fell down the stairs. Sometimes I just cannot bear to care for
her.". The nursing diagnosis that can be established for the client is
a. risk for injury related to poor judgment associated with cognitive impairment and
lack of family caregiver supervision.
b. noncompliance related to confusion and disorientation, as evidenced by lack of
cooperation.
c. anxiety related to confused state, as evidenced by the client wandering at night.
d. impaired verbal communication related to brain impairment, as evidenced by the
client's confusion.

Answer 1

A
The client is at high risk for injury because of her confusion. The risk increases when caregivers are
unable to give constant supervision. No assessment data support the diagnoses of anxiety, impaired
verbal communication, or noncompliance.