The nurse is caring for an ambulatory client who requires treatment for pernicious anemia on a medical unit. The client is weak and short of breath, and recently has become confused

Question

Vital signs at rest are temperature 98.0°F, pulse 98 BPM, respirations 22/minute, blood pressure 96/60, and pulse oximetry 95%. Which nursing diagnosis has the highest priority?
1. Confusion, Acute related to aging, and abnormal vital signs
2. Falls, Risk for related to confusion, weakness, and unfamiliar environment
3. Knowledge, Deficient (anemia treatment) related to a new medical diagnosis and its treatment
4. Walking, Impaired related to weakness, low blood pressure, and fast heart rate

Answer 1

Correct Answer: 2
Rationale 1: The client has new-onset confusion, which is not a normal outcome of aging. The confusion is related to decreased oxygen supply to the brain. This is not the priority nursing diagnosis.
Rationale 2: High risk for falls is the priority because the client is accustomed to being ambulatory but can move around less safely now due to weakness and confusion.
Rationale 3: The client does need education about the condition and its treatment. The early phase of treatment is not an optimal time to teach, because confusion impairs learning.
Rationale 4: The client's walking is impaired, but this is not the priority nursing diagnosis.
Global Rationale: High risk for falls is the priority because the client is accustomed to being ambulatory but can move around less safely now due to weakness and confusion. The client has new-onset confusion, which is not a normal outcome of aging. The confusion is related to decreased oxygen supply to the brain. This is not the priority nursing diagnosis. The client has new-onset confusion, which is not a normal outcome of aging. The confusion is related to decreased oxygen supply to the brain. This is not the priority nursing diagnosis. The client does need education about the condition and its treatment. The early phase of treatment is not an optimal time to teach, because confusion impairs learning. The client's walking is impaired, but this is not the priority nursing diagnosis.