A patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient is unable to follow staff direction or respond to verbal interventions. Which nursing diagnosis has the highest priority?
a. Risk for injury
b. Self-care deficit
c. Disturbed energy field
d. Disturbed thought processes
ANS: A
A patient who is experiencing panic-level anxiety is at high risk for injury, related to an increase in non–goal-directed motor activity, distorted perceptions, and disordered thoughts. Existing data do not support the nursing diagnoses of Self-care deficit or Disturbed energy field. This patient has disturbed thought processes, but the risk for injury has a higher priority.
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