An older adult with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adult's daughter, who becomes defensive and says, "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 impairment, and lack of caregiver supervision
b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation
c. Impaired verbal communication, related to brain impairment as evidenced by the confusion
d. Insomnia, related to 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 provide constant supervision. No assessment data support the diagnoses of Impaired verbal communication or Noncompliance. Sleep pattern disturbance certainly applies to this patient; however, the diagnosis Risk for injury is a higher priority.
You might also like to view...
A patient is prescribed fenofibrate (TriCor). When providing patient teaching, which of the following accurately describes the action of fenofibrate?
A) It binds to bile acids in the intestinal lumen. B) It increases oxidation of fatty acids in the liver. C) It inhibits an enzyme required for hepatic synthesis. D) It inhibits mobilization of free fatty acids from peripheral tissues.
A nurse speaking to a patient who is depressed says, "So what you are saying is that you are feeling very sad today." What is this considered?
a. Listening b. Sharing observations c. Clarifying d. Being available
The perinatal nurse is aware that over one half of all Americans are overweight or obese
A) True B) False
A nurse in an acute care facility helps patients understand how to prevent diabetic neuropathies. This nurse is functioning in the role of:
a. change agent. b. educator. c. manager. d. coordinator.