The nurse is identifying nursing diagnoses appropriate for a client with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting. Which diagnosis would be a priority for this client?

Question

A) Imbalanced Nutrition: Less than Body Requirements
B) Disturbed Sleep Pattern
C) Risk for Injury
D) Disturbed Sensory Perception: Auditory

Answer 1

Answer: C

The client's symptoms are seen in labyrinthitis or Ménière's disease, which disturbs all balance and coordination of motor skills related to gravitational pulls and is a disturbance of the inner ear. The risk for injury is the top priority. With imbalance and altered sensory input/perception, the risk for falls is very high. Actions to prevent injury from falls and/or other trauma should be the highest priority in management of care. Imbalanced nutrition is not the top priority, although this is relative to the symptoms present. The symptoms of vertigo and tinnitus do alter the ability to rest and sleep effectively but should not be the first priority. Long-term sleep deficits can lead to major psychological disorders that do need to be assessed further, but safety is a more immediate problem for this client. Disturbed sensory perception is accurate for a client who has tinnitus, vertigo, and nausea; however, the first priority is safety related to falls.