What should the priority nursing diagnosis be for a patient with fluctuating levels of consciousness, disorientation, and visual and tactile hallucinations?
a. Self-care deficit
b. Risk for injury
c. Disturbed thought processes
d. Fear
B
The physical safety of the patient is the highest priority, and among the diagnoses given here Risk for injury is most directly related to the patient's physical safety. Fluctuating consciousness could lead to falls, or disorientation could lead to injuries during activities of daily living. Hallucinations can induce fear that could lead to dangerous defensive behavior. The other diagnoses, although valid, do not relate to safety and are of lower priority.
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