Asked by Sheree Aulerio on Jun 15, 2024
Verified
A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
A) Disturbed sensory perception
B) Ineffective coping
C) Ineffective denial
D) Risk for injury
Disturbed Sensory Perception
An altered state in which one's ability to perceive environmental stimuli through the senses is impaired or inaccurate.
Ineffective Denial
A defense mechanism where an individual refuses to accept reality or facts, leading to harmful behaviors or lack of problem-solving.
- Acquire knowledge of the signs and symptoms associated with alcohol withdrawal delirium.
Verified Answer
NW
Nicholas WilhoiteJun 17, 2024
Final Answer :
D
Explanation :
Clouded sensorium, agitation, sensory perceptual distortions, and poor judgment increase the risk for injury. Disturbed sensory perception is an applicable diagnosis, but safety has a higher priority. The scenario does not provide data to support the other diagnoses.
Learning Objectives
- Acquire knowledge of the signs and symptoms associated with alcohol withdrawal delirium.
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