Asked by Melanie Mclean on Jul 03, 2024
Verified
An older adult, diagnosed with Alzheimer disease, lives with family and has 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 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
Cognitive Impairment
A decline in memory, decision-making, attention, and other cognitive functions, affecting day-to-day activities.
Lack of Caregiver Supervision
A situation where an individual who needs assistance or care does not receive adequate oversight, leading to risks of harm or neglect.
Risk for Injury
A clinical judgment that an individual has an increased vulnerability to injury that may be physical or psychological.
- Identify markers of physical assault in adults and children, and organize the corrective measures appropriately.
- Pinpoint protective protocols and risk elements for susceptible demographics, encompassing youngsters, adults suffering from dementia, and intimate partner violence survivors.
Verified Answer
AF
Aiman FatimaJul 04, 2024
Final Answer :
A
Explanation :
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.
Learning Objectives
- Identify markers of physical assault in adults and children, and organize the corrective measures appropriately.
- Pinpoint protective protocols and risk elements for susceptible demographics, encompassing youngsters, adults suffering from dementia, and intimate partner violence survivors.