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

Question

Quizplus · Accepted Answer

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.

A Patient Admitted Yesterday for Injuries Sustained in a Fall