What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
A) Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment
B) Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks
C) Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations
D) Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

Question

Quizplus · Accepted Answer

The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgment or when the patient's sensorium is clouded. The other diagnoses may be concerns, but are lower priorities.

What Is the Priority Nursing Diagnosis for a Patient with Fluctuating