Author Question: An older adult with Alzheimer disease lives with family. After observing multiple bruises, the home ... (Read 37 times)

roselinechinyere27m · **on:** Jul 19, 2018

An older adult with Alzheimer disease lives with family. After observing 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 poor judgment, 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

Question 2

After treatment for a detached retina, a victim of domestic violence says, My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens.

I always get an apology, and I can tell my partner feels bad after hitting me. Which nursing diagnosis applies?

a. Social isolation, related to lack of community support system
b. Risk for injury, related to partner's physical abuse when intoxicated
c. Deficient knowledge, related to resources for escape from the abusive relationship
d. Disabled family coping, related to uneven distribution of power within a relationship

Shshxj · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

ANS: A
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.

Answer to Question 2

ANS: B
Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent. Data are not present that show social isolation or disabled family coping, although both are common among victims of violence. Deficient knowledge does not apply to this patient's use of defense mechanisms.