A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority for this client’s plan of care?
A. Disturbed sensory perception (visual)
B. Self-care deficit: Dressing/grooming
C. Impaired verbal communication
D. Risk for injury
Correct Answer: D. Risk for injury
Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury. Provide for safety needs (e.g., supervision, side rails, seizure precautions, placing call bell within reach, positioning needed items within reach/clearing traffic paths, ambulating with devices). This is to prevent untoward incidents and to promote safety.
Option A: Avoid challenging illogical thinking. Challenges to the patient’s thinking can be perceived as threatening and result in a defensive reaction. Orient the patient to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking—defensive reactions may result. Increased orientation ensures greater degree of safety for the patient.
Option B: Modulate sensory exposure. Provide a calm environment; eliminate extraneous noise and stimuli. Increased levels of visual and auditory stimulation can be misinterpreted by the confused patient. Assist the family and significant others in developing coping strategies. The family needs to let the patient do all that he or she is able to do to maximize the patient’s level of functioning and quality of life.
Option C: Give simple directions. Allow sufficient time for the patient to respond, to communicate, to make decisions. This communication method can reduce anxiety experienced in a strange environment.
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