Nokea
A patient, aged 82 years, has Alzheimer's disease. She lives with her daughter's family and goes to a day care facility on weekdays. The nurse at the day care center noticed the patient was unkempt and had multiple bruises. When the daughter arrived to pick her up, the nurse discussed her observations. The daughter became defensive and said that her mother was very difficult to manage. She stated, "My mother is not my mother anymore. She is confused, and she wanders all night. We have to watch her constantly. Last night I fell asleep, and she fell down the stairs. Sometimes I just cannot bear to care for her."Â Which nursing diagnosis would be most important to address for this patient?
Correct Answer: A
Rationale: The correct answer is A: Risk for injury related to impaired cognition, judgment, and coordination and lack of caregiver supervision. The rationale is that the patient's Alzheimer's disease has led to impaired cognitive function, making her at risk for injury due to wandering and falls. The daughter's lack of supervision and inability to manage the patient's needs further exacerbate this risk. Choices B, C, and D are incorrect because they do not directly address the immediate safety concern of the patient being at risk for injury. Nonadherence, anxiety, and impaired communication are important issues but do not take precedence over the patient's safety in this context.