A client with dementia is disoriented, wanders, has decreased appetite, and has trouble sleeping. What is the priority nursing problem?

A client with dementia is disoriented, wanders, has decreased appetite, and has trouble sleeping. What is the priority nursing problem?

• A. Altered sleep pattern
• B. Imbalanced nutrition: less than
• C. Risk for injury
• D. Disturbed thought processes

Answer: (C)

Safety is the priority because disorientation and wandering in a client with dementia create an immediate and serious risk of harm, such as falls, becoming lost, or entering dangerous situations. When someone is not oriented and moves about without a clear plan, injuries can happen quickly and have life-threatening consequences, so preventing harm takes precedence over other concerns like sleep problems or decreased appetite. Once safety measures are in place—like a secure environment, supervision, alarms, appropriate footwear, and distraction or structured activities—the nurse can then address sleep disturbances and nutritional issues. The sleep and nutrition concerns are important for overall well-being, but they do not pose the same immediate threat to the patient as the potential for injury related to wandering and disorientation.

Safety is the priority because disorientation and wandering in a client with dementia create an immediate and serious risk of harm, such as falls, becoming lost, or entering dangerous situations. When someone is not oriented and moves about without a clear plan, injuries can happen quickly and have life-threatening consequences, so preventing harm takes precedence over other concerns like sleep problems or decreased appetite. Once safety measures are in place—like a secure environment, supervision, alarms, appropriate footwear, and distraction or structured activities—the nurse can then address sleep disturbances and nutritional issues. The sleep and nutrition concerns are important for overall well-being, but they do not pose the same immediate threat to the patient as the potential for injury related to wandering and disorientation.