A Patient with a High Level of Motor Activity Runs

question 28

Multiple Choice

A patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient is unable to follow instructions or respond to verbal interventions from staff. Which nursing diagnosis has the highest priority?

• A) Risk for injury
• B) Self-care deficit
• C) Disturbed energy field
• D) Disturbed thought processes

---

Definitions:

Bowel Sounds

Noises made by the movement of the intestines, which can be heard through a stethoscope.

High-Pitched

Describes a sound that is sharp and has a frequency at the higher end of the human's hearing range.

Tarry Stool

Black, sticky stools indicative of gastrointestinal bleeding.

Gastrointestinal Bleeding

The loss of blood occurring within the gastrointestinal tract, which can manifest as vomiting blood or blood in the stool.