A positive CAM-ICU score indicates the highest-priority nursing diagnosis would be which of the following?

• A. Injury, Risk for
• B. Family Processes, Altered
• C. Social Interaction, Impaired
• D. Memory Impaired

Answer: (A)

A positive CAM-ICU indicates delirium, an acute and fluctuating disturbance of attention and cognition that is common in critically ill patients. Delirium brings a high risk of physical injury because confused, disoriented patients may try to pull out lines, fall, or wander, and may not follow safety precautions. Protecting the patient from harm is the immediate nursing priority, so the most important diagnosis is Injury, Risk for, to focus on safety measures, supervision, and prevention of harm.

The other diagnoses describe psychosocial or cognitive aspects that are important but not as urgent as preventing physical injury in the moment. For example, altered family processes and impaired social interaction reflect longer-term psychosocial needs, and memory impairment can occur with delirium but does not carry the same immediate safety priority as the risk for injury.