A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client?
Disturbed sensory perception
Risk for violence: directed toward others
Altered thought processes
Risk for injury
The Correct Answer is B
A. Disturbed sensory perception: While the client is experiencing disturbed sensory perception (auditory hallucinations), the priority is to address the potential harm to others, which is better captured by the "Risk for violence: directed toward others" diagnosis.
B. Risk for violence: directed toward others: This diagnosis is the priority in this situation because the client is expressing homicidal thoughts directed toward a specific target (the president). Ensuring the safety of the client and others is the primary concern.
C. Altered thought processes: Altered thought processes may be evident in psychotic disorders, but the immediate concern is the risk of violence. Addressing altered thought processes would be part of the overall care plan, but it may not be the immediate priority in this case.
D. Risk for injury: While the client may be at risk for injury, the specific concern mentioned by the client is the potential harm to others (the president). Therefore, the "Risk for violence: directed toward others" diagnosis takes precedence.
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Related Questions
Correct Answer is C
Explanation
A. By setting punishments for clients who violate the community rules: This approach is more authoritarian than democratic. In a democratic milieu, the emphasis is on collaboration, shared decision-making, and equal participation, rather than imposing punishments.
B. By setting expectations wherein all clients are not treated on an equal basis: This approach would be contrary to the principles of a democratic milieu. The democratic model promotes equality, inclusion, and the involvement of all clients in decision-making.
C. By setting expectations wherein all clients are treated on an equal basis: This is the correct answer. In a democratic milieu, all clients are encouraged to participate equally in decision-making processes, express their opinions, and contribute to the therapeutic community. This fosters a sense of empowerment and shared responsibility.
D. By dealing with inappropriate behaviors as they occur: While addressing inappropriate behaviors is important in any therapeutic environment, the emphasis on a democratic form of self-government goes beyond reacting to behaviors. It involves actively engaging clients in the decision-making process and promoting a collaborative and supportive community.
Correct Answer is D
Explanation
A. Concern for others: Individuals with antisocial personality disorder typically lack genuine concern for others and may exploit or manipulate them for personal gain.
B. Actively engaged in all unit activities: While engagement in activities can vary, the key feature of antisocial personality disorder is not a high level of engagement but rather a disregard for rules and the rights of others.
C. Mindful of following all of the unit rules: Individuals with antisocial personality disorder often have a history of rule-breaking and may not be consistently mindful of following societal or institutional rules. They may engage in behaviors that violate rules or laws.
D. Manipulative: This is the correct answer. Antisocial personality disorder is characterized by manipulative behaviors, where individuals exploit others for personal gain or pleasure. Manipulation is a key feature of this disorder.
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