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 D
Explanation
Explanation:
A. Task Oriented: This term refers to groups that are formed to accomplish a specific task or achieve a particular goal.
B. Closed: Closed groups have a predetermined membership and do not accept new members after the group has started.
C. Heterogeneous: This term refers to groups that consist of individuals with diverse characteristics, backgrounds, or abilities.
D. Open: An open group is a group that allows for the continuous addition of new members as others leave. It remains open to new participants, and the composition of the group may change over time.
Correct Answer is C
Explanation
Individuals with OCD often engage in compulsive behaviors, such as repetitive cleaning, as a way to alleviate or decrease anxiety associated with obsessive thoughts. In the context of OCD, obsessions are intrusive and distressing thoughts, images, or urges that cause significant anxiety, while compulsions are repetitive behaviors or mental acts performed in response to the obsessions.
A. Decrease the time available for interaction with people:
While individuals with OCD may isolate themselves due to their symptoms, the primary motivation for repetitive behaviors like cleaning is to manage anxiety, not necessarily to avoid interaction with others.
B. Prevent aggressive and impulsive behaviors:
OCD compulsions are not typically aimed at preventing aggressive or impulsive behaviors. They are driven by the need to reduce distress related to obsessive thoughts.
C. Decrease anxiety:
This is the correct answer. Compulsive behaviors in OCD are often ritualistic actions performed to reduce the anxiety associated with obsessive thoughts. Cleaning, in this case, is a way for the individual to feel a sense of control and alleviate anxiety.
D. Manipulate others
The primary motive behind OCD compulsions is to manage personal anxiety, not to manipulate others. Individuals with OCD often recognize that their compulsions are excessive or irrational, but they feel driven to perform them to alleviate anxiety.
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