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. Concrete thinking: Concrete thinking refers to a style of thinking that is focused on immediate and literal aspects of information. The patient's statement involves more than concrete thinking; it includes an irrational belief about the consequences of contagious bacteria, indicating a distorted perception of reality.
B. Agitation: Agitation refers to a state of restlessness or increased activity. The patient's statement does not necessarily reflect agitation but rather a specific paranoid belief about the consequences of bacteria exposure.
C. Paranoia: This is the correct answer. Paranoia involves irrational thoughts and fears of being harmed or persecuted by others. The patient's belief that contagious bacteria are everywhere and will lead to being locked up with other infected people is indicative of paranoid ideation.
D. Poverty of thought: Poverty of thought is characterized by a lack of meaningful or detailed thought content. The patient's statement is not an example of poverty of thought; rather, it involves specific and elaborate content related to a paranoid belief.
Correct Answer is A
Explanation
A. Your child has a chemical imbalance of the brain, which leads to altered thoughts: This is the correct answer. It acknowledges the role of a chemical imbalance in the brain contributing to altered thoughts and hallucinations in the context of schizophrenia.
B. Your child's hallucinations are caused by medication interactions: This explanation is not likely in this context. While medications can have side effects, command hallucinations in schizophrenia are primarily related to the underlying disorder.
C. Your child has too little serotonin in the brain causing delusions and hallucinations: While serotonin is involved in mood regulation, attributing hallucinations solely to low serotonin levels oversimplifies the complex neurobiology of schizophrenia.
D. Your child's abnormal hormonal changes have precipitated auditory hallucinations: Hormonal changes are not considered a primary cause of auditory hallucinations in schizophrenia. The emphasis is on neurobiological and genetic factors influencing brain function.
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