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

Answer and Explanation

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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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.

A. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss B. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights C. Knowledge deficit R/T bipolar disorder AEB concern about symptoms D. Risk for suicide R/T powerlessness AEB insomnia and anorexia

Correct Answer is A

Explanation

A. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss: This is the correct priority nursing diagnosis. The client's significant weight loss is indicative of altered nutrition and poses a more immediate threat to their well-being. Addressing the nutritional deficit takes precedence to ensure the client's physical health and stability.

B. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights: While altered sleep patterns are a concern, the priority in this scenario is the significant weight loss, which is indicative of altered nutrition. Nutritional deficits can have more immediate health consequences.

C. Knowledge deficit R/T bipolar disorder AEB concern about symptoms: While addressing knowledge deficits is important for the client's understanding of their condition, the immediate concern is the client's significant weight loss. Nutritional deficits can lead to serious health issues and should be addressed as a priority.

D. Risk for suicide R/T powerlessness AEB insomnia and anorexia: While the client's symptoms may contribute to a risk for suicide, the immediate focus should be on addressing the altered nutrition, which is a more direct threat to the client's physical health.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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