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. Axons B. Neurotransmitters C. Dendrites D. Synapses

Correct Answer is B

Explanation

A. Axons: Axons are nerve cell processes that transmit signals away from the cell body. While axons are essential for communication between nerve cells, their structure or function is not directly implicated in the altered behavior associated with schizophrenia.

B. Neurotransmitters: This is the correct answer. In schizophrenia, there is evidence of dysregulation in neurotransmitter systems, particularly dopamine. Dopamine dysregulation is associated with both positive and negative symptoms of schizophrenia. In the case of negative symptoms, such as social withdrawal and reduced emotional expression, hypoactivity in dopamine pathways may play a role.

C. Dendrites: Dendrites are nerve cell processes that receive signals from other neurons. Similar to axons, dendrites are crucial for communication between nerve cells, but their structure or function is not specifically implicated in the altered behavior associated with schizophrenia.

D. Synapses: Synapses are the junctions between nerve cells where neurotransmitters are released to transmit signals. While synapses play a critical role in neurotransmission, the altered behavior in schizophrenia is more closely linked to the dysregulation of neurotransmitters, particularly dopamine, than to structural changes in synapses.

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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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