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
A. Histrionic Personality Disorder:
Individuals with histrionic personality disorder typically seek attention and may be overly dramatic, but self-harm as a response to perceived abandonment is not a characteristic feature.
B. Obsessive-Compulsive Personality Disorder (OCPD):
People with obsessive-compulsive personality disorder are characterized by perfectionism, preoccupation with details, and a desire for control. Michelle's behavior, including self-harm in response to perceived rejection, aligns more closely with borderline personality disorder.
C. Narcissistic Personality Disorder:
While narcissistic individuals may exhibit a sense of superiority and a desire for admiration, self-harm in response to abandonment is not a typical trait of narcissistic personality disorder.
D. Borderline Personality Disorder (BPD):
This personality disorder is characterized by unstable relationships, self-image, and emotions. Individuals with BPD may have intense fears of abandonment and engage in impulsive and self-destructive behaviors. Michelle's perception of being disliked, her claim of superiority, and the self-harming action in response to news of the nurse's vacation are consistent with BPD.
Correct Answer is B
Explanation
A. "Did you take your medicine this morning?": While medication adherence is important, this response does not directly address the client's distress or validate their experience. It may come across as dismissive.
B. "I'm sure the voices sound scary, I don't hear any voices speaking.": This response acknowledges the client's experience without confirming or denying the presence of the voices. It expresses empathy and provides reassurance, fostering a therapeutic relationship.
C. "The devil only talks to people who are receptive to his influence": This response introduces a belief system that may not align with the client's reality and could be perceived as judgmental. It's important to avoid imposing personal beliefs on clients experiencing hallucinations.
D. "You are not going to hell. You are a good person": While expressing support and reassurance is positive, making definitive statements about the client's fate or goodness may not be helpful. It's more effective to acknowledge the distress without making absolute affirmations.
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