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. Enables the nurse to assign the appropriate Axis I diagnosis: Nurses typically do not assign Axis I diagnoses. Diagnosing mental health conditions is typically the responsibility of psychiatrists, psychologists, or other licensed mental health professionals. Nurses, however, play a crucial role in gathering information to contribute to the overall assessment process.
B. Enables the nurse to prescribe the appropriate medications: Nurses do not prescribe medications; that is the responsibility of physicians, nurse practitioners, or other prescribers. However, gathering client information is essential for providing accurate information to the prescriber, assisting in medication management, and monitoring for side effects.
C. Enables the nurse to modify behaviors related to personality disorders: While nurses can assist in the management of behaviors related to mental health conditions, the primary purpose of gathering client information is not to modify behaviors related to personality disorders. It is more about understanding the client's needs and tailoring care accordingly.
D. Enables the nurse to make sound clinical judgments and plan appropriate care: This is the correct answer. Gathering client information is a fundamental step in the nursing assessment process. It provides the necessary data for the nurse to make informed clinical judgments, identify health problems, and plan appropriate care interventions. It allows the nurse to understand the client's unique needs, preferences, and potential risks, leading to individualized and effective care planning.
Correct Answer is C
Explanation
A. Psychiatrist: Psychiatrists focus primarily on medical and pharmacological interventions for mental illnesses. While they play a crucial role in diagnosing and treating mental health conditions, they typically do not have the expertise in housing assistance or social services.
B. Behavioral therapist: Behavioral therapists focus on psychotherapeutic interventions to address and modify behavior. They are not typically involved in addressing social determinants of health, such as housing.
C. Social worker: Social workers are specifically trained to address social issues, including housing. They work with clients to assess their social needs, connect them with resources, and advocate for their well-being. In this case, a social worker would be instrumental in helping the client find housing resources and support.
D. Psychologist: Psychologists primarily focus on psychological assessments, therapy, and interventions. Like psychiatrists, their expertise is more centered around mental health treatment rather than addressing the social determinants of health such as housing.
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