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 B

Explanation

A. Hypotensive shock: This is not the correct answer. MAO inhibitors are not associated with causing hypotensive shock. In fact, they can lead to an increase in blood pressure.

B. Hypertensive crisis: This is the correct answer. MAO inhibitors interact with certain foods and drugs, such as those containing tyramine, leading to an increased risk of a hypertensive crisis. Foods rich in tyramine, such as aged cheeses, certain wines, and some processed meats, can cause a sudden and dangerous increase in blood pressure when combined with MAO inhibitors.

C. Cardiac dysrhythmia: While all medications have potential side effects, MAO inhibitors are not typically associated with causing cardiac dysrhythmias.

D. Cardiogenic shock: MAO inhibitors are not known to cause cardiogenic shock. The primary concern with MAO inhibitors is the potential for a hypertensive crisis due to interactions with specific foods and drugs.

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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Explanation

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