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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use clear, calm statements and a confident physical stance:
This is the most appropriate choice. Clear and calm communication, along with a confident physical stance, can help to de-escalate the situation. It demonstrates assertiveness and can potentially prevent further escalation of violence.
B. Provide objective evidence that violence is unwarranted:
While providing objective evidence may be helpful in some situations, individuals with paranoid personality disorder may not respond well to attempts to prove that their perceptions are unwarranted. It could potentially escalate the situation.
C. Empathize with the client's paranoid perceptions:
While empathy is important in communication, empathizing with paranoid perceptions in a way that validates or reinforces them may not be the best approach. It could inadvertently validate the client's distorted thoughts and potentially escalate the situation.
D. Initially restrain the client to maintain safety:
Physical restraint should be a last resort and used only when the safety of the client or others is at immediate risk. Initial restraint can escalate aggression and may not be the most appropriate intervention in the early stages of a violent episode.
Correct Answer is B
Explanation
A. These programs help clients correct distorted body image:
While behavioral programs may incorporate components related to body image, the primary focus is often on addressing and modifying specific behaviors associated with eating disorders, such as binge eating, purging, or restrictive eating.
B. These programs help clients manage uncontrollable behaviors:
This is the correct answer. Behavior modification programs aim to address and modify specific behaviors that contribute to eating disorders. This can include establishing healthier eating patterns, reducing binge-purge cycles, and promoting more adaptive coping strategies.
C. These programs allow clients to maintain control:
While the concept of control is relevant to eating disorders, behavior modification programs are designed to help clients gain control over maladaptive behaviors and establish healthier patterns. It's not about maintaining control over the disorder itself.
D. These programs address underlying client anger:
While emotions, including anger, may play a role in eating disorders, behavior modification programs are more focused on targeting and modifying specific behaviors rather than addressing underlying emotions directly. Emotional aspects may be addressed through additional therapeutic interventions
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