What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects?
Risk for other-directed violence
Ineffective coping
Impaired social interaction
Risk for self-directed violence
The Correct Answer is A
Choice A reason: Safety is always the highest priority in the nursing process. The patient's behaviors—making direct threats, destroying property, and throwing objects—provide clear evidence of an immediate risk to the physical safety of staff and other patients. This diagnosis must be addressed first to establish a secure environment for treatment.
Choice B reason: While the patient is certainly demonstrating ineffective coping, this is a broad diagnosis that does not address the immediate crisis. Ineffective coping focuses on the inability to manage stressors, but in a psychiatric emergency where violence is imminent, the priority must be the containment and prevention of physical harm to others.
Choice C reason: Impaired social interaction is a long-term feature of antisocial personality disorder, characterized by a lack of empathy and disregard for social norms. While this is an appropriate diagnosis for the patient's general personality structure, it is not the priority during an acute episode of aggressive and destructive behavior.
Choice D reason: There is no evidence in the provided scenario to suggest that the patient is at risk for self-harm or suicide. Antisocial personality disorder is more commonly associated with externalizing behaviors (aggression toward others) rather than internalizing behaviors (self-injury), although both can occur. Based on the data, other-directed violence is the clear priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Frequent induced vomiting, a common compensatory behavior in bulimia nervosa, leads to the excessive loss of gastric hydrochloric acid and potassium. This depletion results in metabolic alkalosis and hypokalemia, which is a critically low serum potassium level that can cause life-threatening cardiac dysrhythmias and muscle weakness.
Choice B reason: While tachycardia can occur secondary to dehydration or electrolyte imbalances, it is a non-specific sign and not the primary metabolic finding expected from chronic emesis. Hypokalemia is a more direct and clinically significant biochemical consequence of losing intracellular and extracellular fluids through the upper gastrointestinal tract.
Choice C reason: Hypercalcemia, or elevated serum calcium, is not a standard finding associated with chronic vomiting. In fact, repetitive emesis is more likely to cause shifts in other electrolytes like chloride and sodium. Calcium levels are generally maintained by parathyroid function unless there is significant renal impairment or specific supplement abuse.
Choice D reason: Hypolipidemia, or abnormally low lipid levels, is not a diagnostic expectation for a patient inducing vomiting. While nutritional deficiencies are common in eating disorders, the acute physiological risk and the hallmark laboratory finding specifically related to the act of purging is the disruption of serum electrolytes, particularly potassium.
Correct Answer is D
Explanation
Choice A reason: A serum potassium level of 3.4 mEq/L is slightly below the normal range (3.5 to 5.0 mEq/L). While it requires monitoring and likely oral supplementation, it is generally not considered an emergency threshold for acute hospitalization unless accompanied by cardiac arrhythmias or much more severe depletion (typically <3.0 mEq/L).
Choice B reason: A urine output of 40 mL/hr is within the normal expected range for an adult (minimum 30 mL/hr). This indicates that the patient’s kidneys are currently well-perfused and they are likely not experiencing severe dehydration or acute renal failure, which would be reasons to consider inpatient medical stabilization.
Choice C reason: A blood pressure of 100/60 mm Hg is relatively low but may be normal for many young, thin individuals or athletes. Without symptoms of orthostatic hypotension or evidence of end-organ hypoperfusion, this reading alone does not meet the strict medical stability criteria for admission to an inpatient eating disorder unit.
Choice D reason: A blood pressure of 78/58 mmHg is severely hypotensive and indicates a state of medical instability. In patients with eating disorders, profound hypotension combined with a low or borderline pulse rate suggests a high risk of cardiovascular collapse. This meets the APA criteria for immediate hospitalization to stabilize vital signs and prevent death.
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