A client diagnosed with brief psychotic disorder states, "The voices keep telling me I must kill the president." Which is the priority nursing diagnosis?

Question

Quizplus · Accepted Answer

1.This is incorrect. Disturbed sensory perception addresses the presence of hallucinations. The priority nursing diagnosis is "risk for violence: other directed." The client is having auditory hallucinations commanding the client to kill the president. Others are at risk for harm should the client act on the commands. Safety is always the priority.
2.This is incorrect. The priority nursing diagnosis is "risk for violence: other directed." The client is having auditory hallucinations commanding the client to kill the president. Others are at risk for harm should the client act on the commands. Safety is always the priority. Disturbed thought processes are defined as disruptions in cognitive operations and activities as evidenced by behaviors that indicate the presence of delusional thinking, suspiciousness, and inaccurate interpretation of the environment.
3.This is correct. The priority nursing diagnosis is "risk for violence: other directed." The client is having auditory hallucinations commanding the client to kill the president. Others are at risk for harm should the client act on the commands. Safety is always the priority.
4.This is incorrect. Impaired verbal communication is defined as a state in which an individual experiences a decrease or absence of the ability to use or understand language. Hallucinations can impair the ability to effectively communicate. The priority nursing diagnosis is "risk for violence: other directed." The client is having auditory hallucinations commanding the client to kill the president. Others are at risk for harm should the client act on the commands. Safety is always the priority.

A Client Diagnosed with Brief Psychotic Disorder States, "The Voices