The nurse is caring for a college student who started hearing voices, has not attended classes for the past 4 weeks, was yelling accusations at others, and has stopped communicating with family and friends. Which is the nurse's priority nursing diagnosis?

Question

Quizplus · Accepted Answer

1.This is incorrect. The priority nursing diagnosis is "risk for other-directed violence R/T yelling accusations." Safety is always the priority. Verbal aggression is a behavior indicating risk for violence. The client's agitation indicates there is a potential for violence. Altered thought processes is an appropriate nursing diagnosis but does not take priority over risk of harm to others.
2.This is correct. The priority nursing diagnosis is "risk for other-directed violence R/T yelling accusations." Safety is always the priority. Verbal aggression is a behavior indicating risk for violence. Other risk factors include aggressive body language, command hallucinations, rage reactions, and destruction of objects in the environment.
3.This is incorrect. The priority nursing diagnosis is "risk for other-directed violence R/T yelling accusations." Safety is always the priority. Verbal aggression is a behavior indicating risk for violence. Social isolation and paranoia do not take priority over the risk for other-directed violence.
4.This is incorrect. The priority nursing diagnosis is "risk for other-directed violence R/T yelling accusations." Safety is always the priority. Verbal aggression is a behavior indicating risk for violence. The client's current symptoms do not support this nursing diagnosis.

The Nurse Is Caring for a College Student Who Started