A nurse is developing a plan of care for a client diagnosed with posttraumatic stress disorder (PTSD)who was admitted to the hospital for suicidal ideations and sleep disturbance due to frequent nightmares. Which is the priority nursing diagnosis for this client?
A)Disturbed Sleep Pattern
B)Post-Trauma Syndrome
C)Risk for Other-Directed Violence
D)Risk for Self-Directed Violence

Question

Quizplus · Accepted Answer

A)Because the client is experiencing thoughts of suicide, Risk for Self-Directed Violence would be the priority nursing diagnosis. Although the client reports sleep disturbances related to frequent nightmares, Disturbed Sleep Pattern would not be the priority nursing diagnosis. Post-Trauma Syndrome may be appropriate for this client; however, it would not be the priority nursing diagnosis. There is no indication in the findings that the client is at risk for injuring or harming others; therefore, Risk for Other-Directed Violence would not be appropriate for this client.
B)Because the client is experiencing thoughts of suicide, Risk for Self-Directed Violence would be the priority nursing diagnosis. Although the client reports sleep disturbances related to frequent nightmares, Disturbed Sleep Pattern would not be the priority nursing diagnosis. Post-Trauma Syndrome may be appropriate for this client; however, it would not be the priority nursing diagnosis. There is no indication in the findings that the client is at risk for injuring or harming others; therefore, Risk for Other-Directed Violence would not be appropriate for this client.
C)Because the client is experiencing thoughts of suicide, Risk for Self-Directed Violence would be the priority nursing diagnosis. Although the client reports sleep disturbances related to frequent nightmares, Disturbed Sleep Pattern would not be the priority nursing diagnosis. Post-Trauma Syndrome may be appropriate for this client; however, it would not be the priority nursing diagnosis. There is no indication in the findings that the client is at risk for injuring or harming others; therefore, Risk for Other-Directed Violence would not be appropriate for this client.
D)Because the client is experiencing thoughts of suicide, Risk for Self-Directed Violence would be the priority nursing diagnosis. Although the client reports sleep disturbances related to frequent nightmares, Disturbed Sleep Pattern would not be the priority nursing diagnosis. Post-Trauma Syndrome may be appropriate for this client; however, it would not be the priority nursing diagnosis. There is no indication in the findings that the client is at risk for injuring or harming others; therefore, Risk for Other-Directed Violence would not be appropriate for this client.

A Nurse Is Developing a Plan of Care for a Client