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?
A.
Disturbed sensory perception
B.
Risk for violence: directed toward others
C.
Altered thought processes
D.
Risk for injury
The correct answer and Explanation is :
The correct nursing diagnosis to prioritize in this situation is B. Risk for violence: directed toward others.
Explanation:
When a client with a brief psychotic disorder reports hearing voices instructing them to commit a violent act, such as killing the president, the primary concern is the risk of harm to others. Brief psychotic disorder is characterized by the sudden onset of psychosis, which can include delusions, hallucinations, and disorganized thinking. The client’s report of voices commanding violent behavior indicates a significant risk of acting on these commands, which can endanger others.
Here’s why “Risk for violence: directed toward others” is the most appropriate priority:
- Immediate Risk: The report of voices instructing the client to commit a violent act poses an immediate threat to the safety of others. The nurse must assess and address this risk to prevent potential harm.
- Directing Care: By prioritizing this diagnosis, the nurse can implement interventions focused on safety. This might include close monitoring of the client, ensuring a safe environment, and possibly initiating a psychiatric evaluation to determine the need for further interventions or medications to manage symptoms.
- Assessment and Intervention: The nurse should assess the client’s mental state, including the nature of the voices, the client’s intent, and their ability to control their actions. Interventions might include crisis intervention strategies, engaging the client in reality-based conversations, and coordinating with the healthcare team for possible admission to a secure facility if needed.
While “Disturbed sensory perception,” “Altered thought processes,” and “Risk for injury” are relevant diagnoses, they do not directly address the immediate danger posed by the client’s reported intent to commit a violent act. “Disturbed sensory perception” and “Altered thought processes” are more general diagnoses related to the psychotic symptoms themselves, while “Risk for injury” is less specific to the risk of violence directed at others.
Overall, the safety of others is paramount in this scenario, making “Risk for violence: directed toward others” the appropriate priority.