Author Question: A client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to ... (Read 102 times)

mwit1967 · **on:** Jul 19, 2018

A client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client?

1. Disturbed sensory perception
2. Altered thought processes
3. Risk for violence: directed toward others
4. Risk for injury

Question 2

A patient tells the nurse that one result of his chronic stress is that he has considerable fatigue. He usually sleeps from 11:00 PM to 6:30 AM.

He reports he now sets his alarm to give himself an extra 30 minutes of sleep each morning but feels no better and is rushed for work. Which nursing response would best address the patient's concerns? a. You may need to speak to your doctor about taking a sedative to help you sleep..
b. Exercising just before retiring for the night may help you to sleep better..
c. Perhaps going to bed a half hour earlier would work better than sleeping later..
d. A glass of wine in the evening might take the edge off and help you to rest..

yasmin · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

3
Rationale: The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices commanding him to kill someone is at risk for other-directed violence. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.

Answer to Question 2

C
Sleeping later in the morning may disturb circadian rhythms and in this case is adding, rather than reducing, the stress in his life. Going to bed earlier and arising at the usual time alleviates fatigue more effectively. Sedatives may offer some benefit but are a short-term intervention with potential side effects, and other nonpharmacological interventions might work as well or better. Exercise earlier in the evening could induce tiredness and ease the process of falling asleep, but doing so right before bedtime would likely be stimulating and interfere with sleep instead. Alcohol is sedating but is also potentially addictive, and encouraging its use could increase the risk of using alcohol maladaptively as a response to stress in general.