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Author Question: A client is being admitted to the inpatient unit for stabilization of psychoses. The client's mother ... (Read 56 times)

fnuegbu

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A client is being admitted to the inpatient unit for stabilization of psychoses. The client's mother found the client trying to drown a cat in the bathtub. The client believed it was possessed by the devil.
 
  The mother reports that the father also suffered from a mental illness and was physically abusive. Based on this information the priority nursing diagnosis is: 1. Post-Trauma Syndrome.
  2. Disturbed Thought Processes.
  3. Risk for Injury.
  4. Risk for Violence: Other-Directed.

Question 2

The client on the inpatient unit who should be assessed as being at highest risk for directing violent behavior toward others is which of the following?
 
  1. A veteran who has a diagnosis of post-traumatic stress disorder who was admitted for severe sleep disturbance secondary to nightmares
  2. A middle-aged woman who has completed alcohol withdrawal and is participating in a rehabilitation program
  3. An adolescent who was admitted for suicidal ideation and was suspended from school for getting into a fight with a classmate
  4. A male client in his twenties who has bipolar disorder with delusions of grandeur



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FergA

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Answer to Question 1

4
Rationale: Risk factors for violence directed at others include cognitive impairment or psychoses, history of being abused or witnessing abuse as a child, and cruelty to animals. No information is provided that would confirm the presence of post-trauma or risk for self-injury. Disturbed Thought Processes is an appropriate diagnosis but not the priority.

Answer to Question 2

3
Rationale: The greatest risk factor for aggressive behavior is prior history of aggressive behavior. Although the other options contain risk factors (delusions, disturbing symptoms), there is no indication of a prior history of aggressive behavior. Clients experiencing active symptoms of alcohol withdrawal are high risk due to the potential reality distortion, but this risk decreases once the withdrawal is complete.




fnuegbu

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Reply 2 on: Jul 19, 2018
Wow, this really help


abro1885

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Reply 3 on: Yesterday
Thanks for the timely response, appreciate it

 

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