A client is being admitted to the inpatient unit for ...

[fnuegbu]

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

[FergA]

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]

TYSM

[FergA]

Excellent