A client admitted to the inpatient unit has a diagnosis of ...

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A client admitted to the inpatient unit has a diagnosis of schizophrenia, residual type. The nursing diagnosis that has the highest priority for this client is:
 
  1. Disturbed Thought Process
  2. Impaired Social Interaction
  3. Impaired Verbal Communication
  4. Risk for Violence: Self-Directed or Other-Directed

Question 2

The nursing student taking care of a client in the mental health clinic learns through assessment that the client's wife insisted he admit himself into the clinic even though his wife is the one with a documented history of mental illness.
 
  The client states, I just want her to be happy. The nursing student suspects that the client's relationship with his wife may be: 1. Enmeshed.
  2. Disengaged.
  3. Hostile.
  4. Skewed.

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Answer to Question 1

4
Rationale: Risk for Violence: Self-Directed or Other-Directed is the nursing diagnosis that is most closely related to patient safety, which is the highest priority in nursing care of any client. Impaired Social Interaction, Disturbed Thought Processes, and Impaired Verbal Communication represent accurate and important nursing diagnoses, but client safety is the highest priority for planning care.

Answer to Question 2

4
Rationale: Families in which one mate is severely dysfunctional are called skewed families. The other mate, who is usually aware of the dysfunction of the partner, assumes a passive, peace-making, submissive stance to preserve the relationship. The couple's relationship does not appear enmeshed, disengaged, or hostile.