A patient with paranoid schizophrenia is hospitalized after ...

[LCritchfi]

A patient with paranoid schizophrenia is hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof and suspicious and says, Two staff members I saw talking were plotting to kill me.
 
  Based on data gathered at this point, which nursing diagnoses relate? Select all that apply.
 
  a. Risk for other-directed violence
  b. Disturbed thought processes
  c. Risk for loneliness
  d. Spiritual distress
  e. Social isolation

Question 2

An older adult patient takes digoxin and hydrochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation.
 
  These findings are most characteristic of:
 
  a. delirium
  b. dementia
  c. amnestic syndrome
  d. Alzheimer's disease

[Mollythedog]

Answer to Question 1

ANS: A, B
Delusions of persecution and ideas of reference support the nursing diagnosis of Disturbed thought processes. Risk for other-directed violence is substantiated by the patient's feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses.

Answer to Question 2

ANS: A
Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.