43. A client is responding with hostility to staff and other clients. A nurse's priority diagnosis for this client should be:
43. A client is responding with hostility to staff and other clients. A nurse's priority diagnosis for this client should be:
. Distorted sensory perception.
. Impaired social interaction.
. Risk for violence.
. Impaired thought processes.
Test-Taking Tip
Priority is the key, and safety is a priority.
Content Area: Mental Health, Common Behavioral Problems; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Psychosocial Integrity/Sensory/Perceptual Alterations
.
Answer 1 is incorrect because the client may have distorted perceptions or thoughts (e.g., thinking others are out to harm the client), but these may not necessarily lead to a safety issue to self or others. Answer 2 is incorrect because the client's problems with social interaction are not a priority because safety is more important to establish at this time. Answer 3 is most correct because a client who is full of intense anger and rage may pose a safety issue for others. Answer 4 is incorrect because the client may have altered thoughts (e.g., believing one is related to royalty). Hostility and threat to others is a priority.