Psychotic Disorders no. 4026

Psychotic Disorders no. 4026

QUESTION: A man with a 5-year history of multiple psychiatric admissions is brought to the emergency department by the police. He was found wandering the streets disheveled, shoeless, and confused. Based on his previous medical records and current behavior he is diagnosed with chronic undifferentiated schizophrenia. The nurse should assign highest priority to which nursing diagnosis?

✓O a.) <i>Risk for injury</i>
✘O b.) <i>Impaired verbal communication</i>
✘O c.) <i>Disturbed thought processes</i>
✘O d.) <i>Dressing or grooming self-care deficit</i>

RATIONALE

RATIONALE: Client safety is the most important consideration; therefore, assessing risk for injury takes highest priority. <i>Impaired verbal communication,</i> manifested by noncommunicativeness; <i>disturbed thought processes,</i> evidenced by inability to understand the situation; and <i>dressing or grooming self-care deficit,</i> evidenced by a disheveled appearance, are appropriate nursing diagnoses but aren't the highest priority.
NURSING PROCESS STEP: Analysis
CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application