NCLEX National Council Licensure Examination(NCLEX-RN) NCLEX-RN Question # 215 Topic 22 Discussion

NCLEX National Council Licensure Examination(NCLEX-RN) NCLEX-RN Question # 215 Topic 22 Discussion

NCLEX-RN Exam Topic 22 Question 215 Discussion:
Question #: 215
Topic #: 22

A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is:


A.

Sensory-perceptual alteration: auditory command hallucinations


B.

Alteration in thought processes: paranoid delusions


C.

Potential for violence directed at others


D.

Impaired verbal communication: loose associations


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