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NCLEX-RN · Question #702
NCLEX-RN Question #702: Real Exam Question with Answer & Explanation
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Question
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:
Options
- ASensory-perceptual alteration: auditory command hallucinations
- BAlteration in thought processes: paranoid delusions
- CPotential for violence directed at others
- DImpaired verbal communication: loose associations
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