A.24years old man is admitted to Psychiatric unit. During his admission process he tells the nurse “voices are telling me that the end is near and that I should prepare myself for heaven “.When preparing a care plan for this patient .What will be the highest priority nursing diagnosis for this patient?.
A.Impaired safety concerns.
B.In ability to focus on self.
C.Ineffective listening to the nurse. D.Potential for violence to himself related to hallucinating commands.
Correct answer is D.
Rationale: He is hearing voices that are directing him unrealistically.
Nurses You Move Me 