A 28-year-old female client was admitted 3 days ago after she ran nude through the streets shouting that she was the "Queen of Hearts."
Since admission, the client remains delusional, shouts obscenities, and demonstrates loosely asso-ciated thoughts. Based on these data, the nurse should develop a nursing diagnosis of:
1. Risk for violence
2. Defensive coping
3. Disturbed thought processes
4. Impaired memory
ANS: 3
Delusions and loose associations suggest disturbed thought processes. 1. No data exist to support the diagnosis risk for violence. 2. This diagnosis is not supported by data in the scenario. 4. No data exist to support memory impairment.
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