Assessment of a client with schizophrenia reveals that he is hearing voices that tell him that people are staring at him, and that he is seeing illusions. When developing the plan of care for this client, which nursing diagnosis would be most appropriate?
A) Disturbed Thought Processes
B) Risk for Self-Directed Violence
C) Disturbed Sensory Perception
D) Ineffective Coping
Ans: C
The most appropriate nursing diagnosis would be Disturbed Sensory Perception related to his hallucinations and illusions. Disturbed Thought Processes would be appropriate for delusions, confusion, and disorganized thinking. Risk for Self-Directed Violence would be appropriate if the client verbalized that the voices were telling him to harm himself. Although Ineffective Coping could apply, there is nothing to support this nursing diagnosis.
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