A client has been admitted to the detoxification unit after binge drinking. Even though the client is not currently intoxicated, he is combative and exhibits altered thought processes. Which nursing diagnosis would be the priority?
A) Risk for Injury related to effects of alcohol abuse
B) Risk for Self-Mutilation related to alcohol withdrawal and altered thought processes
C) Risk for Other-Directed Violence related to alcohol withdrawal
D) Risk for Delayed Development related to chronic effects of alcohol intoxication
Ans: C
The priority nursing diagnosis is Risk for Other-Directed Violence related to alcohol withdrawal. The most common nursing diagnoses for clients experiencing intense anger and aggression are Risk for Self-Directed Violence and Risk for Other-Directed Violence. Although the other answers are possible nursing diagnoses, there is no evidence to support a risk for injury, self mutilation, or delayed development.
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