The nurse is planning care for a client admitted to psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive highest priority?

Correct Answer: A. Risk for violence toward self or others

Because of such factors as suspiciousness, anxiety, and hallucinations, the client with paranoid schizophrenia is at risk for violence toward himself or others. Paranoid schizophrenia is characterized by predominantly positive symptoms of schizophrenia, including delusions and hallucinations. These debilitating symptoms blur the line between what is real and what isn’t, making it difficult for the person to lead a typical life.

• Option B: The positive symptoms of schizophrenia—things like hallucinations and delusions—are less likely to go unnoticed. After the prodromal phase, the patient enters the active phase of schizophrenia, during which they experience debilitating thoughts and perceptual distortions. They may experience impaired motor or cognitive functions, including disorganized speech and disorganized or catatonic behavior.
• Option C: Early symptoms of schizophrenia may seem rather ordinary and could be explained by a number of other factors. This includes socializing less often with friends, trouble sleeping, irritability, or a drop in grades. During the onset of schizophrenia — otherwise known as the prodromal phase — negative symptoms mount. These negative symptoms might include an increasing lack of motivation, decreasing inability to pay attention or social isolation.
• Option D: The paranoia in paranoid schizophrenia stems from delusions—firmly held beliefs that persist despite evidence to the contrary — and hallucinations — seeing or hearing things that others do not. Both of these experiences can be persecutory or threatening in nature. A patient may hear a voice or voices in their head that they do not recognize as their own thoughts or internal voice. These voices can be demeaning or hostile, driving a person to do things they would not do otherwise.