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A young adult client is admitted to the hospital with a diagnosis of schizophrenia, paranoid type. The client has been saying, "The voices in heaven are telling me to come home to God." What should initial nursing care be focused on? 1 Disturbed self-esteem 2 Potential for self-harm 3 Dysfunctional verbal communication 4 Impaired perception of environmental stimuli

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Answer:

The answer is number 2: Potential for self-harm.

Explanation:

The initial nursing care should be focused on client’s safety. The priority is always over the clients need, as for the things he’s saying it’s clear he’s hallucinating and has a risk of injury himself, expressing overwhelming emotional distress.  The other options are important but can be handled after.  

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