# Situation: A 35-year-old man with schizophrenia is brought to the emergency department by police after a dispute with a neighbor. He is not intoxicated on assessment, and his vital signs are normal. While waiting, he says, "If that neighbor comes near me again, I will stab him with the knife in my bag." He also believes the neighbor is poisoning his water and has not bathed or changed his clothes for a week. Which nursing diagnosis should the nurse rank as the PRIORITY?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630092  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 35-year-old man with schizophrenia is brought to the emergency department by police after a dispute with a neighbor. He is not intoxicated on assessment, and his vital signs are normal.

While waiting, he says, "If that neighbor comes near me again, I will stab him with the knife in my bag." He also believes the neighbor is poisoning his water and has not bathed or changed his clothes for a week. Which nursing diagnosis should the nurse rank as the PRIORITY?

## 보기

1. Disrupted thought processes
2. Risk for suicidal self-injurious behavior
3. Decreased self-care ability syndrome
4. Risk for other-directed violence **✔ 정답**

**정답: 4**

## 해설

A threat against a named person, with a weapon at hand, signals danger to others and takes priority as a safety problem. His false belief and neglected self-care are real problems but do not pose the same immediate threat.

## 심화 해설

Priority setting in psychiatric emergencies

When a patient with schizophrenia makes a direct, specific threat while stating that a weapon is available, the nurse must first address the danger the patient poses to another person. In this scenario, the man identifies a particular neighbor, describes a concrete method of harm, and reports having a knife in his bag. That combination moves the situation from a general concern about psychotic symptoms into an immediate safety risk for an identifiable individual.

A threat against a named person, combined with access to a weapon, is the strongest signal that violence toward others may be imminent and therefore becomes the highest-priority nursing diagnosis. The other options describe real problems — the false belief about poisoning reflects disrupted thought processes, and not bathing for a week indicates impaired self-care — but neither of those diagnoses carries the same urgency as a credible threat of harm to a specific person.

Risk for other-directed violence is the correct priority because safety concerns are always ranked first in the nursing process. The nurse must act to protect the potential victim before addressing the underlying thought disorder or hygiene deficits. In emergency and acute care mental health settings, violence risk assessment begins with identifying whether a patient has a target, a plan, and the means to carry it out.

Longitudinal research on violence in psychosis supports this clinical priority. A systematic review of risk factors for violence in people with schizophrenia-spectrum disorders found that recent threats, access to weapons, and hostility are among the factors most consistently associated with subsequent violent behavior [1]. The presence of a specific victim and an available weapon are not merely contextual details; they are core elements of imminent risk.

The clinical reality of violence in mental health settings further reinforces the need to prioritize other-directed violence. A literature review on violence risk-assessment screening tools reported that 90% of physicians and nurses working in mental health areas have experienced violence from patients, and approximately 80% of violent acts from patients are directed toward nurses [2]. These figures highlight why a stated threat with a weapon at hand cannot be deferred while the nurse addresses thought content or self-care.

Watch out! Do not confuse Risk for other-directed violence with Risk for suicidal self-injurious behavior. The patient’s threat is directed at the neighbor, not at himself. There is no statement of self-harm, hopelessness, or suicidal ideation in the scenario, so option 2 is not supported.

Key point! In any psychiatric emergency, the first question is always: Is someone in immediate danger? If the answer is yes, the priority diagnosis must reflect that danger. Here, the named neighbor is the person in danger, and the nurse’s first responsibility is to ensure the patient does not have access to the knife and that the potential victim is protected.

The false belief that the neighbor is poisoning his water is a paranoid delusion, which falls under Disrupted thought processes. However, delusions alone do not automatically create an emergency unless they are linked to a threat or action. In this case, the delusion is directly connected to the threat, which is precisely why the violence risk takes priority over the thought disorder itself. The delusion explains the motivation, but the threat and the weapon define the immediate risk.

Poor hygiene and unchanged clothing for a week indicate Decreased self-care ability syndrome, a legitimate nursing concern. But self-care deficits are chronic, lower-acuity problems. They can be addressed after the immediate safety threat is contained. A patient who has not bathed for a week is not in the same category of urgency as a patient who says he will stab his neighbor and has a knife available.

| Nursing diagnosis | Key feature in scenario | Priority level |
| --- | --- | --- |
| Risk for other-directed violence | Specific threat to neighbor, stated method, weapon at hand | Highest — immediate safety risk |
| Disrupted thought processes | Paranoid delusion about water poisoning | Moderate — contributes to threat but not the immediate danger itself |
| Decreased self-care ability syndrome | No bathing or clothing change for one week | Lower — chronic concern, address after safety is ensured |
| Risk for suicidal self-injurious behavior | No evidence of self-harm or suicidal ideation | Not supported by scenario |

The nurse’s immediate actions should include removing the patient’s bag or securing the knife, notifying security and the treatment team, and documenting the exact words of the threat. The neighbor may also need to be alerted if a credible, specific threat exists, depending on local duty-to-warn laws. These steps flow directly from identifying Risk for other-directed violence as the priority diagnosis.

In summary, the presence of a named victim, a specific plan, and an available weapon places this patient at high risk for harming another person. That risk outranks the thought disturbance and the self-care deficit because it demands immediate protective action. The priority nursing diagnosis is therefore Risk for other-directed violence [1][2].References (research sources)

- [1]Systematic review of risk factors for violence in psychosis: 10-year update.Meta-analysis/systematic reviewLagerberg T, Lambe S, Paulino A, Yu R, Fazel S (2025) · DOI: 10.1192/bjp.2024.120

- [2]Violence risk-assessment screening tools for acute care mental health settings: Literature review.Research articleAnderson KK, Jenson CE (2019) · DOI: 10.1016/j.apnu.2018.08.012

## 임상 시나리오

Violence Risk Triage in Psychiatric EmergenciesTarget, Plan, Means: The Three Questions That Set Priority
When a patient makes a specific threat against an identifiable person, the nurse must immediately assess three elements: target, plan, and means. In this case, the patient named a neighbor, described stabbing, and reported having a knife in his bag. This triad elevates the situation to an imminent safety risk and makes Risk for other-directed violence the priority nursing diagnosis.

Safety concerns are always ranked first in the nursing process. Delusions about poisoning and poor hygiene are real problems, but they do not carry the same urgency as a credible threat to a specific person. The nurse must act to protect the potential victim before addressing underlying thought disorder or self-care deficits.

CautionDo not dismiss a threat because the patient appears calm or has normal vital signs. The presence of a weapon combined with a named target and a stated method is a high-risk indicator. Notify security and the treatment team, and initiate precautions to protect the identified individual.

## 핵심 개념

- **Risk for other-directed violence** — A nursing diagnosis indicating a patient may physically harm another person, prioritized when there is a specific target, plan, and means.
- **Violence risk assessment** — A structured evaluation of whether a patient has a target, a plan, and the means to carry out harm, used to determine immediate safety needs.
- **Priority setting in psychiatric emergencies** — The principle that safety concerns, including danger to self or others, are ranked first in the nursing process before addressing other diagnoses.
- **Disrupted thought processes** — A nursing diagnosis reflecting impaired cognition or perception, such as delusions, but not necessarily an immediate safety risk.
- **Decreased self-care ability syndrome** — A nursing diagnosis indicating impaired ability to perform activities of daily living, such as bathing or changing clothes.

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