A 19 year old patient has a diagnosis of Borderline personality disorder. The patient approaches the nurse and shows multiple fresh cuts on both arms. Which is the most therapeutic response by the nurse?

"After I clean your wounds, I would like for you to journal how you were feeling before you cut yourself.

I’m so sorry you cut your arms Let's discuss how you were feeling

Wow. what happened to you?".

What did you use to cut yourself! I will need to search your room

Answer and Explanation

The Correct Answer is A

A. "After I clean your wounds, I would like for you to journal how you were feeling before you cut yourself."

This response is the most therapeutic. It acknowledges the patient's self-harm behavior, addresses the immediate physical needs by offering to clean the wounds, and encourages the patient to reflect on their emotions through journaling. This approach promotes self-awareness and provides a constructive coping strategy.

B. "I’m so sorry you cut your arms. Let's discuss how you were feeling."

This response is empathetic and encourages communication about the patient's emotions. While it acknowledges the self-harm and invites discussion, it does not suggest a specific coping strategy like journaling. It is still a supportive and therapeutic approach.

C. "Wow. What happened to you?"

This response may come off as judgmental or dismissive. It does not acknowledge the patient's emotional state or offer immediate support for the physical wounds. The tone and wording may make the patient feel uncomfortable or judged.

D. "What did you use to cut yourself! I will need to search your room."

This response is not therapeutic and may be perceived as confrontational and invasive. It does not prioritize the patient's emotional well-being and may violate the patient's trust and privacy. Searching the room without consent is not a recommended approach.

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Correct Answer is D

Explanation

A. Enables the nurse to assign the appropriate Axis I diagnosis: Nurses typically do not assign Axis I diagnoses. Diagnosing mental health conditions is typically the responsibility of psychiatrists, psychologists, or other licensed mental health professionals. Nurses, however, play a crucial role in gathering information to contribute to the overall assessment process.

B. Enables the nurse to prescribe the appropriate medications: Nurses do not prescribe medications; that is the responsibility of physicians, nurse practitioners, or other prescribers. However, gathering client information is essential for providing accurate information to the prescriber, assisting in medication management, and monitoring for side effects.

C. Enables the nurse to modify behaviors related to personality disorders: While nurses can assist in the management of behaviors related to mental health conditions, the primary purpose of gathering client information is not to modify behaviors related to personality disorders. It is more about understanding the client's needs and tailoring care accordingly.

D. Enables the nurse to make sound clinical judgments and plan appropriate care: This is the correct answer. Gathering client information is a fundamental step in the nursing assessment process. It provides the necessary data for the nurse to make informed clinical judgments, identify health problems, and plan appropriate care interventions. It allows the nurse to understand the client's unique needs, preferences, and potential risks, leading to individualized and effective care planning.

A. "Mental health disorders are broken down by their manifestations." B. "Treatments for mental health disorders always allow clients to return to full functioning." C. Mental health disorders are preventable" D. Mental health disorders are primarily caused by biological factors."

Correct Answer is A

No explanation

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A 19 year old patient has a diagnosis of Borderline personality disorder. The patient approaches the nurse and shows multiple fresh cuts on both arms. Which is the most therapeutic response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the purpose of a nurse gathering client information?

Correct Answer is D

Explanation

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Correct Answer is A

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