A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious and wants to cut their arms. The nurse should:
advise the client to take an anxiolytic to decrease their anxiety level.
restrain the client to prevent self-harm.
assist the client to identify the trigger situation and choose a coping strategy.
encourage the client use self-harm behaviors to release emotion.
The Correct Answer is C
C. Individuals with borderline personality disorder often struggle with intense emotions and may engage in self-harming behaviors as a maladaptive coping mechanism. Helping the client identify triggers for their distress and teaching them alternative coping strategies, such as mindfulness, grounding techniques, or distress tolerance skills, can empower them to manage their emotions in healthier ways.
A. Anxiolytic medications can help alleviate anxiety symptoms but they are not typically the first-line intervention for addressing acute distress in individuals with borderline personality disorder (BPD).
B. Restraint should not be the first response to a client expressing distress or suicidal ideation. Physical restraint should only be used as a last resort in situations where there is an imminent risk of harm to the client or others and should be implemented by trained professionals following established protocols.
D. Encouraging self-harm behaviors reinforces maladaptive coping strategies and can increase the risk of harm to the client. It is essential to provide support and interventions aimed at reducing self-harming behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Dividing tasks into smaller, attainable steps and reward successful completion aligns with the principles of behavioral therapy and is likely to be effective for improving the task performance of an adolescent with ADHD. Breaking tasks into smaller, manageable steps can help reduce overwhelm and improve focus.
B. Removing privileges if homework is not completed within a 2-hour period is punitive and may not be effective for improving the task performance of an adolescent with ADHD. Negative consequences, such as removing privileges, can lead to feelings of frustration, demotivation, and resistance to task completion.
C. Methylphenidate is a commonly prescribed stimulant medication for ADHD, and discontinuing it abruptly without medical supervision can lead to withdrawal symptoms and worsening of ADHD symptoms.
D. Mandating isolation in the room is overly restrictive and can lead to feelings of frustration, isolation, and resentment, which can further impact task performance and exacerbate ADHD symptoms.
Correct Answer is C
Explanation
C. Acceptance and trust create a sense of safety and security for the client within the therapeutic relationship. When the client feels accepted and valued by the nurse, they are more likely to feel comfortable opening up and engaging in the therapeutic process.
A. Establishing a therapeutic alliance provides a safe and supportive environment for the client to express their feelings without fear of judgment or rejection. However, therapeutic alliance goes beyond this.
B. Therapeutic activities can indeed provide an outlet for tension and stress but the establishment of a therapeutic alliance goes beyond engaging in specific activities.
D. Focusing on positive behaviors and strengths can contribute to building self-esteem. However, the establishment of a therapeutic alliance involves more than just focusing on behaviors.
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