A nurse is admitting a client who has borderline personality disorder and is at risk for self-mutilation. Which of the following interventions should the nurse incorporate in the plan of care?

Provide additional attention to the client

Apply mechanical restraints before administering medication

Obtain a verbal contract from the client

Limit staff members who work with the client

Answer and Explanation

The Correct Answer is C

A. Provide additional attention to the client: While individuals with BPD may crave attention and validation, providing excessive attention can reinforce maladaptive behaviors. Instead, the focus should be on providing consistent and appropriate support while also setting boundaries to encourage healthy coping mechanisms.

B. Apply mechanical restraints before administering medication: Mechanical restraints should only be used as a last resort when less restrictive interventions have failed to ensure the safety of the client and others. Applying restraints before attempting other interventions is not appropriate and may escalate the situation.

C. Obtain a verbal contract from the client: A verbal contract is an agreement between the client and the treatment team regarding safety measures and coping strategies. This intervention involves collaboratively establishing agreements with the client, which can help empower them to take responsibility for their behaviors and engage in treatment planning.

D. Limit staff members who work with the client: Limiting staff members who work with the client may inadvertently isolate the client and hinder the development of therapeutic relationships. Consistency in staffing and a collaborative approach among team members are often more beneficial in providing comprehensive care.

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Correct Answer is B

Explanation

A. Keep the client hospitalized until there is no longer a threat

Nurses do not have the authority to unilaterally detain clients in a hospital. This decision is typically made by a physician or a legal authority, especially in the context of a medical-surgical unit where mental health professionals may need to be involved.Keeping a client hospitalized without proper legal procedures and mental health evaluation could lead to legal repercussions for unlawful detainment.

B. Ensure the client's ex-partner is notified of the threat

This option involves notifying the potential victim about the threat made by the client. While it's important to ensure the safety of others, the nurse's legal duty primarily lies with protecting the confidentiality of the client's information. Without consent from the client or a legal obligation, such as mandatory reporting laws for imminent harm, the nurse cannot disclose the threat to the ex-partner.

C. Ask a friend or family member to monitor the client

While involving family or friends might provide support, it is not a sufficient or appropriate response to a threat of harm. It does not address the immediate risk posed to the ex-partner and may not comply with legal obligations.

D. Transfer the client to a mental health facility

Transferring the client to a mental health facility for further evaluation and treatment might be necessary, but it must be done through appropriate medical and legal channels. It addresses the need for a thorough mental health assessment and ensures that the client receives the necessary care.

A. A nurse did not clarify a client's prescription that was difficult to read resulting in a medication error B. A nurse posted private information on social media about a client who has substance use disorder C. A nurse placed a client in mechanical restraints without containing a prescription, resulting in injury D. A nurse threatened a client with physical harm after the client became verbally abuse to staff members

Correct Answer is A

Explanation

A. A nurse did not clarify a client's prescription that was difficult to read resulting in a medication error: This scenario describes a medication error due to the nurse's failure to exercise reasonable care by not clarifying a difficult-to-read prescription. This constitutes negligence, making it an example of an unintentional tort.

B. A nurse posted private information on social media about a client who has substance use disorder: This scenario involves a breach of confidentiality, which is a violation of the client's privacy rights. However, it is considered an intentional tort (specifically, invasion of privacy) rather than an unintentional tort.

C. A nurse placed a client in mechanical restraints without containing a prescription, resulting in injury: This scenario describes a failure to follow proper procedures (restraining a client without a prescription), resulting in harm to the client. This also constitutes negligence, making it an example of an unintentional tort.

D. A nurse threatened a client with physical harm after the client became verbally abusive to staff members: This scenario involves the nurse's intentional act of threatening physical harm to the client, which constitutes an intentional tort (assault).

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A nurse is admitting a client who has borderline personality disorder and is at risk for self-mutilation. Which of the following interventions should the nurse incorporate in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is caring for a client who tells the nurse about their intentions to harm an ex-partner. Which of the following actions is a legal duty of the nurse?

Correct Answer is B

Explanation

A charge nurse is planning an in-service for newly licensed nurses on tort law in mental health care. Which of the following scenarios should the charge nurse provide as an example of an unintentional tort?

Correct Answer is A

Explanation

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