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 D

Explanation

A. "Have you thought about taking a sleeping pill?”: While this response acknowledges the client's report of feeling tired, it immediately jumps to suggesting a specific solution without exploring the underlying reasons for the fatigue. It also assumes that medication is the appropriate intervention without further assessment.

B. "Your fatigue will pass, and everything will be just fine.”: This response minimizes the client's concerns and feelings by dismissing them with a vague reassurance. It does not validate the client's experience or offer practical support.

C. "Do you have a family member who can assist you?”: This response acknowledges the client's difficulty with grocery shopping and offers a practical solution by asking about available support from family members. It encourages the client to explore their support system and potential resources.

D. "Let's discuss how to get you the help you need.”: This response demonstrates empathy, validation, and a willingness to collaborate with the client to address their needs. It acknowledges the client's concerns and offers to explore solutions together, empowering the client to be actively involved in their care.

A. “I place my child in time-out for 15 minutes when they misbehave.” B. "I send my child to their room for the time-out period." C. “I make use of time-out after gang three warnings." D. “I use a kitchen timer to mark the end of the time-out period.”

Correct Answer is D

Explanation

A. “I place my child in time-out for 15 minutes when they misbehave.”: This statement indicates a clear understanding of time-out as a form of discipline. Time-out is typically implemented for a short duration, often recommended to be around one minute per year of the child's age (e.g., 3 minutes for a 3-year-old). Placing the child in time-out for 15 minutes aligns with this understanding.

B. "I send my child to their room for the time-out period.": Sending a child to their room as a time-out may not be as effective, as the child may have access to toys, books, or other distractions in their room. Time-out is more effective when the child is placed in a designated, neutral area with minimal stimulation.

C. “I make use of time-out after giving three warnings.": While giving warnings before implementing time-out can be part of a structured discipline approach, the number of warnings may vary depending on the situation and the child's behavior. There is no universally recommended number of warnings before using time-out.

D. “I use a kitchen timer to mark the end of the time-out period.”: Using a kitchen timer to mark the end of the time-out period is a practical strategy that helps ensure consistency and fairness in the duration of time-out. It indicates an understanding of the need to adhere to a specific time frame for time-out.Using a timer helps ensure that the time-out duration is consistent and allows the child to know when the consequence ends.

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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?

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