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 A

Explanation

A. Initiate one-to-one observation: This intervention involves assigning a staff member to directly observe and monitor the client continuously. It is crucial in ensuring the client's safety, particularly after a suicide attempt, as it helps prevent further harm or self-injury. Therefore, initiating one-to-one observation is the priority intervention.

B. Encourage the client to participate in group activities: Group activities may be beneficial for the client's overall well-being and recovery, but they are not the priority immediately after a suicide attempt. Safety and stabilization take precedence.

C. Administer an antidepressant: While antidepressant medication is an essential component of treatment for major depressive disorder, initiating medication is not the priority at this moment. The client's safety and stabilization should be addressed first before starting pharmacological treatment.

D. Set up a time for individual meetings with the client: Individual meetings and therapeutic interventions are important for addressing the client's mental health needs, but they are not the priority immediately after a suicide attempt. Safety measures should be implemented first.

A. Leading a group discussion with several clients who have schizophrenia and are dealing with tardive dyskinesia B. Screening college students who demonstrate manifestations of depressive disorder C. Training volunteers in an adult day care facility to communicate effectively with clients who have cognitive impairments D. Teaching personal coping skills to a group of adults whose parents have Alzheimer's disease

Correct Answer is B

Explanation

A. Leading a group discussion with several clients who have schizophrenia and are dealing with tardive dyskinesia: This activity involves providing support and education to individuals already experiencing a mental health condition and its associated complications. It falls under tertiary prevention, which focuses on minimizing the impact of established disease through treatment and rehabilitation.

B. Screening college students who demonstrate manifestations of depressive disorder: Screening individuals for depressive disorder symptoms, especially in a population known to be at risk (e.g., college students), aims to identify mental health issues early and intervene promptly. This falls under secondary prevention, which involves early detection and treatment to prevent the progression of a condition.

C. Training volunteers in an adult day care facility to communicate effectively with clients who have cognitive impairments: This activity focuses on improving communication and interaction skills with clients who have cognitive impairments. It falls under tertiary prevention, aiming to improve the quality of life and function of individuals already affected by cognitive impairment.

D. Teaching personal coping skills to a group of adults whose parents have Alzheimer's disease: This activity aims to empower individuals with coping skills to manage the stress and challenges associated with having a parent with Alzheimer's disease. It falls under tertiary prevention, focusing on minimizing the negative consequences of an already existing condition.

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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

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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