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. Flight of ideas: This speech pattern is characterized by rapidly shifting from one idea to another that are unrelated or loosely related. It often reflects disorganized thinking seen in conditions like mania or schizophrenia.

B. Word salad: Word salad refers to a jumble of words and phrases that lack coherence or meaning. It typically involves random or illogical word combinations that do not make sense when put together.

C. Neologisms: Neologisms are newly created words or phrases that have meaning only to the individual. They may be completely invented or may have personal significance to the speaker but are not understood by others.

D. Clang associations: Clang associations involve the stringing together of words based on similar sounds rather than logical connections. It often results in rhyming or repetitive speech patterns that lack coherence.

A. "Has a family member indicated that you should cut down on your drinking?” B. “Have you had a glass of wine in the last week?” C. “Do you drink alcohol with your friends?” D. "Do you enjoy drinking alcohol?”

Correct Answer is A

Explanation

A. "Has a family member indicated that you should cut down on your drinking?”: This question assesses whether there have been any external concerns or criticisms related to the client's alcohol consumption, which is a common feature in alcohol use disorder.

B. “Have you had a glass of wine in the last week?”: While this question assesses recent alcohol consumption, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.

C. “Do you drink alcohol with your friends?”: This question addresses social drinking behavior but does not specifically focus on the potential for alcohol use disorder or problematic drinking patterns.

D. "Do you enjoy drinking alcohol?”: While enjoyment of alcohol may be relevant to the overall assessment, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.

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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 B

Explanation

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Correct Answer is A

Explanation

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