A nurse is assisting with the care of a 45-year-old female client who is in the emergency department.

Exhibits

Click to highlight the findings from the nurses’ notes that indicate partner violence and should be reported to the provider.

Nurses’ Notes for Highlighting:
Bruises noted in various stages of healing to the face, bilateral arms, and abdomen. Laceration to the left cheek cleansed and covered with an adhesive bandage. Left shoulder cleansed, antiseptic ointment applied, and covered with gauze dressing. Client states, “I fell getting out of the shower and scraped my face and shoulder on the bathroom counter. I tried to catch myself when I fell, and that is how I broke my arm.” Client has been married for 22 years and has two children. Client works part-time and volunteers at a community center. Client is tearful, does not make eye contact, and only speaks when spoken to. Client requests not to notify their partner because they do not want them to have to miss work or worry. Client reports poor appetite and difficulty sleeping.

Choice A rationale

Encouraging communication with staff during self-harm urges is a crucial intervention for clients with borderline personality disorder. This allows for immediate support, redirection of focus, and the opportunity to implement coping strategies before an episode of self-harm occurs, aligning with the principles of dialectical behavior therapy often used for this disorder.

Choice B rationale

Assisting the client in developing healthy coping mechanisms for intense emotions is fundamental in managing borderline personality disorder. Individuals with this disorder often experience emotional dysregulation, and learning adaptive coping skills provides them with tools to manage distress, reduce impulsivity, and decrease the likelihood of self-harm.

Choice C rationale

Advising the client to avoid expressing feelings assertively is countertherapeutic. Clients with borderline personality disorder may struggle with expressing emotions appropriately. Encouraging avoidance can lead to suppressed feelings, potential emotional outbursts, and increased risk of self-harm. Assertive communication skills should be fostered.

Choice D rationale

Offering additional attention only when self-mutilating behaviors occur can inadvertently reinforce these behaviors. This approach can create a pattern where the client engages in self-harm to gain attention, rather than learning healthier ways to seek support and manage their emotions. Consistent and proactive support is more effective.

Choice A rationale

Expressing increased comfort with their altered appearance in the mirror indicates a positive step towards acceptance of the changed body image following a mastectomy. This suggests the client is beginning to integrate the physical changes into their self-perception and is moving towards adaptation.

Choice B rationale

Worrying about a partner's perception, while a normal concern, does not necessarily indicate acceptance of the altered body image. It suggests preoccupation with external validation and potential insecurity about the physical changes' impact on the relationship, rather than internal acceptance.

Choice C rationale

Preferring loose-fitting clothing to conceal the changes suggests a desire to hide the altered body rather than accepting it. This behavior indicates a lack of comfort and potentially negative feelings about the mastectomy's physical consequences, hindering the process of body image adaptation.

Choice D rationale

Focusing on recovery and adapting to the changes demonstrates a proactive and accepting attitude towards the altered body image. This statement indicates a willingness to integrate the changes into their life and move forward, signifying a positive adjustment to their post-mastectomy self-perception.