A nurse is assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following Interventions is the nurse's priority?
Exploring reasons for her behavior
Providing strategies for redirecting violent behavior
Encouraging the client to talk about her feelings
Protecting the client from self-harm behavior
The Correct Answer is D
A. Exploring reasons for her behavior is important for understanding the underlying issues, but the immediate priority is to ensure the client's safety.
B. Providing strategies for redirecting violent behavior is a relevant intervention, but it is not the priority in this situation. Safety concerns related to self-harm take precedence.
C. Encouraging the client to talk about her feelings is a valuable therapeutic intervention, but in the context of borderline personality disorder, the immediate priority is to address the risk of self-harm. Once the client's safety is ensured, exploring feelings and developing coping strategies can be part of the ongoing therapeutic process.
D. Protecting the client from self-harm behavior is the priority because individuals with borderline personality disorder are at an increased risk of engaging in self-harming behaviors,
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I should sit on the side of the bed before standing up in the morning."
Amitriptyline is a tricyclic antidepressant that can cause orthostatic hypotension, a sudden drop in blood pressure upon standing. To minimize the risk of dizziness or fainting, clients taking amitriptyline should be advised to sit on the side of the bed for a few moments before standing up, especially in the morning when orthostatic changes may be more pronounced.
B. "I may experience an increased libido." This statement is not related to the common side effects of amitriptyline. Changes in libido are not typically associated with this medication.
C. "I will avoid drinking caffeinated beverages." While it's generally a good idea to limit caffeine intake, this statement is not a specific instruction related to amitriptyline. However, reducing caffeine consumption can be beneficial because amitriptyline may enhance the stimulant effects of caffeine.
D. "I can no longer eat pepperoni pizza." This statement is not directly related to amitriptyline. There are no specific dietary restrictions associated with amitriptyline use, and the client can continue to eat pepperoni pizza unless there are individual dietary concerns or interactions with other medications.
Correct Answer is D
Explanation
A. Using opioids to treat hallucinations is not a common reason, as opioids are not typically prescribed for this purpose. Hallucinations might be indicative of another underlying mental health condition that needs assessment and appropriate treatment.
B. Witnessing parents using drugs or alcohol to cope is a risk factor for substance use disorders, but it does not directly explain the client's initiation of opioid use. There may be other contributing factors, such as pain or anxiety.
C. Using opioids to promote sleep and rest is a possibility, especially if the client has chronic pain or anxiety affecting their sleep. Opioids can have sedative effects, which might be appealing to individuals experiencing sleep difficulties. However, treating pain and anxiety is often a primary reason for opioid use in such cases.
D. To treat pain and ease anxiety.
Chronic back pain due to a gymnastics injury and anxiety are identified as pre-existing conditions. The client may have started using opioids to manage chronic pain and potentially as a way to cope with anxiety. Opioids are often prescribed for pain relief, and individuals may misuse them to self-medicate emotional distress.
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