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

Answer and Explanation

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,

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Correct Answer is B

Explanation

A. Hyperexcitability is not typically associated with major depressive disorder. In fact, individuals with depression often experience a decrease in energy, motivation, and overall activity levels.

B. Significant change in weight.
Major depressive disorder (MDD) is often associated with changes in appetite and weight. Clients with MDD may experience either weight loss or weight gain. This can result from changes in eating habits related to the individual's emotional state.

C. Exaggerated response of pleasure to stimuli is not a characteristic finding in major depressive disorder. In contrast, individuals with depression may experience anhedonia, which is a reduced ability to experience pleasure from previously enjoyable activities.

D. Attention-seeking behavior is not a specific characteristic of major depressive disorder. Individuals with depression may withdraw socially and experience difficulties in concentration and attention.

A. I know you can read it yourself, but will you?" B. "We do this every day. Why are you so angry with me this morning? C. “I expect you to speak to me in a civil tone of voice." D. Fine. Here is the schedule. I expect you to be on time for your therapy sessions.

Correct Answer is C

Explanation

A. "I know you can read it yourself, but will you?" This response may escalate the situation and may not effectively address the inappropriate tone. It also has the potential to be perceived as confrontational.

B. "We do this every day. Why are you so angry with me this morning?" This response is somewhat confrontational and may not be as effective in setting clear boundaries. It also focuses on the client's emotion without directly addressing the inappropriate tone.

C. “I expect you to speak to me in a civil tone of voice."

Option C sets clear boundaries and communicates the expectation of respectful communication. Addressing the inappropriate tone of voice is important in working with individuals with borderline personality disorder. It reinforces the importance of maintaining a therapeutic and respectful interaction.

D. "Fine. Here is the schedule. I expect you to be on time for your therapy sessions." While this response provides the information, it doesn't address the issue of the client's disrespectful tone. It's important to address the inappropriate behavior while still providing necessary information.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

As part of the plan of care for a client with borderline personality disorder, the nurse reviews the day's schedule with him each morning. While doing so, the client states. "Why don't you shut up already! I can read it myself, you know!" Which of the following is an appropriate nursing response?

Correct Answer is C

Explanation

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