A nurse is caring for a client in the outpatient mental health facility.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence

The nurse should include in the teaching to the client that behavioral therapy will

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and

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Correct answers: A,B,C

Rationale:

A. Hallucinations, specifically command auditory hallucinations, significantly elevate the risk of self-harm in psychiatric patients. These sensory perceptions may direct the individual to perform lethal acts. Impaired reality testing during such episodes overrides the client's typical coping mechanisms.

B. Depression is a primary mood disorder characterized by pervasive hopelessness and anhedonia, which are strong predictors of suicidality. Neurochemical imbalances in serotonin and norepinephrine pathways contribute to the suicidal ideation. The presence of a previous history increases risk.

C. Delusions involve fixed, false beliefs that can lead to extreme distress or perceived persecution. In cases of somatic or guilt-based delusions, the client may view suicide as a necessary escape or a form of atonement. Disorganized thinking complicates safety planning.

D. Catatonia is a psychomotor syndrome characterized by stupor, mutism, or purposeless hyperactivity, rather than active suicidal ideation. While it indicates severe mental illness, the physical immobility typically precludes the planning or execution of a suicide attempt. It is not an primary risk factor.

E. Tinnitus is the perception of noise or ringing in the ears and is generally a physical or neurological symptom. While chronic tinnitus can cause significant distress, it is not a psychiatric indicator of suicide risk in the clinical stem. It lacks direct correlation with self-harm.

A. Provide additional attention to the client. Clients with borderline personality disorder (BPD) often engage in self-harm as a way to cope with emotional distress or gain attention. While monitoring is important, excessive attention can reinforce maladaptive behaviors. A structured approach with consistent boundaries is more effective.
B. Apply mechanical restraints before administering medication. Restraints should only be used as a last resort when a client is an imminent danger to themselves or others. The first step in preventing self-mutilation is to implement less restrictive interventions, such as verbal contracts, distraction techniques, or therapy.
C. Obtain a verbal contract from the client. A verbal or written safety contract (also called a no-harm contract) is an effective tool for clients at risk for self-mutilation. It encourages the client to express distress verbally instead of self-harming and helps them develop alternative coping strategies. However, this should be used alongside close monitoring and therapy.
D. Limit staff members who work with the client. While consistency in care is important for clients with BPD, limiting staff interaction may reduce opportunities for therapeutic relationships. Instead, a consistent and structured approach from a trained care team helps build trust and emotional regulation skills.