A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply)

Choice A reason: Support groups aid long-term coping in BPD, fostering peer connection, but don’t address immediate risks like self-harm, a frequent acute issue. This strategy builds skills over time, not safety now. It’s valuable but secondary to preventing injury, so it’s not the priority.

Choice B reason: Preventing self-inflicted injury is the priority in BPD, where impulsivity and emotional dysregulation often lead to cutting or worse. Safety (airway, breathing, circulation) extends to self-harm risk, requiring urgent measures like monitoring or contracts. This protects life, making it the top strategy.

Choice C reason: Awareness of thoughts and feelings supports therapy (e.g., DBT) in BPD, reducing reactivity long-term, but doesn’t prevent immediate self-harm risk. It’s a foundational skill, not an acute safeguard. Safety precedes insight, so this isn’t the priority now.

Choice D reason: Teaching assertiveness improves BPD relationships, reducing conflict, but doesn’t tackle the urgent self-harm threat. It’s a behavioral tool, effective over time, not in crisis. Injury prevention outweighs communication skills in immediate care planning, making this secondary.

Choice A reason: Veracity refers to truthfulness, such as providing accurate information about medications to the client. Supporting a refusal doesn’t inherently involve honesty or disclosure; it’s about respecting a decision. In this case, the nurse isn’t focusing on truth-telling but on honoring the client’s choice. Veracity applies to communication, not decision-making rights, so it doesn’t fit the nurse’s action of supporting the client’s refusal here.

Choice B reason: Autonomy is the ethical principle of respecting a client’s right to make their own decisions, including refusing treatment, if competent. By supporting the client’s refusal, the nurse upholds this self-determination, a cornerstone of patient-centered care. In bipolar disorder, unless the client poses an immediate danger, autonomy prevails. This action directly reflects the nurse prioritizing the client’s personal agency over forcing medication.

Choice C reason: Beneficence involves acting in the client’s best interest, often by encouraging treatment like medications to manage bipolar symptoms. Supporting refusal contradicts this, as it may not promote well-being in a clinical sense. The nurse’s action prioritizes choice over potential benefit, so beneficence isn’t the principle displayed here, despite its relevance to overall care goals.

Choice D reason: Justice ensures fair treatment and resource allocation among clients, unrelated to supporting an individual’s medication refusal. This principle applies to equity in care delivery, not personal decisions about treatment. The nurse’s action focuses on one client’s rights, not fairness across a group, making justice an incorrect fit for this scenario.