A nurse is caring for a client who has borderline personality disorder.
Which of the following actions should the nurse take?

Choice A rationale:

While role modeling healthy ways to express anger is important, it is not the priority when a client is being aggressive toward others. Safety is the primary concern.

Choice B rationale:

Assisting the client to explore techniques to reduce stress is a helpful intervention but is not the priority when the client is actively being aggressive toward others.

Choice C rationale:

Suggesting the client make a list of things that make him angry is a therapeutic intervention, but it is not the priority when the client's behavior poses an immediate threat to others.

Choice D rationale:

Asking the client if he intends to harm others is the priority because it assesses the immediate risk to the safety of others. This information is crucial for determining the appropriate interventions to ensure the safety of everyone in the facility. Depending on the client's response, the nurse can take further steps to manage the aggressive behavior. Safety is the top priority in such situations. .

The correct answer is Choice D: The client states that he is unable to eat more than once a day.

Choice D rationale: Inability to eat more than once a day raises concerns about the client's nutritional status and overall physical well-being. Malnutrition can lead to several health complications, such as impaired immunity, muscle wasting, and poor wound healing. Additionally, the stress of grieving may exacerbate these effects. Ensuring proper nutrition is essential for supporting the client's physical health, which in turn influences their emotional resilience and ability to cope with the grieving process.

Choice A rationale: Anger towards healthcare providers or other individuals involved in the deceased person's care is a common reaction during the grieving process. While addressing emotional aspects of grief is essential, prioritizing physical health concerns, such as inadequate nutrition, takes precedence in nursing care.

Choice B rationale: Guilt is a common emotion experienced by individuals who are grieving, and in this case, the client's guilt revolves around not spending enough time with their partner. However, assessing and addressing physical health concerns, like poor nutritional intake, are of higher priority in the client's care plan.

Choice C rationale: Recalling negative experiences during the marriage is a part of the client's grieving process, which involves reflecting on various aspects of the relationship with the deceased partner. This psychological aspect is significant but does not take priority over addressing physical health concerns, such as inadequate nutrition.