A nurse is caring for a client who has borderline personality disorder (BPD). What should the nurse monitor in the client’s Medication Administration Record?
Medication compliance.
Adverse reactions.
Medication interactions.
Dosage adjustments.
The Correct Answer is A
Choice A rationale:
Medication compliance is crucial in the management of BPD because:
Instability and Impulsivity: Individuals with BPD often struggle with impulsivity and unstable moods, which can lead to inconsistent medication adherence. They may forget to take their medications, take them at the wrong times, or stop taking them altogether when they feel better or worse. This can disrupt the therapeutic effects of the medications and increase the risk of relapse or worsening symptoms.
Multiple Medications: BPD is often treated with a combination of medications, such as mood stabilizers, antidepressants, and antipsychotics. Each medication has its own unique dosing schedule, side effects, and potential for interactions. Monitoring compliance ensures that the client is taking all medications as prescribed, reducing the risk of adverse events and optimizing treatment outcomes.
Mental Health Stigma: Unfortunately, mental health stigma can contribute to medication noncompliance. Individuals with BPD may feel ashamed or embarrassed about their diagnosis, leading them to hide their medication use or avoid taking medications altogether. By openly discussing medication compliance and addressing any concerns, nurses can help reduce stigma and promote adherence.
Therapeutic Relationship: A strong therapeutic relationship between the nurse and client is essential for promoting medication compliance in BPD. Nurses can foster trust and open communication by:
Actively listening to the client's concerns about medications.
Providing clear and concise education about the purpose and benefits of medications.
Collaborating with the client to develop a medication regimen that fits their lifestyle and preferences.
Regularly assessing medication adherence and addressing any barriers to compliance.
Offering support and encouragement to the client throughout the treatment process.
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Related Questions
Correct Answer is D
Explanation
The correct answer is D. Limit the client’s participation in group activities.
Explanation:
Clients with schizophrenia and paranoia may struggle in large group settings, where they could misinterpret interactions, feel threatened, or become agitated. Gradual integration into smaller, structured groups is typically recommended, rather than full exclusion, but limiting group participation can help reduce anxiety and prevent aggressive behaviors.
Why the other options are incorrect:
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A. Place the client in seclusion if she is experiencing visual hallucinations – Seclusion is only used if the client poses a danger to themselves or others. Experiencing hallucinations alone does not warrant seclusion.
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B. Minimize staff supervision of the client’s interactions with others – Increased supervision is necessary to ensure safety and monitor behavioral cues that may indicate escalating aggression.
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C. Directly tell the client that delusions are not real – Confronting delusions outright can lead to agitation. Instead, acknowledge the client’s feelings while gently redirecting toward reality-based interactions.
Correct Answer is B
Explanation
Choice A rationale:
Asking "Why do you believe you are hearing voices?" is not a suitable response because it challenges the client's reality and can make them feel defensive or invalidated. It's important to validate the client's experience and avoid questioning the reality of their hallucinations.
It can also imply that the client is somehow responsible for their hallucinations, which can be stigmatizing and distressing.
It's more helpful to focus on the content of the hallucinations and how they are affecting the client, rather than on the cause of the hallucinations.
Choice B rationale:
Asking "What are the voices instructing you to do?" is a suitable response because it allows the nurse to assess the content of the hallucinations and the potential for harm.
This information can be used to develop a safety plan and to help the client manage their symptoms.
It also demonstrates to the client that the nurse is taking their concerns seriously and is interested in understanding their experience.
Choice C rationale:
Telling the client "You need to comprehend that there are no voices" is not a suitable response because it is dismissive of the client's experience and can make them feel like they are not being heard or understood.
It's important to remember that hallucinations are very real to the person experiencing them, and telling them that they are not real is not helpful.
It can also damage the therapeutic relationship between the nurse and the client.
Choice D rationale:
Asking "Are the voices familiar to you?" is not a suitable initial response because it is not directly relevant to the client's safety or to the assessment of their symptoms.
While it may be helpful to gather information about the nature of the voices at some point, the priority is to assess the potential for harm and to develop a safety plan.
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