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?

Choice A rationale:

Administering an anti-anxiety medication may not be the most appropriate first action. While medication can help to reduce anxiety, it does not address the underlying issue of suicidal ideation. In some cases, medications can even increase the risk of suicide, especially in the first few weeks of treatment.

Instituting mouth checks to assure the medication is swallowed is not a standard practice in this situation. It is more important to focus on ensuring the client's safety and providing emotional support.

Choice B rationale:

Informing the provider about the client's statement is important, but it is not the first action that the nurse should take. The priority is to ensure the client's immediate safety.

The provider can be informed after the client has been stabilized and is no longer at immediate risk of harm.

Choice C rationale:

Assuring that a staff member stays with the client at all times is the most important first step in ensuring the client's safety. This will help to prevent the client from acting on their suicidal thoughts and provide an opportunity for the nurse to assess the client's risk for suicide and intervene as needed.

It also allows the nurse to provide emotional support and reassurance to the client.

Choice D rationale:

Questioning the client about a suicide plan and method is important, but it should not be done until the client's safety has been ensured. Asking about a suicide plan can be triggering for some clients and may increase their risk of suicide.

It is important to approach this topic sensitively and only when the client is feeling safe and supported.

Choice A rationale:

Hemoglobin (Hgb) of 11 g/dL is slightly below the normal range for adult females (12-16 g/dL) but is not considered a critical value.

It may indicate mild anemia, which is common in bulimia nervosa due to factors such as poor nutrition and blood loss from self-induced vomiting. However, it would not typically be the most urgent finding requiring immediate intervention.

Choice B rationale:

Potassium of 2.8 mEq/L is significantly below the normal range (3.5-5.0 mEq/L) and is considered a critical value, indicating severe hypokalemia.

Hypokalemia is a potentially life-threatening electrolyte imbalance that can lead to cardiac arrhythmias, muscle weakness, respiratory failure, and even death.

It is a common complication of bulimia nervosa due to excessive vomiting and/or laxative abuse, which can lead to significant potassium loss.

Therefore, this finding would be the nurse's priority, necessitating immediate intervention to correct the hypokalemia and prevent potentially life-threatening complications.

Choice C rationale:

Serum chloride of 96 mEq/L is slightly below the normal range (98-106 mEq/L) but is not considered a critical value.

It may be associated with hypokalemia, as chloride and potassium are often lost together in conditions like bulimia nervosa.

However, it would not typically be the most urgent finding requiring immediate intervention.

Choice D rationale:

Serum amylase of 240 units/L is elevated above the normal range (30-110 units/L) but is not considered a critical value.

It may indicate inflammation of the pancreas (pancreatitis), which can be a complication of bulimia nervosa due to recurrent vomiting and/or alcohol abuse.

However, it would not typically be the most urgent finding requiring immediate intervention, especially in comparison to severe hypokalemia.