A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?

Choice A reason: While attending support group meetings can be beneficial for individuals with borderline personality disorder by providing a sense of community and shared experiences, it is not the immediate priority. Support groups can offer emotional support and coping strategies, but they do not directly address the urgent safety concerns that may arise with this disorder.

Choice B reason: Discussing the use of assertive behavior is an important aspect of therapy for individuals with borderline personality disorder, as it can help them express their needs and feelings in a healthy way. However, this is part of a long-term strategy for improving interpersonal relationships and communication skills, rather than an immediate safety concern.

Choice C reason: Implementing measures to prevent intentional self-inflicted injury is the priority when planning care for a client with borderline personality disorder. Due to the high risk of self-harm and suicidal behaviors associated with this disorder, ensuring the client's safety is the most critical and immediate concern. This may include creating a safe environment, developing a crisis plan, and closely monitoring the client.

Choice D reason: Assisting the client to maintain awareness of their thoughts and feelings is a key component of therapy for borderline personality disorder, as it can help them understand and manage their emotions more effectively. However, while this is important for long-term management, it is not the immediate priority when compared to ensuring the client's safety.

Choice A reason: Identifying the client's stressors is a crucial step in managing agitation. Understanding what triggers the client's distress can help the nurse to address the underlying issues and de-escalate the situation.

Choice B reason: Using short, simple sentences can help to communicate effectively with an agitated client. It ensures that the client can process the information without being overwhelmed, which is important for calming the situation.

Choice C reason: Speaking to the client in a loud voice is not recommended as it may escalate the situation. It's important to maintain a calm and soothing tone to avoid further agitation.

Choice D reason: Requesting that security guards restrain the client should be a last resort, only if the client poses an immediate threat to themselves or others. Less restrictive measures should be attempted first.

Choice E reason: Standing directly in front of an agitated client can be perceived as confrontational. It's better to maintain a non-threatening stance and ensure there is enough space to allow the client to feel safe.