A nurse is caring for a client with borderline personality disorder (BPD) who has a history of self-injury and frequent hospitalizations. On the second day of admission, the client says. "You're the only nurse here who actually cares. Everyone else just wants to get rid of me." Later that day, the client is found with superficial cuts on their forearm. Which of the following is the most appropriate nursing response?
"I'm concerned about your safety. Let's talk about what led up to you hurting yourself today."
"You're just doing this to get attention, and that's not going to work here
"I'll notify the physician so they can change your medications"
"You know that hurting yourself is not acceptable. Let's talk about better ways to cope
The Correct Answer is A
Rationale:
A. This response is empathetic, supportive, and therapeutic. It validates the nurse’s concern for safety while inviting the client to explore the emotional triggers behind the self-injury, which is key in caring for individuals with BPD.
B. This response is judgmental and dismissive, which can damage the therapeutic relationship and escalate emotional distress in a client with BPD.
C. While medication review may be necessary later, immediately shifting focus to medication ignores the root emotional cause of the behavior and does not address the current crisis therapeutically.
D. Although setting limits is important, this response is overly directive and lacks empathy, which may come off as punitive rather than supportive.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. Serotonin syndrome is more commonly associated with SSRIs, SNRIs, or combining serotonergic agents—not typically with MAOIs alone.
B. MAOIs are not known to cause kidney damage or require salt and potassium restriction.
C. MAOIs can cause a hypertensive crisis when taken with tyramine-rich foods (e.g., aged cheese, cured meats). This is a critical teaching point for patient safety.
D. MAOIs are not typically associated with hypernatremia, and while weight changes can occur, increasing fluids is not a standard precaution.
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. To prove malpractice, it must be shown that a duty of care existed—meaning the nurse had a legal responsibility to provide care to the client.
B. A voluntary act is not a required legal element for malpractice; professional negligence can occur even without intentional acts.
C. Willful intent is not necessary for malpractice; it is based on negligence, not intent.
D. The family must show that the nurse breached the standard of care, meaning the nurse failed to act as a reasonable nurse would under similar circumstances.
E. There must be evidence that the client suffered harm as a direct result of the nurse’s breach in care.
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