A nurse is contributing to the plan of care for a client who has borderline personality disorder.
Which of the following interventions should the nurse recommend?

Encourage the client to communicate with staff when feeling urges for self-harm.

Assist the client in developing healthy coping mechanisms for intense emotions.

Advise the client to avoid expressing their feelings assertively.

Offer the client additional attention only when self-mutilating behaviors occur.

Answer and Explanation

Correct Answer : A,B

Choice A rationale

Encouraging communication with staff during self-harm urges is a crucial intervention for clients with borderline personality disorder. This allows for immediate support, redirection of focus, and the opportunity to implement coping strategies before an episode of self-harm occurs, aligning with the principles of dialectical behavior therapy often used for this disorder.

Choice B rationale

Assisting the client in developing healthy coping mechanisms for intense emotions is fundamental in managing borderline personality disorder. Individuals with this disorder often experience emotional dysregulation, and learning adaptive coping skills provides them with tools to manage distress, reduce impulsivity, and decrease the likelihood of self-harm.

Choice C rationale

Advising the client to avoid expressing feelings assertively is countertherapeutic. Clients with borderline personality disorder may struggle with expressing emotions appropriately. Encouraging avoidance can lead to suppressed feelings, potential emotional outbursts, and increased risk of self-harm. Assertive communication skills should be fostered.

Choice D rationale

Offering additional attention only when self-mutilating behaviors occur can inadvertently reinforce these behaviors. This approach can create a pattern where the client engages in self-harm to gain attention, rather than learning healthier ways to seek support and manage their emotions. Consistent and proactive support is more effective.

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Correct Answer is A

Explanation

Choice A rationale

"Tell me about your baby. Where is she now?" is the priority response because it immediately assesses the safety and well-being of the baby. The mother's statement suggests potential distress and inability to cope, raising concerns about the infant's care.

Choice B rationale

"Do you have a friend who could help you?" explores the client's support system, which is important but secondary to ensuring the immediate safety of the baby.

Choice C rationale

"Having a newborn must be stressful" is an empathetic statement that acknowledges the client's feelings. While therapeutic, it does not address the potential immediate needs and safety of the baby.

Choice D rationale

"Do you have other children?" gathers information about the client's family situation, but it is not the priority when there is a potential concern about the well-being of the newborn. .

A. "If the provider prescribes medication, I will have to administer it.”. B. "You agreed to take medication when you decided to be admitted.”. C. "You have the right to refuse to take the medication.”. D. "I can make a list of the medications that you don't want to take.”. . . .

Correct Answer is C

Explanation

Choice A rationale

"If the provider prescribes medication, I will have to administer it" is an inaccurate statement regarding a voluntarily admitted client's rights. Voluntarily admitted clients generally retain the right to refuse medication, even if it is prescribed by a provider. This response undermines the client's autonomy.

Choice B rationale

"You agreed to take medication when you decided to be admitted" is also generally inaccurate for voluntary admissions. While the client may agree to a treatment plan that includes medication, voluntary admission itself does not automatically equate to mandatory medication administration. The client still has the right to refuse.

Choice C rationale

"You have the right to refuse to take the medication" is the correct and most appropriate response. Voluntarily admitted clients retain their right to informed consent and the right to refuse treatment, including medication, unless there is a specific court order indicating otherwise or an imminent risk of harm to themselves or others. This response respects the client's autonomy.

Choice D rationale

"I can make a list of the medications that you don't want to take" is a helpful action in acknowledging the client's concern and preferences. However, it does not directly address the client's question about their right to refuse medication. While documenting preferences is important, the initial response should clearly state their right to refusal. .

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A nurse is contributing to the plan of care for a client who has borderline personality disorder.Which of the following interventions should the nurse recommend?

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A nurse is contributing to the plan of care for a client who has borderline personality disorder.
Which of the following interventions should the nurse recommend?