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. Insomnia B. Hypothermia C. Hyperreflexia D. Diaphoresis E. Slurred speech F. Anxiety

Correct Answer is ["A","C","D","F"]

Explanation

Choice A rationale: Insomnia

Withdrawal from stimulants like methamphetamine often leads to insomnia, agitation, and restlessness. The body's central nervous system experiences difficulty regulating sleep due to prior overstimulation, making restful sleep challenging.

Choice B rationale: Hypothermia

Hypothermia is not a typical withdrawal symptom of heroin or methamphetamine. Instead, opioid withdrawal more commonly causes hyperthermia (increased body temperature) due to autonomic instability.

Choice C rationale: Hyperreflexia

Hyperreflexia (exaggerated reflexes) is often seen in stimulant withdrawal, including methamphetamine withdrawal, due to neurological overactivity as the body adjusts to the absence of stimulants.

Choice D rationale: Diaphoresis

Profuse sweating (diaphoresis) is a classic symptom of heroin withdrawal, as the body struggles to regulate temperature and autonomic function after stopping opioid use.

Choice E rationale: Slurred speech

Slurred speech is more common in intoxication rather than withdrawal. Opioid withdrawal generally results in restlessness, anxiety, and muscle aches rather than speech impairment.

Choice F rationale: Anxiety

Anxiety is a significant withdrawal symptom for both heroin and methamphetamine, as withdrawal disrupts neurotransmitter balance, particularly dopamine and serotonin regulation.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["A","C","D","F"]

Explanation

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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?