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 B

Explanation

Choice A rationale

Clang associations involve the meaningless rhyming of words, often seen in psychotic disorders. While this indicates a disturbance in thought processes, it does not pose an immediate threat to the client or others, making it a lower priority compared to potential harm.

Choice B rationale

Command hallucinations are auditory hallucinations that instruct the client to perform an action, which can be harmful to themselves or others. This requires immediate attention and assessment to ensure the client's safety and the safety of those around them.

Choice C rationale

Neologisms are newly coined words or phrases whose meaning is only understood by the client. This reflects disorganized thinking but does not indicate an immediate crisis or safety risk, making it a less urgent concern than command hallucinations.

Choice D rationale

Ideas of reference are false beliefs that irrelevant occurrences or details in the world directly relate to oneself. While these can cause distress, they do not typically involve an immediate risk of harm, making this a lower priority compared to command hallucinations.

A. Maintain the confidentiality of the client's statement. B. Notify local law enforcement about the client's threat. C. Prevent the client from leaving the facility. D. Ask for the client's consent to notify the friend. E. Assess the client's intent and ability to carry out the threat.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale

Maintaining confidentiality is important in the nurse-client relationship; however, the duty to protect a third party from harm overrides confidentiality. When a client expresses intent to harm someone, the nurse has a legal and ethical obligation to take action to prevent that harm.

Choice B rationale

Notifying local law enforcement about the client's threat is a necessary step to ensure the safety of the potential victim. Law enforcement has the authority and resources to intervene and assess the situation, potentially preventing harm. This aligns with the duty to warn.

Choice C rationale

Preventing the client from leaving the facility is crucial to ensure the safety of the intended victim and to further assess the client's mental state. The client's stated intention to harm someone indicates a potential crisis that requires immediate intervention and prevents them from acting on their threat.

Choice D rationale

Asking for the client's consent to notify the friend is not the appropriate immediate action when there is a direct threat of harm. The safety of the potential victim takes precedence over the client's autonomy in this situation. Delaying notification could have serious consequences.

Choice E rationale

Assessing the client's intent and ability to carry out the threat is a critical step in determining the level of risk. This involves asking further questions about the specifics of their plan, their access to means, and their history of violence. This assessment will guide further intervention and safety measures. .

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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?