A nurse is creating a plan of care for a client who has borderline personality disorder. Which of the following actions should the nurse include in the plan?
Assess the client for triggers of self-mutilating behavior.
Encourage the client to use splitting behaviors.
Assist the client in developing more dependent relationships.
Use sympathy when developing the therapeutic relationship with the client
The Correct Answer is A
A. Assess the client for triggers of self-mutilating behavior: Clients with borderline personality disorder are at risk for self-harm. Identifying triggers helps the nurse implement preventive strategies, provide timely interventions, and promote safety, which is a critical component of care planning.
B. Encourage the client to use splitting behaviors: Splitting, or viewing people as all good or all bad, is a maladaptive coping mechanism. Encouraging this behavior would worsen interpersonal relationships and is not therapeutic.
C. Assist the client in developing more dependent relationships: Borderline personality disorder involves unstable and intense interpersonal relationships. Promoting dependence is counterproductive; the goal is to foster healthy, balanced relationships and coping strategies.
D. Use sympathy when developing the therapeutic relationship with the client: Sympathy can reinforce maladaptive behaviors and dependency. Therapeutic relationships should focus on empathy, consistency, and clear boundaries rather than sympathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I wonder if the metal in my knee will show up in airport screenings.": This statement reflects curiosity and does not indicate a lack of understanding of the procedure or its risks.
B. "The physical therapy has not been working, so I will need to have the surgery.": The client is expressing a reason for pursuing surgery, which shows understanding of the indication and is appropriate.
C. "I look forward to being able to bend my knee again when I sit in a chair.": This statement demonstrates realistic expectations for postoperative outcomes, indicating understanding of the procedure’s benefits.
D. "I am thankful there are no serious complications from this type of surgery.": This statement indicates a misunderstanding of informed consent. The client shows a lack of awareness that all surgeries carry potential risks. The nurse should contact the surgeon to ensure the client fully understands possible complications before signing.
Correct Answer is D
Explanation
A. Insert an indwelling catheter if the client has not voided in 3 hr: Inserting an indwelling catheter involves an invasive procedure and requires clinical judgment and assessment for contraindications such as coagulopathy, which is common in acute liver failure. This task should remain with the registered nurse (RN) rather than being delegated to an LPN.
B. Obtain the abdominal girth now and every 4 hr: Measuring abdominal girth is a repetitive, non-invasive monitoring task that is within the scope of practice of assistive personnel. The RN should delegate this task to the AP, allowing the LPN to perform tasks requiring slightly higher clinical skills.
C. Assess and document the level of consciousness every hour: Assessing neurological status requires ongoing clinical judgment and the ability to detect subtle changes in mental status, which is critical in clients with hepatic encephalopathy. This responsibility cannot be delegated and must be performed by the RN.
D. Measure the amount of gastric drainage every 2 hrs: Monitoring and documenting the amount of NG tube drainage is within the scope of practice for an LPN. It requires basic assessment skills, accurate measurement, and reporting changes to the RN, making it appropriate to delegate to the LPN.
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