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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Levothyroxine for hypothyroidism: Levothyroxine is a thyroid hormone replacement that is considered safe in pregnancy. Proper management of maternal hypothyroidism is essential for fetal neurodevelopment, and it does not pose teratogenic risk.
B. Phenytoin for seizure disorder: Phenytoin is an antiepileptic drug associated with fetal hydantoin syndrome, which can cause congenital malformations such as cleft lip, cardiac defects, and skeletal abnormalities. It carries a known risk for teratogenic effects, requiring careful monitoring and potential consideration of alternative therapies.
C. Magnesium oxide for constipation: Magnesium oxide is generally safe for use during pregnancy for the treatment of constipation. It does not have teratogenic effects and is considered appropriate for maternal use when needed.
D. Ferrous sulfate for chronic anemia: Iron supplementation is essential in pregnancy to prevent maternal anemia and support fetal growth. Ferrous sulfate is safe and does not cause congenital malformations, making it an appropriate therapy during pregnancy.
Correct Answer is A
Explanation
A. Determine the client's living situation: Assessing the client’s home environment is the first step in evaluating eligibility for home assistance. Understanding factors such as accessibility, caregiver support, and safety needs provides a foundation for planning appropriate interventions and resources tailored to the client’s circumstances.
B. Problem solve with the client: Problem-solving is an important part of care planning but should occur after the nurse has gathered essential information about the client’s living situation. Without this initial assessment, problem-solving may not address the client’s actual needs.
C. Offer community resources to the client: Providing information about resources is helpful but premature without first understanding the client’s living conditions and specific support requirements. This ensures recommendations are relevant and actionable.
D. Assist the client with decision-making: Supporting decision-making is crucial for client-centered care but comes after the nurse has assessed the client’s situation and presented appropriate options. Initial assessment informs safe and effective guidance.
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