A nurse is discussing borderline personality disorder and the risk for self-harm with a newly licensed nurse. Which of the following situations should the nurse identify as the highest risk for self-harm?
When discharged from the hospital
When attending dialectical behavior therapy
When attending narrative therapy
When getting married
The Correct Answer is A
A. Individuals with borderline personality disorder (BPD) often experience intense and unstable emotions, impulsivity, and difficulties in regulating their emotions and behaviors. As a result, transitions, such as being discharged from the hospital, can be particularly challenging and may increase the risk of self-harm or suicidal behavior.
B. While dialectical behavior therapy (DBT) is an evidence-based treatment for BPD and focuses on teaching coping skills to manage emotions and reduce self-harming behaviors, attending therapy sessions may actually decrease the risk of self-harm for individuals actively participating in treatment.
C. Narrative therapy is another therapeutic approach that focuses on helping individuals reframe their life stories and experiences. While narrative therapy may be beneficial for some aspects of BPD treatment, it may not specifically address the immediate risk factors for self-harm.
D. Getting married may be a significant life event that brings about both positive and negative emotions, but it does not inherently indicate the highest risk for self-harm in individuals with BPD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. This response politely declines the client's request while explaining the reason behind it, which is hospital policy. It maintains professionalism and boundaries.
A nurses should not provide their home address to clients, as it can compromise their privacy and potentially lead to boundary violations or safety concerns.
B. It is important for the nurse to respond to the client's request for personal information in a professional and appropriate manner.
D. It is important for nurses to communicate boundaries firmly but respectfully, without causing unnecessary distress to the client.
Correct Answer is D
Explanation
D. In the immediate aftermath of a sexual assault, the primary focus of the SANE nurse is to ensure the safety and well-being of the client. This includes providing a safe and supportive environment for the client, assessing and treating any physical injuries, addressing immediate medical needs, and offering emotional support and crisis intervention.
A, B, and C involve aspects of legal procedures and involvement of law enforcement, but they may not be appropriate or feasible for every client in every situation. Additionally, the decision to involve law enforcement or pursue legal action should be made in collaboration with the client and should prioritize their safety, autonomy, and well-being.
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