A nurse is in the day room of an acute care mental health facility with a group of clients who are watching television.

Suddenly, one of the clients jumps up screaming and runs out of the room.

What should the nurse do next?

Choice A rationale:

Providing strategies for redirecting violent behavior is a relevant intervention for individuals with borderline personality disorder, as they may exhibit impulsive and aggressive behaviors. However, it is not the priority in this situation. The immediate focus should be on ensuring the client's safety and preventing self-harm.

Strategies for redirecting violent behavior can be implemented once the client's safety is stabilized. These strategies might include:

De-escalation techniques

Distraction techniques

Time-outs

Setting clear boundaries and expectations

Teaching coping skills for managing anger and frustration Choice B rationale:

Exploring reasons for her behavior is important for understanding the underlying issues that contribute to the client's selfharming behaviors. However, it is not the priority in the initial phase of treatment. The focus should be on ensuring the client's immediate safety and preventing harm.

Once the client is stabilized, exploring the reasons for her behavior can be done through individual therapy, group therapy, or other therapeutic modalities. This exploration can help the client gain insight into her patterns of thinking, feeling, and behaving, and develop healthier coping mechanisms.

Choice C rationale:

Encouraging the client to talk about her feelings is a valuable therapeutic intervention, as it can help the client express and process emotions in a healthy way. However, it is not the priority in the context of borderline personality disorder, where the risk of self-harm is high.

Encouraging emotional expression can be beneficial once the client's safety is ensured and appropriate coping skills are in place. This can be done through individual therapy, journaling, or other expressive arts therapies.

Choice D rationale:

Protecting the client from self-harm behavior is the nurse's priority when working with a client who has borderline personality disorder. This is because individuals with this disorder have a high risk of engaging in self-injurious behaviors, such as cutting, burning, or overdosing on medication.

It is important to implement various safety measures to protect the client, including:

Close observation and monitoring

Removal of potentially harmful objects from the environment

Clear communication of expectations and boundaries

Collaboration with the healthcare team to develop a comprehensive safety plan

Regular assessment of suicide risk

Choice A rationale:

Establishing rapport with the client is essential when caring for someone experiencing acute anxiety. It creates a foundation of trust and understanding, which can help the client feel more comfortable and willing to engage in therapeutic interventions. Here's a detailed explanation of why rapport is crucial in this context:

Reduces Anxiety: A strong rapport can help to reduce the client's anxiety by fostering a sense of safety and security. When a client feels understood and supported, it can help to calm their nervous system and decrease the intensity of their anxiety symptoms.

Increases Communication: Effective communication is essential for identifying the cause of anxiety and developing appropriate interventions. When a nurse has a good rapport with a client, the client is more likely to be open and honest about their thoughts, feelings, and experiences. This can lead to a more accurate assessment and a more effective treatment plan.

Improves Cooperation: Clients who have a good rapport with their nurse are more likely to cooperate with treatment recommendations. This is because they trust the nurse's expertise and feel confident that the nurse has their best interests in mind.

Enhances Coping: A strong therapeutic relationship can help to improve the client's coping skills. The nurse can provide support, encouragement, and guidance as the client learns to manage their anxiety.

Techniques for establishing rapport:

Active listening: Pay close attention to the client's verbal and nonverbal communication, demonstrating that you are genuinely interested in what they have to say.

Empathy: Show understanding and compassion for the client's experiences and feelings.

Respect: Treat the client with dignity and respect, acknowledging their autonomy and choices.

Genuineness: Be authentic and honest in your interactions with the client.

Trustworthiness: Demonstrate that you are reliable and dependable, and that you will maintain confidentiality.

Cultural sensitivity: Be aware of and respect the client's cultural background and beliefs.

Choice B rationale:

Avoiding eye contact can convey disinterest, disrespect, or dishonesty, which can further heighten anxiety. Maintaining appropriate eye contact demonstrates attentiveness, empathy, and understanding, which can help to build trust and rapport.

Choice C rationale:

Speaking in a high-pitched voice can be perceived as agitated or tense, which can exacerbate the client's anxiety. It's essential to speak in a calm, soothing, and reassuring tone to promote relaxation and a sense of safety.

Choice D rationale:

Validating the client's feelings and identifying the cause of anxiety are crucial steps in effective anxiety management.

Validation helps the client feel understood and accepted, while identifying the cause can guide the development of appropriate interventions to address the underlying triggers.