A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care?

Implement measures to prevent intentional self-inflicted injury.

Discuss the appropriate use of assertive behavior with the client.

Encourage the client to attend weekly support group meetings.

Assist the client to maintain awareness of her thoughts and feelings.

Answer and Explanation

The Correct Answer is A

A. Implement measures to prevent intentional self-inflicted injury:
This choice is the priority. Individuals with borderline personality disorder are at an increased risk of self-harm and suicidal behaviors. Implementing measures to prevent intentional self-inflicted injury, such as close monitoring, removing potentially harmful objects, and creating a safe environment, is crucial to ensuring the client's safety and well-being.

B. Discuss the appropriate use of assertive behavior with the client:
Teaching assertive behavior is an important aspect of therapy for individuals with borderline personality disorder. Learning to express emotions and needs in a healthy, assertive manner can improve their interpersonal skills and relationships. However, this choice is secondary to ensuring the client's safety. Safety concerns need to be addressed before moving on to other therapeutic interventions.

C. Encourage the client to attend weekly support group meetings:
Support group meetings can provide valuable social support and a sense of belonging for individuals with borderline personality disorder. Being part of a supportive community can offer understanding and coping strategies. While this is a beneficial intervention, it is not the priority. Safety concerns and addressing self-harm risk take precedence.

D. Assist the client to maintain awareness of her thoughts and feelings:
Developing self-awareness and emotional regulation skills is essential in managing borderline personality disorder. Techniques such as mindfulness and dialectical behavior therapy (DBT) can help individuals become more aware of their thoughts and emotions. While important for long-term management, this intervention is not the priority when immediate safety concerns are present. Safety should always be the first focus of care.

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Correct Answer is C

Explanation

A. Reaction Formation:
Reaction formation is a defense mechanism where an individual expresses feelings or behaviors that are the opposite of their true feelings or impulses. For example, someone who harbors unconscious aggressive feelings might display exaggerated friendliness and kindness. In the given scenario, the behavior of the newly licensed nurse is not contradictory to their true feelings; they are imitating the charge nurse willingly.

B. Suppression:
Suppression is a conscious effort to push down or hide certain thoughts or feelings. Unlike repression (which is unconscious), suppression involves a deliberate choice not to think about or dwell on certain emotions or thoughts. In the scenario, the behavior of the newly licensed nurse is not an example of suppression because they are not consciously trying to hide their actions.

C. Identification:
Identification is a defense mechanism where an individual unconsciously models their behavior, feelings, or attitudes after those of someone else, especially someone they perceive as powerful or significant. In this scenario, the newly licensed nurse is imitating the behaviors of the charge nurse, which is an example of identification.

D. Compensation:
Compensation is a defense mechanism where an individual consciously or unconsciously covers up weaknesses, frustrations, or feelings of inadequacy by emphasizing strengths or seeking to excel in other areas. It involves making up for a perceived lack by putting extra effort into another aspect of life. The scenario does not describe the newly licensed nurse compensating for any perceived weakness; they are simply imitating the charge nurse's behavior.

A. "Since injuring my knee. I've decided to become the team manager." B. "Since my mom died, I focus all my attention on my grades." C. “I didn't tell the teacher about the bullying because it wouldn't have changed anything." D. "I'm not even going to think about writing that thesis paper until after prom."

Correct Answer is A

Explanation

A. "Since injuring my knee, I've decided to become the team manager."
Option A represents an adaptive use of the ego defense mechanism known as sublimation. Sublimation is a process in which a person channels potentially negative or harmful impulses or feelings into more socially acceptable and constructive activities. In this case, the adolescent with the injured knee is using the opportunity to become the team manager, which is a positive and constructive way to stay engaged with the team despite the setback of the injury.

B. "Since my mom died, I focus all my attention on my grades."
This is an example of reaction formation, a defense mechanism where someone overemphasizes the opposite of their true feelings. In this case, the individual might be hiding or avoiding their grief by focusing on grades.

C. "I didn't tell the teacher about the bullying because it wouldn't have changed anything."
This is an example of rationalization, where the individual provides a logical-sounding but potentially inaccurate explanation for their actions. It can be a defense mechanism to justify or make more acceptable one's choices.

D. "I'm not even going to think about writing that thesis paper until after prom."
This is an example of procrastination or avoidance, which is not an ego defense mechanism but a coping or time-management strategy. It doesn't represent an adaptive use of a defense mechanism in this context.

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A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care?

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