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 ["B","D","E"]

Explanation

A. The client follows a strict routine of daily activities:
This choice is less likely to be a risk factor for borderline personality disorder. BPD is characterized by impulsivity and difficulties in maintaining stable routines or relationships. Individuals with BPD often struggle with adhering to strict routines due to impulsive behaviors and emotional dysregulation.

B. The client reports having a substance use disorder:
Individuals with borderline personality disorder often struggle with impulse control and emotional regulation. Substance use can be a way for them to cope with intense emotions and mood swings. The presence of a substance use disorder can indicate a higher risk for borderline personality disorder due to these coping mechanisms.

C. The client is a twin:
Being a twin, in itself, is not a direct risk factor for borderline personality disorder. However, if there are genetic or environmental factors contributing to the disorder, both twins might be at risk due to shared genetic material and upbringing. It's essential to consider the specific familial and environmental context when assessing the risk in twins.

D. The client's mother abandoned him as a child:
Early childhood experiences play a significant role in the development of personality disorders, including borderline personality disorder. Abandonment, neglect, or other forms of trauma can disrupt a child's sense of security and trust, leading to difficulties in regulating emotions and forming stable relationships later in life.

E. The client's father has an impulse control disorder:
Growing up in an environment where a parent has an impulse control disorder can create an unstable living situation. Inconsistent parenting and unpredictable behaviors can contribute to emotional instability and difficulties in regulating impulses, which are hallmark features of borderline personality disorder.

A. Obtain a prescription for restraints on an as-needed basis. B. Have the provider assess the client within 1 hr after applying the restraints. C. Request that the provider renew the prescription for restraints every 8 hr. D. Evaluate the client hourly while the restraints are applied.

Correct Answer is B

Explanation

A. Obtain a prescription for restraints on an as-needed basis:
Restraints should never be used on an as-needed basis without a specific, individualized order from a healthcare provider. Restraints are a significant intervention that should only be used when necessary, and they require a clear prescription outlining the duration, reason, and method of application.

B. Have the provider assess the client within 1 hour after applying the restraints:
This option is the correct choice. It is crucial to involve the healthcare provider promptly after restraints are applied. The provider needs to assess the patient's physical and mental status, and the appropriateness of the restraints, and consider alternatives or modifications to the intervention. Regular assessments ensure the patient's safety and well-being while addressing the initial reason for applying restraints.

C. Request that the provider renew the prescription for restraints every 8 hours:
Restraining a patient every 8 hours without ongoing assessment and a clear clinical rationale is inappropriate and goes against best practices. Restraints should only be used when absolutely necessary and should be reevaluated frequently. Requesting a renewal on a fixed schedule without considering the patient's changing condition is not a safe or ethical approach.

D. Evaluate the client hourly while the restraints are applied:
While regular monitoring of a patient in restraints is essential, evaluating the patient every hour might not be sufficient, especially in the early stages after the application of restraints. The patient should be continuously monitored, with assessments conducted more frequently, especially immediately after applying the restraints, to ensure their safety and well-being.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a young adult client who has a new diagnosis of borderline personality disorder. Which of the following findings should the nurse identify as risk factors for this disorder? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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