A nurse on a mental health unit is caring for a client.

Exhibits

The nurse is contributing to the plan of care for the client. Which of the following actions should the nurse recommend? (Select all that apply.)

Establish consequences for unacceptable behaviors.

Encourage the client to verbalize their feelings.

Provide clear boundaries for behavior toward peers and staff members.

Determine if the client is having thoughts of harming themselves or others.

Bargain with the client when setting behavioral expectations.

Instruct the client on coping mechanisms and relaxation techniques.

Answer and Explanation

Correct Answer : A,B,C,D,F

A. Establish consequences for unacceptable behaviors: This approach helps the client understand the impact of their actions and encourages accountability, which is important for behavior management in borderline personality disorder.
B. Encourage the client to verbalize their feelings: Encouraging the expression of feelings helps the client develop better emotional awareness and communication skills, which are essential for managing their emotions and interpersonal relationships.
C. Provide clear boundaries for behavior toward peers and staff members: Setting clear boundaries is crucial for maintaining a safe environment and helps the client understand acceptable behavior, promoting healthier interactions with others.
D. Determine if the client is having thoughts of harming themselves or others: Regular assessment of self-harm and harm to others is essential, especially given the client's history of self-injury and a recent suicide attempt. This ensures the client's safety and allows for timely intervention if needed.
E. Instruct the client on coping mechanisms and relaxation techniques: Teaching coping strategies and relaxation techniques equips the client with tools to manage anxiety and emotional distress, which are common in borderline personality disorder.
F. Bargain with the client when setting behavioral expectations: Bargaining may reinforce manipulative behaviors and does not provide the structure that clients with borderline personality disorder often need. Instead, establishing firm and consistent expectations without negotiation is more beneficial for their treatment.

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Correct Answer is D

Explanation

A. Dissociative amnesia: This condition involves an inability to recall important personal information, usually related to trauma or stress. The symptoms described do not align with memory loss but rather with a physical sensation (numbness) that interferes with driving.
B. Depersonalization/derealization disorder: This disorder is characterized by persistent feelings of detachment from oneself or one's surroundings. The client's reported symptoms do not reflect feelings of detachment but rather a physical manifestation that affects their ability to drive.
C. Factitious disorder: This disorder involves intentionally producing or feigning symptoms to assume the sick role. The client’s symptoms are not self-induced for the purpose of gaining attention or sympathy, which is a key feature of factitious disorder.
D. Functional neurological symptom disorder: This condition is characterized by neurological symptoms, such as numbness or weakness, that cannot be explained by medical conditions. The client’s experience of numb hands while driving fits this disorder, as it reflects a physical symptom with no identifiable organic cause.

A. Medication compliance B. Information about insurance coverage C. Resources for group therapy in the community D. Awareness of potential for self-harm

Correct Answer is D

Explanation

A. Medication compliance: While medication compliance is important in the management of borderline personality disorder, it is not the immediate priority when discussing the disorder with the family. Understanding the nature of the disorder and its implications for safety is more critical.
B. Information about insurance coverage: While understanding insurance coverage is necessary for accessing treatment, it is not a priority in the context of discussing the immediate risks associated with borderline personality disorder.
C. Resources for group therapy in the community: While providing resources for group therapy is valuable, the primary concern should be ensuring the family is aware of the potential for self-harm. This knowledge is essential for recognizing warning signs and promoting safety.
D. Awareness of potential for self-harm: Clients with borderline personality disorder are at increased risk for self-harming behaviors, including suicidal thoughts and actions. Educating the family about this risk is crucial for ensuring they can provide support and seek help when needed. Prioritizing safety and awareness helps create a protective environment for the client.

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A nurse on a mental health unit is caring for a client. Exhibits The nurse is contributing to the plan of care for the client. Which of the following actions should the nurse recommend? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who states, "When I get in the car to drive to work in the morning, my hands go numb. It is to the point where I can't grip the steering wheel." Which of the following conditions is the client likely experiencing?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with the family of a client who has a new diagnosis of borderline personality disorder about the disorder. Which of the following information should be the nurse's priority?

Correct Answer is D

Explanation

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A nurse on a mental health unit is caring for a client.

Exhibits

The nurse is contributing to the plan of care for the client. Which of the following actions should the nurse recommend? (Select all that apply.)