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. Remove the client from the room: While ensuring the client's safety is important, removing them from the room may not be necessary and could escalate the situation further. The nurse should first assess the immediate environment and the client's feelings before making such a decision.
B. Touch the client's arm reassuringly: Physical contact can sometimes be perceived as threatening by clients experiencing acute symptoms. It is essential to respect the client's personal space, especially when they are in a distressed state.
C. Ask the client to describe what is being seen: Encouraging the client to describe what they are experiencing may increase their agitation or anxiety. It might be more effective to provide reassurance without delving into the specifics of their hallucination at this moment.
D. Tell the client that there is nothing there: Providing reassurance by acknowledging the client's distress while gently affirming that there is nothing present can help to ground the client. This response validates their feelings without reinforcing the hallucination, promoting a sense of safety and calmness.

A. When attending dialectical behavior therapy B. When attending narrative therapy C. When discharged from the hospital D. When getting married

Correct Answer is C

Explanation

A. When attending dialectical behavior therapy: While individuals with borderline personality disorder may experience emotional distress during therapy sessions, attending dialectical behavior therapy (DBT) typically provides skills and support to manage emotions and reduce self-harm risks. Therefore, this situation is not considered the highest risk.
B. When attending narrative therapy: Narrative therapy focuses on helping individuals reframe their stories and experiences, which can be beneficial. While any therapeutic setting can evoke emotions, attending narrative therapy does not significantly increase the risk of self-harm compared to other situations.
C. When discharged from the hospital: This situation is often associated with the highest risk for self-harm. The transition from a controlled environment to the challenges of everyday life can lead to feelings of abandonment, loss of support, and increased stress, making individuals vulnerable to self-harming behaviors.
D. When getting married: While significant life changes, such as marriage, can evoke anxiety, they do not typically represent the highest risk for self-harm. The supportive context of a marriage and the associated positive emotions usually outweigh the potential for increased risk at that moment.

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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 has schizophrenia. The client suddenly moves to the corner of the room and shouts, "Get it away from me!" Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is C

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.)