What is the nurse's priority assessment for a patient with borderline personality disorder?
Suicidal or homicidal ideations
Sleep patern changes
Impulsive behaviours
Only support systems
The Correct Answer is A
Borderline personality disorder is a serious mental illness characterized by instability in mood, behaviour, and self-image. Patients with borderline personality disorder are at a high risk of self-harm, suicide, and impulsive behaviours. Therefore, the nurse's priority assessment should be to identify any suicidal or homicidal ideations, as these can be life-threatening emergencies. Once identified, appropriate interventions should be initiated, such as suicide precautions, crisis management, and referral to mental health professionals for further evaluation and treatment.
While sleep patern changes, impulsive behaviours, and support systems are also important aspects to assess in patients with borderline personality disorder, they are not the priority when compared to suicidal or homicidal ideations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This response acknowledges the client's distress and opens the opportunity for the client to express their feelings and concerns. It also demonstrates empathy and a willingness to listen, which can help deescalate the situation and build trust between the nurse and client.
Option a ("Others are being distracted; Please, quiet down and go to your room") is dismissive of the client's feelings and may further escalate the situation.
Option c ("Please go to your room to get control of yourself") is directive and may be perceived as confrontational, potentially increasing the client's agitation.
Option d ("What's going on? Be quiet") is insensitive and dismissive of the client's distress and may further agitate the client.
Correct Answer is A
Explanation
Denial is a defense mechanism where an individual refuses to accept or acknowledge the existence of a problem or a reality that causes anxiety or distress. In this scenario, the client is denying that their coughing is related to their lung cancer, and instead attributing it to a common cold that everyone is getting. This denial may be a way for the client to avoid facing the reality of their illness and the potential consequences of smoking.
Option b, reaction formation, is a defense mechanism where an individual expresses feelings or behaviors that are the opposite of their true feelings to reduce anxiety.
Option c, sublimation, is a defense mechanism where an individual channels their unacceptable impulses into more acceptable or socially appropriate behaviors.
Option d, suppression, is a defense mechanism where an individual consciously pushes down or avoids their thoughts or feelings. None of these defense mechanisms are being exhibited in the scenario described.
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