A 19 year old patient has a diagnosis of Borderline personality disorder. The patient approaches the nurse and shows multiple fresh cuts on both arms. Which is the most therapeutic response by the nurse?
"After I clean your wounds, I would like for you to journal how you were feeling before you cut yourself.
I’m so sorry you cut your arms Let's discuss how you were feeling
Wow. what happened to you?".
What did you use to cut yourself! I will need to search your room
The Correct Answer is A
A. "After I clean your wounds, I would like for you to journal how you were feeling before you cut yourself."
This response is the most therapeutic. It acknowledges the patient's self-harm behavior, addresses the immediate physical needs by offering to clean the wounds, and encourages the patient to reflect on their emotions through journaling. This approach promotes self-awareness and provides a constructive coping strategy.
B. "I’m so sorry you cut your arms. Let's discuss how you were feeling."
This response is empathetic and encourages communication about the patient's emotions. While it acknowledges the self-harm and invites discussion, it does not suggest a specific coping strategy like journaling. It is still a supportive and therapeutic approach.
C. "Wow. What happened to you?"
This response may come off as judgmental or dismissive. It does not acknowledge the patient's emotional state or offer immediate support for the physical wounds. The tone and wording may make the patient feel uncomfortable or judged.
D. "What did you use to cut yourself! I will need to search your room."
This response is not therapeutic and may be perceived as confrontational and invasive. It does not prioritize the patient's emotional well-being and may violate the patient's trust and privacy. Searching the room without consent is not a recommended approach.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I can see that you are angry. Let's discuss ways to approach Peter with your concerns."
This response is empathetic and invites the client to discuss their concerns. However, it doesn't explicitly address the client's request for the nurse to take action. The more appropriate approach would involve the nurse taking direct responsibility for addressing the issue.
B. "Why are you overreacting to the issue?"
This response may be perceived as dismissive and judgmental. It does not validate the client's concerns or address the issue constructively.
C. "You should bring this to the attention of your treatment team."
While involving the treatment team is important, the client has directly approached the nurse with a concern. It is appropriate for the nurse to take the initial step in addressing the issue directly rather than immediately redirecting the client to the treatment team.
D. "I'll talk to Peter and present your concerns."
This is the most appropriate response. It acknowledges the client's concerns, takes responsibility for addressing the issue, and ensures that the client's voice is heard. The nurse can discuss the matter with Peter and work towards a resolution.
Correct Answer is D
Explanation
A. Concern for others: Individuals with antisocial personality disorder typically lack genuine concern for others and may exploit or manipulate them for personal gain.
B. Actively engaged in all unit activities: While engagement in activities can vary, the key feature of antisocial personality disorder is not a high level of engagement but rather a disregard for rules and the rights of others.
C. Mindful of following all of the unit rules: Individuals with antisocial personality disorder often have a history of rule-breaking and may not be consistently mindful of following societal or institutional rules. They may engage in behaviors that violate rules or laws.
D. Manipulative: This is the correct answer. Antisocial personality disorder is characterized by manipulative behaviors, where individuals exploit others for personal gain or pleasure. Manipulation is a key feature of this disorder.
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