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 B
Explanation
A. "The voices talk only at night when I'm trying to sleep."
This statement does not necessarily indicate a direct threat to the patient or others. It may be a manifestation of hallucination, but it doesn't explicitly pose a danger.
B. "The voices say everyone is trying to kill me."
This statement suggests paranoid delusions and a direct threat to the patient's safety. The nurse should implement safety measures to protect the patient and others from potential harm.
C. "I hear angels playing harps."
This statement describes a positive or benign hallucination, which may not require immediate safety measures. While it might be distressing for the patient, it doesn't pose an imminent danger.
Correct Answer is B
Explanation
A. "I will take Lithobid on an empty stomach": This statement is incorrect. Lithobid is usually taken with meals or right after meals to minimize gastrointestinal side effects. Taking it on an empty stomach may lead to increased side effects.
B. "I will maintain normal salt intake": This statement is correct. Lithium levels in the blood can be influenced by sodium levels. Maintaining a consistent and normal salt intake is important for the proper functioning of lithium in the body. Both low and high sodium levels can affect lithium levels.
C. "I will consume more fluids": This statement is generally correct. Adequate fluid intake is important to prevent dehydration, as lithium is excreted by the kidneys. However, it should be balanced, and excessive fluid intake should be avoided to prevent lithium toxicity.
D. "I will limit my intake of fluids daily": This statement is incorrect. While fluid intake should be monitored and maintained at a reasonable level, restricting fluids too much can lead to dehydration and an increased risk of lithium toxicity.
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