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. WBC count 3,300/mm³.
Clozapine, an atypical antipsychotic medication, is associated with a risk of agranulocytosis, which is a severe reduction in white blood cell (WBC) count. A WBC count of 3,300/mm³ is significantly below the normal range, and it indicates a contraindication to the use of clozapine.
B. Asthma:
Asthma is not a contraindication to clozapine. However, it is important to monitor respiratory function as antipsychotic medications can have side effects related to respiratory function.
C. Hypertension:
Hypertension alone is not a contraindication to clozapine. Clozapine can, however, be associated with some cardiovascular side effects, so blood pressure should be monitored regularly.
D. Fasting blood glucose 120 mg/dL:
An elevated fasting blood glucose level is not a contraindication to clozapine. However, it is important to monitor metabolic parameters as antipsychotic medications, including clozapine, can be associated with metabolic side effects.
Correct Answer is B
Explanation
A. Allow the client to pace alone until physically tired: While pacing can be a coping mechanism, leaving the client alone may not be the most therapeutic approach. It is important for the nurse to provide support and assess the client's emotional state.
B. Walk with the client at a gradually slower pace: This is the correct answer. Walking with the client at a gradually slower pace allows the nurse to offer support and engage in therapeutic communication. It provides a calming presence and can assist the client in self-regulating their anxiety.
C. Have a staff member escort the client to her room: Escorting the client to her room might be perceived as restrictive or punitive. It is generally more beneficial to engage in supportive interventions and encourage coping strategies.
D. Instruct the client to sit down and stop pacing: Giving direct orders to stop pacing may increase anxiety and may not be an effective approach. It is often better to engage in a supportive manner and explore ways to help the client manage their anxiety.
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