A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious and wants to cut their arms. The nurse should:
advise the client to take an anxiolytic to decrease their anxiety level.
restrain the client to prevent self-harm.
assist the client to identify the trigger situation and choose a coping strategy.
encourage the client use self-harm behaviors to release emotion.
The Correct Answer is C
C. Individuals with borderline personality disorder often struggle with intense emotions and may engage in self-harming behaviors as a maladaptive coping mechanism. Helping the client identify triggers for their distress and teaching them alternative coping strategies, such as mindfulness, grounding techniques, or distress tolerance skills, can empower them to manage their emotions in healthier ways.
A. Anxiolytic medications can help alleviate anxiety symptoms but they are not typically the first-line intervention for addressing acute distress in individuals with borderline personality disorder (BPD).
B. Restraint should not be the first response to a client expressing distress or suicidal ideation. Physical restraint should only be used as a last resort in situations where there is an imminent risk of harm to the client or others and should be implemented by trained professionals following established protocols.
D. Encouraging self-harm behaviors reinforces maladaptive coping strategies and can increase the risk of harm to the client. It is essential to provide support and interventions aimed at reducing self-harming behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Naloxone administration can rapidly reverse the effects of opioids, potentially leading to the rapid onset of opioid withdrawal symptoms, which may include respiratory depression. Therefore, close monitoring of the client's airway, respiratory rate, oxygen saturation, blood pressure, and heart rate is critical to ensure their safety and stability.
A. Assessing and managing the client's gastrointestinal status may be necessary depending on the clinical situation but it is not the most urgent concern immediately following naloxone administration.
C. Assessing urinary output and ensuring adequate fluid balance is important. However, it is not the highest priority immediately after naloxone administration.
D. Hyperpyrexia, or extremely high fever, is not a common immediate concern following naloxone administration.
Correct Answer is A
Explanation
A. Turkey contains tryptophan, which can have a calming effect and aid in sleep, while cheese provides calcium, and milk is a good source of protein and hydration.
B. Fried foods can be heavy and may exacerbate agitation or restlessness. Additionally, mashed potatoes are high in simple carbohydrates, which may cause rapid spikes and crashes in energy levels.
C. Chips are typically high in unhealthy fats and low in essential nutrients, and cola provides little to no nutritional value while containing high amounts of sugar and caffeine, which may exacerbate symptoms of mania.
D. Caffeine content in tea may not be ideal for someone experiencing mania, as it can further stimulate agitation or hyperactivity.
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