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 D
Explanation
D. This response is consistent with the characteristics of antisocial personality disorder, which include a lack of remorse, as well as a tendency to rationalize behavior or blame others. Individuals with this disorder often fail to accept responsibility for their actions and may exhibit behaviors that are impulsive, reckless, and violate the rights of others without feeling guilty.
A. Individuals with antisocial personality disorder often lack remorse or empathy for the consequences of their actions and may not experience feelings of shame or guilt, even when their behavior results in harm to others.
B. Expressing genuine remorse or empathy for the harm caused to others is uncommon in individuals with antisocial personality disorder.
C. Claiming to have no memory of the behavior or the events leading up to it is a common defense mechanism used. This may serve to avoid accountability or responsibility for their actions, rather than indicating genuine memory impairment. However, it is not characteristic for antisocial personality disorder.
Correct Answer is B
Explanation
B. This statement demonstrates progress and indicates that the client is beginning to take responsibility off themselves for the sexual assault. Acknowledging that the assault was not their fault is a crucial step in healing from trauma. It shows an acceptance of reality and a shift away from self-blame or feelings of guilt.
A. It may indicate that the client is still struggling to acknowledge the true nature of the assault and may not have fully processed their feelings and experiences related to the trauma.
C. This statement may suggest avoidance or attempts to control future situations to prevent similar experiences. While seeking support and safety measures can be beneficial, solely relying on external factors such as double dates to prevent sexual assault may not address underlying issues or promote healing from the trauma.
D. It suggests a continuation of internalized victim-blaming beliefs and may indicate that the client has not fully shifted away from feelings of guilt or responsibility for the assault.
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